Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 The Citadel At Saint Joseph Village during CMS and state inspections, most recent first.
A resident with multiple cardiac and musculoskeletal conditions, recently post-CABG and receiving subacute rehab, was discharged home with documented plans and NP recommendations for continued home health PT, OT, nursing, and a bath aide. Social services documented that in-home services would be arranged through a local home health agency, but the discharge instructions given to the resident stated that no services were contacted and did not list any home health provider. After discharge, the resident and family waited for home health that never arrived and later learned from the home health intake coordinator that no referral had been received from the facility; services were only started after the family contacted the agency and orders were obtained from the physician’s office. This sequence of events shows the facility failed to implement the planned home health referral and did not ensure that post-discharge services were actually arranged.
A resident with recent MI, CABG, and HTN was admitted on a hospital discharge order specifying a Heart Healthy DASH diet and a no added salt diet. The facility entered a no added salt diet and later changed it to a 2–3 g sodium diet, despite the RD acknowledging that the regular menu would exceed 3 g sodium on most days and that the facility did not have a formal DASH diet option. On the first night, the resident was served a large portion of pulled pork with barbecue sauce and visible fat, which she recognized as inconsistent with her low sodium, low fat diet and ate only partially. The RD later stated she would have expected staff to enter a no added salt diet based on the discharge orders and acknowledged that the intended order may have been for both a DASH diet and a no added salt diet.
The facility failed to maintain accurate controlled substance records and documentation for several residents. For a resident receiving PRN hydrocodone-acetaminophen, a narcotic count revealed one missing tablet that was not signed out on the control sheet, and the LPN involved could not explain the discrepancy. Another resident with scheduled and PRN alprazolam had a tablet removed and documented as being used for a different resident, while the MAR did not show administration for the original resident. A third resident had Norco signed out twice on the control sheet without staff signatures and with no corresponding MAR entries. Additionally, four residents’ controlled substance sheets were not signed at the time of administration, even though the LPN later signed them during a narcotic count, contrary to facility policy requiring real-time documentation and accurate shift-to-shift controlled drug counts.
Dishwasher temperature was below the sanitizing level and the garbage disposal was clogged. Surveyors observed the dishwasher leaking water onto the floor, with food and wrappers in the water, and noted a strong odor of rotting food in the dish room. The Dietary Manager stated a pipe on the dishwasher falls off daily, the machine was not reaching the proper temperature for hot water sanitization, and food was removed from the clogged disposal.
A facility failed to maintain resident dignity during mealtimes when multiple residents seated at the same table were served at different times, causing some to wait while tablemates ate and one resident to receive the wrong meal before the correct tray arrived. The facility also failed to assist a cognitively intact resident with facial hair grooming; she had visible coarse facial hair on her face and neck, stated it had not been shaved since admission, and said it was embarrassing. Staff acknowledged that residents should be served together at the table and that facial hair grooming is a dignity issue.
Medication administration timing errors occurred when an LPN gave several residents’ scheduled meds outside the allowed time window, including late acetaminophen, memantine, ramipril, rivaroxaban, glipizide, gabapentin, vitamin C, and delayed IV meropenem for a resident with a bacterial infection. One resident’s chlorhexidine mouth rinse was also unavailable in the med cart, and the DON stated meds should be given within 1 hour before or after the scheduled time.
Pureed diet foods were not prepared to the ordered consistency for multiple residents. A cook blended pureed fried steak and corn, but the finished items were observed as ground or mechanical soft rather than smooth, and a resident on a pureed diet reported meat pieces in his meal and left most of the tray uneaten. The DON and RD confirmed the tray did not appear pureed, and facility policy and recipes required a smooth, pudding-like consistency.
Failure to Offer Bedtime Snacks: Residents reported that HS snacks were not being offered routinely and were only available if requested. The DON said snacks were being passed at varying times, often earlier in the day or around 4 PM, and staff stated they did not know snacks had to be offered at bedtime. Resident council minutes also documented that residents were not receiving a bedtime snack and were told to ask for one.
A resident with Alzheimer’s disease, dementia, chronic pain, and limited LE ROM was observed sitting in a wheelchair with the left leg twisted inward, knees bent, and the back of the knees far from the seat. The resident complained of LLE pain and did not appear comfortable. A CNA, restorative nurse, and DPT all observed that the wheelchair positioning was poor and that the chair appeared too small for the resident.
A resident with dementia, dependent edema, and multiple chronic conditions was ordered elasticated tubular support bandages for both legs each morning and at bedtime. Staff observed the resident sitting in a wheelchair without the leg wraps in place, and a CNA confirmed they were not on. An LPN thought the night nurse applied them, another LPN confirmed the order, and the DON noted the TAR showed one nurse signed them as applied while another did not. The resident's care plan did not include the wraps, and progress notes did not show refusal of care.
A resident with CHF, a history of falls, and a care plan identifying high fall risk fell out of bed during repositioning. The resident said a CNA rolled her toward the edge of the bed and she fell to the floor, with no side rails in place at the time. The CNA and DON stated the resident required 2 staff for rolling in bed, and the fall occurred when her legs shifted and carried her over the edge.
A resident with an indwelling urinary catheter, neurogenic bladder, MS, DM, CKD, HTN, and a UTI had her catheter drainage bag repeatedly held at or above shoulder level during transfers and care. CNAs and an RN were observed lifting or handing the bag while the resident remained seated or was being prepared for a transfer, and yellow urine was seen backflowing in the tubing. The resident’s care plan required the drainage bag to stay below bladder level, and staff acknowledged that it should be kept below the waist/bladder to reduce backflow.
A resident with dysphagia, a gastrostomy, and dependence on tube feeding had an unlabeled open bottle of enteral formula left on a dresser, a feeding tube that was slightly pulled out with no intact dressing at the site, and bloody drainage on the tubing. An LPN reported the bolus feeding and meds had already been given, and another LPN later administered a bolus feeding after flushing the tube but did not check placement first, stating there were no orders and that she had not received education on the tube-feeding policy.
IV Antibiotic Infused Too Quickly During Pump Setup: An RN started an IV ampicillin infusion for a resident with a PICC line and attempted to attach the tubing to the pump after connecting it to the resident. The white clamp opened during setup, allowing the antibiotic to flow freely, and about 20-30 mL infused in less than a minute instead of over 60 minutes as labeled. The resident had a UTI, CKD, bladder cancer, dysphagia, and cognitive communication deficit.
A facility failed to keep respiratory masks covered and stored to prevent cross contamination for 3 residents receiving respiratory care. Surveyors observed an uncovered CPAP mask and nebulizer mask with visible soilage for one resident, and uncovered nebulizer masks placed next to urinals on bedside tables for two other residents. The ADON/IC stated the masks are normally kept in little black bags for sanitary reasons and infection control, and the residents had respiratory diagnoses such as asthma, OSA, COPD, and chronic respiratory failure with orders for nebulizer and CPAP/BiPap care.
An LPN was found with a resident’s expired insulin aspart pen on a med cart, and the resident’s MAR showed the insulin was administered on multiple days after the pen would have been expired. On another med cart, a Norco 5/325 mg tablet was found taped back into the card, and the LPN stated staff sometimes do this if a medication is popped out but not used. The DON stated insulin pens are discarded after 28 days and narcotics should be wasted with a 2nd nurse witness, not taped back into the card.
Failure to follow EBP occurred when an LPN and CNAs provided care for a resident with a feeding tube while wearing gloves but no gowns. The resident had multiple diagnoses including dysphagia, cognitive deficits, aphasia, spastic hemiplegia, and a gastrostomy, and was ordered to be on EBP for feeding tube care. The resident’s dressing was observed twisted with bloody drainage and not secure, and the LPN performed feeding tube site care and dressing change without the required gown.
The facility did not honor resident preferences for bacon, a previously available breakfast item, after a change in ownership and guidance from the food service provider. Multiple residents and staff reported frequent requests and complaints about the absence of bacon and other breakfast meats, with documentation in grievance logs and resident council meetings. The dietary manager and registered dietitian confirmed the removal was based on nutritional guidance, and the facility lacked a policy addressing resident menu preferences.
Three residents experienced safety failures, including a laceration from improper catheter management during dressing, unsafe handling of a urinary catheter during ambulation, and a fall during showering due to inadequate supervision and miscommunication about transfer needs. These incidents involved residents with catheters, fall risks, and sensory impairments, resulting in injury and unsafe conditions.
Multiple residents reported that CNAs used personal cell phones during showers and in common areas, leading to feelings of neglect and lack of attention. Resident Council Meeting minutes confirmed ongoing concerns about staff phone use, and the DON acknowledged this as an issue, contrary to facility policy requiring staff to focus on residents and maintain their dignity.
A resident who needed staff assistance for bathing did not consistently receive the required number of showers, with records showing a 13-day gap between showers. The DON confirmed that staff are expected to provide showers twice weekly, but the facility lacked a formal policy on shower frequency.
A resident with visual impairment and a physician order for an ophthalmology consult did not receive a timely follow-up appointment after the original was canceled due to insurance issues. The resident reported worsening vision and had not seen an eye doctor or had vision testing in over a year. Facility records confirmed no rescheduled appointment, and the DON acknowledged the lapse, despite facility policy requiring timely coordination of such services.
A resident with a recent cardiac surgery did not receive daily cleansing of a surgical incision as ordered by the physician. The wound care nurse overlooked the order, and the DON was unaware of its existence, resulting in the order not being entered or followed. The facility's records only showed monitoring of the incision, with no evidence of the required cleansing being performed.
A resident with multiple chronic conditions did not receive medications as ordered when an LPN administered levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of one. The resident expressed the importance of timely administration due to dietary restrictions, and facility policy requires adherence to prescribed medication times until reviewed by the pharmacist.
Multiple residents did not consistently receive or have documented wound care and weekly skin checks as ordered, with missed treatments and incomplete records noted for wound care, skin protectant applications, and weekly assessments, despite facility policy and staff acknowledgment of their importance.
A discrepancy in a resident's lorazepam count was identified by two nurses, but the missing medication was not reported to administration or authorities as required. The ADON and Administrator confirmed that the incident was not communicated or documented according to facility policy.
A resident with a stage four pressure injury did not receive or have documentation for several ordered wound care treatments, as evidenced by gaps in the Treatment Administration Record and confirmed by the wound care nurse. Facility policy requires documentation of dressing changes, but this was not consistently done.
A resident's controlled substance records for lorazepam and morphine were not accurately maintained, with a 4 ml discrepancy in lorazepam count and incomplete documentation for a morphine dose. Staff were unable to determine the exact amount of medication in the bottle due to unclear graduation marks, and required procedures for reporting and resolving discrepancies were not followed.
A resident with multiple health issues, including a high fall risk, was injured when a CNA attempted to reposition them alone on a low air loss mattress, contrary to facility policy requiring two staff members. This resulted in the resident falling and sustaining fractures, necessitating hospitalization.
A facility failed to maintain the patency of a resident's CVC, leading to occlusion and replacement. The resident reported that the catheter was not flushed as required, and records showed multiple missed flushes and Heparin locks. Staff interviews revealed inconsistent practices and a lack of specific training for CVC flushing, contributing to the catheter's occlusion.
The facility failed to provide pureed Swiss steak with a smooth, uniform texture for residents on a pureed diet. The cook did not achieve the required consistency, and the Dietary Manager confirmed the gritty texture, which required chewing. The facility's policy mandates a smooth texture for pureed foods.
A facility failed to follow proper sanitation practices during the preparation of pureed diets for residents. A cook used the same spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses, leading to potential cross-contamination. The Dietary Manager confirmed that the facility's policy requires washing, rinsing, and sanitizing kitchenware after each use, which was not followed.
A resident with emotional distress and multiple diagnoses was not treated with dignity by CNAs in a facility. Despite the care plan's emphasis on a warm and calm approach, the resident was told to stop moaning, and her incontinence brief was replaced without her consent, causing distress. The DON confirmed the staff's actions were inappropriate and not in line with the facility's dignity policy.
A facility failed to safely transfer a resident by not using a gait belt, as required by the resident's care plan. A CNA assisted the resident from a wheelchair to a bed without applying a gait belt, lifting the resident under the arm and guiding their hips with her hands. This was contrary to the facility's policy and the resident's care plan, which mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the DON confirmed the necessity of using a gait belt for the resident's safety.
A resident experienced multiple medication administration errors, including incorrect dosing and failure to notify a physician when withholding medication. An LPN withheld Diltiazem without parameters, administered Timolol Maleate incorrectly, gave an incorrect dose of Milk of Magnesia, and omitted Vitamin D3. The facility's error rate was 10.81%, exceeding the acceptable 5% threshold.
A resident with Type 1 diabetes did not receive the correct insulin medications as prescribed by their endocrinologist due to transcription errors at the facility. The resident's After Visit Summary specified changes to their insulin regimen, but the facility's MAR showed incorrect insulin types and dosages were ordered and administered. The error was discovered during a medication audit by an LPN, highlighting the need for accurate medication management.
A resident with multiple health conditions fell and sustained a head injury during a transfer due to a CNA's failure to maintain a hold on the gait belt, contrary to facility procedures. The resident hit her head on an oxygen concentrator, requiring emergency medical treatment. Staff interviews confirmed the expectation of using gait belts during transfers to prevent such incidents.
A resident with dementia experienced escalating agitation due to inappropriate care by multiple staff members in a small space, leading to physical distress and lack of proper documentation. Despite having a care plan that required a calm approach, staff failed to follow guidelines, resulting in a deficiency in care.
A resident sustained a fractured femur during an unsafe transfer by a CNA who was unfamiliar with her needs and did not use a gait belt. The resident's knees buckled, and she was lowered to the floor, later diagnosed with a periprosthetic fracture. The RN noted limited leg movement and discomfort, but the resident was placed in a chair without immediate intervention. The resident, with a history of osteopenia, eventually expired under hospice care.
A facility failed to assess, treat, and document skin damage for a resident, leading to the discovery of foam patches swollen with urine on the resident's body. The resident, who preferred minimal changes, had saturated briefs and liners. CNAs and the wound care RN were unaware of the patches, and further assessment revealed a dried fluid blister and moisture-associated skin damage. The facility's records did not document these issues, indicating a failure to follow skin monitoring policies.
A resident's family requested the discontinuation of scheduled melatonin, to be given only as needed upon family request. Despite this, the resident continued to receive the scheduled dose, leading to increased sleepiness and decreased eating and drinking. The facility failed to inform the NP and update the medication orders accordingly.
The facility failed to treat residents with dignity, as evidenced by reports from three residents. One resident reported that a CNA threw her shoes under her bed, another resident stated that the CNA was rude and unhelpful when she requested assistance to use the bathroom, and a third resident reported that the CNA frequently used inappropriate language. These actions were in violation of the facility's dignity policy.
Failure to Initiate Home Health Referral at Discharge
Penalty
Summary
The deficiency involves the facility’s failure to initiate a home health referral for a resident who was discharged home, despite documented plans and clinical recommendations for post-discharge services. The resident had multiple significant diagnoses, including fibromyalgia, non-ST elevation myocardial infarction, prior CABG with aortocoronary bypass graft, chronic pain syndrome, muscle wasting and weakness, major depressive disorder, Bell’s palsy, generalized anxiety disorder, and osteoarthritis. The care plan documented that the resident intended a short-term stay with a goal to return to the community, and that facility staff would assist with referrals as needed to meet discharge goals. A facility discharge assessment indicated a planned discharge home under the care of an organized home health service, with active discharge planning and a referral to a local contact agency. Provider documentation prior to discharge consistently indicated the need for continued services after leaving the facility. Nurse practitioner notes stated that, despite the resident’s good participation in subacute rehab and functional improvements, the resident needed to continue with home health PT and OT to improve strength, balance, endurance, and mobility, and to maintain independence with ADLs and decrease fall risk. Social services documented on the day of discharge that the resident requested to leave that day and that she would discharge home with in-home PT, OT, nursing, and a bath aide through a local home health agency, and that she also planned to begin cardiac rehab in July. However, the written discharge instructions given to the resident listed discharge to home with a cardiac diet and home exercise program, noted the resident as independent in all ADLs, and specifically documented “no services contacted,” with no home health agency or physician information included. Post-discharge accounts from the resident and the home health intake coordinator confirmed that no referral was actually sent by the facility at the time of discharge. The resident reported that social services told her home health PT and OT would be set up, but no one contacted her for at least one to two weeks; when her family called the home health agency, they were told no referral had been received. The home health intake coordinator stated that their records showed no referral from the facility and that services were only initiated after the resident’s son contacted the agency, prompting the coordinator to obtain orders directly from the physician’s office. Facility staff interviews indicated that therapy typically recommends home health and that the physician or NP has final authority on referrals, and current social services staff described a process of faxing referrals and expecting confirmation from agencies. The facility’s own policy on resident-initiated discharges requires documentation of discharge planning and arrangements for post-discharge care, but in this case, the documented plan for home health services was not carried out, and the medical record showed no services contacted at discharge.
Failure to Provide Ordered Low Sodium Cardiac Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident with the ordered low sodium diet consistent with hospital discharge instructions and physician orders. The resident had significant cardiac history, including myocardial infarction, coronary artery bypass graft surgery, and hypertension, and was cognitively intact. The hospital discharge packet, printed the day before admission, specified a Heart Healthy DASH diet and a No Added Salt diet, with a note that the hospital diet order could be substituted with the facility’s equivalent diet description. Upon admission, the physician’s orders reflected a No Added Salt diet starting on 5/28/25, which was later changed on 6/6/25 to a 2–3 g sodium diet with thin liquids. The Registered Dietitian (RD) stated that at the time of admission the facility only had two sodium-restricted options: a No Added Salt diet (regular diet with no salt packets) and a 2–3 g sodium diet, and that the regular menu would exceed 3 g of sodium on most days. On the night of admission, the resident reported being served a large portion of pulled pork with barbecue sauce and visible fat, which she described as salty and inconsistent with her understanding that she should be on a low sodium and low fat diet. She took a picture of the meal and shared it with her family, stating she ate less than half because she knew she was not supposed to eat it. The RD acknowledged being notified by staff the day after admission that the resident had been served pulled pork and that the resident’s son was unhappy. When later shown the hospital discharge orders, the RD stated she would have expected staff to enter a No Added Salt diet because that was what was ordered and the facility did not have a DASH diet option, and further acknowledged that the intended order may have been for both a DASH diet and a No Added Salt diet. The RD also stated that if the DASH diet’s sodium recommendation was less than 3 g, the facility’s 2–3 g sodium diet would most closely align with that restriction, and confirmed that the purpose of sodium restriction is to minimize swelling and reduce blood pressure.
Inaccurate Documentation and Discrepancies in Controlled Substance Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate records and documentation for controlled medications for multiple residents. For one resident with an order for hydrocodone-acetaminophen (Norco) 5-325 mg every four hours as needed for pain, a narcotic count showed 14 pills remaining in the punch card, while the Controlled Drug Receipt/Record/Disposition Form indicated 15 pills remaining with the last documented dose given several days earlier, leaving one tablet unaccounted for. The LPN who participated in the narcotic count stated she had counted with the previous nurse, did not know why there was a discrepancy, and did not remember administering the medication. Another resident had an order for alprazolam 0.25 mg twice daily and every 12 hours as needed; the controlled drug record showed a tablet removed and documented as given for another resident, while that resident’s MAR did not show administration of alprazolam on that date. For a third resident, the Controlled Drug Receipt/Record/Disposition Form showed Norco signed out twice on the same day without any staff member’s name recorded, and the MAR showed that the resident did not receive Norco on that date. Additionally, controlled substance sheets for four other residents were signed off by the same LPN during a narcotic count, and the LPN stated she had administered the controlled substances but had not signed them out on the controlled substance sheets, even though the MARs showed the medications were scheduled for administration earlier that morning. Staff interviews confirmed that narcotics are supposed to be counted at shift change by two nurses, with one reviewing the book and the other the cart, and that medications should be documented at the time they are given. Facility policies required the individual administering medications to initial the MAR after each administration and mandated end-of-shift controlled substance counts with documentation and reporting of discrepancies to nursing leadership.
Dishwasher Temperature Below Sanitizing Level and Garbage Disposal Clogged
Penalty
Summary
The facility failed to ensure the dishwasher was operating at an appropriate temperature to sanitize dishes and silverware and failed to maintain the garbage disposal system. During observation on 3/3/26 at 9:06 AM, the dishwasher was draining large amounts of water onto the dish room floor, and the water contained small amounts of food and wrappers. The dishwasher was started and showed a wash cycle temperature of 144 degrees Fahrenheit, while the front of the machine listed a reference wash cycle temperature of 150 degrees Fahrenheit. A strong odor of rotting food was present in the dish room, and the sink with the garbage disposal was full of orange/brown water with food floating in it. At 9:19 AM, the Dietary Manager stated that a pipe on the back of the dishwasher falls off every day at a minimum and, when it falls off, water leaks all over the floor. He replaced the pipe, which greatly decreased the leaking, and stated he was unsure why the dishwasher was not reaching the appropriate temperature. He also stated the garbage disposal was clogged and removed food items that appeared to be coleslaw, french fries, and other unidentifiable food from the disposal system. Later, at 12:50 PM, he stated the dishwasher should reach 150 degrees for hot water sanitization and that if it does not reach the desired temperature, dishes will not get sanitized properly.
Dignity and Grooming Failures During Meals and Personal Care
Penalty
Summary
The facility failed to ensure six residents were treated with dignity during mealtimes when residents seated at the same table were not served together. On 3/4/26, R25, R94, and R106 were seated together at lunch, but R94 began eating before R25 and R106 received their trays. R94 stated she was trying to wait so they could all eat together, but her food was getting cold. R25 stated they always had to wait a long time after R94 got served and that they should all be eating at the same time. R25’s tray was initially incorrect and was not corrected until 12:10 PM, 26 minutes after she was first served and after the other tablemates had already been waiting. On the same day, R19 and R85 were seated with R73 at lunch, but R19 and R85 were not served until 10 minutes after R73 had started eating. R85 stated she did not like that they were not served at the same time and that they should all eat together. Later that meal period, R32 was served while R65, who was seated at the same table, did not receive a tray before staff began clearing tables and plating hall trays; V5 was notified that R65 had not been served 18 minutes after R32 received her meal. The facility also failed to provide facial hair grooming assistance for R31. R31, who had multiple sclerosis, diabetes, chronic kidney disease, hypertension, and was cognitively intact, required substantial/maximal assistance with personal hygiene and ADLs. She was observed with coarse gray and white facial hair on her upper lip, chin, and neck on 3/3/26 and again on 3/4/26. R31 stated the facial hair had not been shaved since her admission and that she wished staff would shave it because it was embarrassing. A CNA stated female residents were usually not shaved unless they asked, and the DON stated female residents should not have facial hair unless it was their preference and that CNAs should offer to shave R31 when they noticed facial hair and on shower days. The facility policy stated residents shall be treated with dignity and groomed as they wish to be groomed, including facial hair.
Medication administration timing errors
Penalty
Summary
The facility failed to administer medications at ordered times, resulting in a 31% medication error rate based on 29 opportunities with 9 errors for 4 of 6 residents reviewed for medication pass. For one resident receiving meropenem 1000 mg IV every 12 hours for a bacterial infection and acetaminophen 650 mg at 8 AM and 8 PM, acetaminophen was given at 9:30 AM, 1 hour and 30 minutes late, and the resident stated she did not think she had received her morning meropenem. The LPN stated she could not administer the IV meropenem because she was not an RN and needed to get the RN from the other side of the building, and the medication was then reported as late 3 hours and 38 minutes after the scheduled time. Additional timing errors were identified for other residents. One resident’s memantine 10 mg scheduled for 8 AM and 8 PM was administered at 9:41 AM, 1 hour and 41 minutes late. Another resident’s ramipril 5 mg, rivaroxaban 2.5 mg, glipizide 10 mg, gabapentin 300 mg, and vitamin C were administered at 9:36 AM instead of the scheduled 7 AM and 8 AM times, making the vitamin C 2 hours and 36 minutes late and the remaining medications 1 hour and 36 minutes late. For another resident, chlorhexidine mouth rinse scheduled for 8 AM and 8 PM was unavailable in the medication cart, and the LPN stated it had been reordered but had not yet arrived from the pharmacy. The DON stated medications should be administered within 1 hour before or 1 hour after the scheduled time, and the facility policy stated medications must be administered in a safe and timely manner and within one hour of the prescribed time unless otherwise specified.
Pureed Diet Foods Served at Improper Consistency
Penalty
Summary
The facility failed to prepare pureed foods to the desired consistency for 8 of 8 residents reviewed who were ordered a pureed diet, including R2, R35, R46, R48, R53, R87, R90, and R91. On 3/3/26, the facility provided a list of residents receiving pureed diets, and a cook prepared pureed fried steak and pureed corn by blending each item and pouring them into pans. The cook described the finished items as pureed, but the surveyor observed the meat was ground rather than smooth and the corn was not a smooth consistency. At lunch, R35 stated his food was not pureed and that there were pieces of meat in it; he also reported swallowing problems and problems with his teeth. His meal tray was observed with mashed potatoes with gravy, corn with kernel chunks, and meat with chunks, and only a few bites had been taken. The resident’s ticket indicated a pureed diet with double portions of meat, and the physician orders showed a regular diet with pureed texture. A test tray requested by the surveyor showed meat that was thick with small chunks and corn with pieces of hull in it. The Administrator stated the tray appeared to be mechanical soft, and the Registered Dietician stated pureed foods should not have chunks because this creates a choking hazard for residents with swallowing difficulties. The facility’s pureed preparation policy and recipes called for a smooth, pudding-like consistency.
Failure to Offer Bedtime Snacks
Penalty
Summary
The facility failed to provide HS (bedtime) snacks for 6 of 6 residents reviewed for HS snacks in a sample of 23. During a Resident Council meeting, residents stated the kitchen did not send snacks every day and that snacks were only available when they requested them. They said they were not offered snacks routinely and wanted at least to be offered a snack because of the long wait from dinner until breakfast the next day. The residents involved included 5 residents with no cognitive impairment on their most recent facility assessments and 1 resident with mild cognitive impairment. Resident Council minutes from January 2026 documented that residents were not being offered a bedtime snack and were encouraged to ask for snacks when they stated they did not receive one. The DON stated snacks were passed with water at different times, usually after breakfast on day shift and around 4 PM on second shift, and said she did not realize they had to be offered after dinner as an HS snack. A CNA stated second shift snacks were passed with water when she first came in for her shift and she did not know they had to be offered at bedtime. The Administrator stated there was no reason residents should not be offered snacks at bedtime and that staff needed to offer a snack and document whether the resident accepted it. The facility policy titled, Snacks (Between Meal and Bedtime), Serving, stated the purpose of the procedure is to provide the resident with adequate nutrition.
Wheelchair Did Not Fit Resident’s Positioning Needs
Penalty
Summary
The facility failed to ensure that a resident had a wheelchair that fit and maintained proper body alignment and positioning needs for one resident reviewed for accommodation of needs. On 3/4/26 at 9:03 AM, the resident was observed sitting in a wheelchair in the common area with the left leg twisted inward, knees bent, and the back of the knees about 1 foot away from the seat of the wheelchair. The resident complained of pain to the left leg and did not appear comfortable. A CNA observed the resident and stated the resident did not look comfortable in the wheelchair. A restorative nurse later observed the resident and stated the positioning in the wheelchair was not good and that the wheelchair did not appear to fit as it should. The Director of Physical Therapy also observed the resident and stated the wheelchair looked too small and that a larger one could be obtained. The resident’s face sheet listed diagnoses including Alzheimer’s disease, unspecified protein calorie malnutrition, depression, dementia, obstructive and reflux uropathy, chronic atrial fibrillation, anxiety, urinary tract infection, chronic pain, mitral valve insufficiency, disorders of the kidney and ureter, cardiomegaly, and hypertension. The MDS showed severe impairment of memory and cognition, functional limitation in range of motion to both lower extremities, wheelchair use, substantial/maximal assistance for rolling, and dependence for transfers.
Failure to Apply Ordered Leg Wraps
Penalty
Summary
The facility failed to ensure elasticated tubular support bandages were in place for one resident who was reviewed for quality of care. The resident had diagnoses including Alzheimer's disease, unspecified protein calorie malnutrition, depression, dementia, chronic atrial fibrillation, anxiety, chronic pain, cardiomegaly, hypertension, and other conditions. The physician order directed staff to apply elasticated tubular support bandages to both legs in the morning and remove them at bedtime every day and night shift, because the resident had dependent edema from sitting in a wheelchair. The resident was observed sitting in a wheelchair with grip socks on and no leg wraps on the lower legs, and a CNA confirmed no wraps were in place and was not aware the resident had any. An LPN stated the wraps should be done as ordered and thought they were put on by the night nurse, while another LPN later confirmed the resident was supposed to have them applied in the morning and removed at bedtime. The DON stated the wraps were to be applied in the morning, that nurses and CNAs monitor compliance, and that they should be signed out on the TAR when done. The DON reviewed the March 2026 TAR and noted one nurse had signed that the wraps were applied at 6:30 AM, but another nurse had not signed that they were on when asked about it. The resident's care plan did not include the use of elasticated tubular support bandages, and progress notes from January through March 2026 did not show any refusal of care.
Unsafe repositioning led to resident fall from bed
Penalty
Summary
The facility failed to ensure a resident was positioned safely to prevent a fall for 1 of 4 residents reviewed for falls. The resident was admitted with congestive heart failure and a history of falling, and the quarterly assessment documented the resident as cognitively intact and requiring partial/moderate assistance with rolling right to left, with the helper lifting, holding, or supporting the trunk and limb during movement. The care plan identified the resident as high risk for falls related to functional deficits. The incident report documented that the resident fell out of bed during repositioning and was lowered to the floor gently by the aide. The resident later stated that a CNA was repositioning her in bed, rolled her toward the edge of the bed, and her feet went over first before she rolled and fell to the floor between the aide and the bed. She reported that the side rails were not on the bed at the time and said this was not the first time she had fallen out of bed. The CNA stated the resident had always required 2 staff for rolling in bed and that bars had recently been put on the bed because she had rolled out of bed. The DON stated the aide rolled the resident toward herself and the momentum of the resident's legs moved her over the edge of the bed.
Indwelling Catheter Drainage Bag Held Above Bladder Level
Penalty
Summary
The facility failed to ensure an indwelling catheter drainage bag was maintained below the level of the bladder for one resident with an indwelling urinary catheter. On 3/4/26, during multiple observations, CNAs and an RN handled the resident’s catheter drainage bag while the resident was seated in an electric wheelchair or being prepared for transfer, and the bag was repeatedly held at or above shoulder level, which was above the level of the bladder. During these observations, yellow urine was seen flowing back toward the resident in the catheter tubing. The resident had diagnoses including multiple sclerosis, diabetes, chronic kidney disease, hypertension, neuromuscular dysfunction of the bladder, and urinary tract infection. The resident’s assessment showed she was cognitively intact and had an indwelling urinary catheter. Her care plan, initiated 2/11/26, identified the need for an indwelling catheter related to neurogenic bladder and included an intervention to keep the drainage bag lower than the level of the bladder. Staff interviews confirmed awareness that the catheter bag should be kept below the resident’s waist or bladder level to reduce backflow.
Tube Feeding Care Not Properly Managed
Penalty
Summary
The facility failed to label an open bottle of tube feeding, failed to ensure a feeding tube dressing was intact, and failed to check feeding tube placement before administering tube feeding for one resident who was NPO and dependent on tube feeding. The resident had diagnoses including hypoxic ischemic encephalopathy, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, Down syndrome, and a gastrostomy. On observation, an open bottle of tube feeding with 300 mL remaining was found on the resident’s dresser without a label showing when it had been opened. The resident was later observed lying in bed with the abdomen exposed, the feeding tube slightly pulled out, and no dressing around the tube site; the dressing was twisted, had bloody drainage, and was hanging down on the tubing. An LPN stated she had already given the resident a bolus tube feeding and medications and said the dressing could be changed as needed. The next day, another LPN administered a 325 mL bolus tube feeding after flushing the tube but did not check placement before giving the feeding, stating there were no orders to check placement and that she had not received education on the facility’s tube feeding policy. The resident’s physician orders included split gauze to the tube site, bolus tube feeding five times daily, monitoring for tolerance, and flushing before and after use; the care plan also directed residual checks and tube placement checks every shift.
IV Antibiotic Infused Too Quickly During Pump Setup
Penalty
Summary
The facility failed to follow professional standards when starting an IV antibiotic for one resident with a PICC line. During observation, the RN flushed the resident’s PICC with 10 mL of NS, clamped the line, and left the syringe attached. She then prepared ampicillin 500 mg in 100 mL of NS, primed the IV tubing, and attempted to attach the tubing to the resident’s PICC before placing the tubing into the IV pump and setting the rate. While she was trying to load the tubing into the pump, the white C-clamp opened and the antibiotic began flowing freely into the resident’s PICC line. The surveyor intervened after seeing a steady stream of fluid passing through the drip chamber, and the RN then closed the roller clamp. The resident received approximately 20-30 mL of the 100 mL antibiotic in less than a minute. The resident had diagnoses including chronic kidney disease, urinary tract infection, bladder cancer, dysphagia, disorders of the muscles, lack of coordination, and cognitive communication deficit. The physician order was for ampicillin sodium 500 mg IV four times daily for a urinary infection for 10 days, and the medication label directed that 100 mL be infused over 60 minutes every 6 hours. The DON stated the antibiotic should not have been free flowing while the RN tried to place the tubing in the pump, and the facility policy stated the IV tubing should not be attached to the resident’s IV site until it is inserted into the pump and set at the prescribed rate, with the roller clamp closed while loading the tubing.
Uncovered Respiratory Masks Stored Improperly
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by leaving respiratory masks uncovered and stored in a manner that did not prevent cross contamination for 3 of 3 residents reviewed for respiratory care. For R3, surveyors observed a CPAP face mask sitting face down uncovered on the bedside table with white substances and tan flakes on the inside of the mask, and the nebulizer mask was also uncovered on the bedside table with dirt inside. R3’s record showed diagnoses including hypoxic ischemic encephalopathy, asthma, obstructive sleep apnea, dysphagia, and other chronic conditions, with orders for BiPap/CPAP at bedtime and nebulizer mask/tubing changes weekly and as needed. The care plan addressed respiratory needs, but there was no plan in place for BiPap/CPAP. For R107, surveyors observed the resident asleep in bed with oxygen via nasal cannula, while a urinal sat on the bedside table with the nebulizer mask uncovered next to it. For R29, surveyors observed the resident sitting up in bed with a urinal containing urine on the bedside table, and the nebulizer machine and uncovered mask were placed next to the urinal. The ADON/Infection Control Preventionist stated respiratory masks are kept in little black bags next to the machines for sanitary reasons and infection control, and stated the masks should not be sitting next to urinals or with urinals left out. R107 and R29 both had diagnoses including COPD and other respiratory or cardiac conditions, and both had physician orders for nebulizer mask/tubing changes weekly and as needed, with respiratory care included in their care plans.
Expired insulin pen and improperly stored narcotic found on medication carts
Penalty
Summary
The facility failed to dispose of a resident’s expired insulin aspart pen and failed to store a narcotic in a manner that prevented medication diversion. During review of a medication cart assigned to an LPN, the surveyor found R90’s insulin aspart pen with an open date of 12/15 and an expiration date of 1/15. The LPN stated the pen had likely been missed because the resident rarely used sliding scale insulin and acknowledged it should have been discarded after being open for more than 28 days. The LPN then disposed of the pen and obtained a new one from the medication room. Review of R90’s February and March MARs showed the resident received insulin aspart on multiple days while the pen would have been expired. During a narcotic count on another medication cart, the surveyor found R80’s Norco 5/325 mg card with one tablet taped back into the card. The LPN stated that if a medication is popped out and not used, staff usually tape it back in so it is not wasted, and said she would need to verify whether the tablet was actually Norco. The DON stated insulin pens are discarded after 28 days of opening and narcotics should be wasted in a drug buster with a second nurse witness, and should not be taped back into the card because it creates the potential for diversion or the medication could get loose or mixed up with other medications. The facility policy stated outdated drugs are not to be used and must be returned to the dispensing pharmacy or destroyed.
Failure to Follow Enhanced Barrier Precautions During Feeding Tube Care
Penalty
Summary
Facility staff failed to follow enhanced barrier precautions (EBP) when providing care for a resident with a feeding tube. On 3/3/26 at 1:24 PM, the resident was observed lying in bed with the dressing around the feeding tube twisted, with bloody drainage, and the dressing was down on the tubing and not secure to the abdomen. At 1:28 PM, an LPN and a CNA entered the room wearing gloves but no gowns and repositioned the resident. The LPN removed the old dressing from around the feeding tube, performed site care, and placed a new dressing, and the LPN and CNA then repositioned the resident in bed. The CNA stated the resident was incontinent of bowel movement and left to get help, then returned with another CNA. The resident’s face sheet listed diagnoses including hypoxic ischemic encephalopathy, asthma, critical illness myopathy, type 2 diabetes mellitus, obstructive sleep apnea, dysphagia, cognitive communication deficit, aphasia, spastic hemiplegia, GERD, iron deficiency anemia, BPH, Down syndrome, hyperlipidemia, hypothyroidism, major depressive disorder, anxiety disorder, hypertension, gastrostomy, and bipolar disorder. Physician orders for March 2026 included EBP, and the care plan dated 1/29/26 stated the resident required EBP related to the feeding tube, with staff to wear gloves and gowns for device care or use of feeding tubes. The facility’s EBP policy stated EBP is indicated for high-contact care activities involving indwelling medical devices, including feeding tubes, and requires the use of gown and gloves for such care.
Failure to Honor Resident Menu Preferences Regarding Bacon
Penalty
Summary
The facility failed to honor resident preferences regarding menu items, specifically the provision of bacon, which had previously been available to residents before a change in facility ownership. Multiple residents and staff reported that bacon was regularly requested and had been a staple breakfast item prior to the new corporation taking over. After the change in ownership, bacon was removed from the menu, and staff were instructed by the food service provider that bacon would no longer be supplied due to its perceived lack of nutritional value. Observations confirmed that bacon was not present in the facility's food storage areas, and the alternative menu no longer listed bacon-containing items. Residents expressed dissatisfaction and frustration with the removal of bacon, noting that it was a preferred food item and a source of enjoyment during meals. Several residents reported repeatedly requesting bacon and being told it was unavailable, while staff corroborated that complaints about the lack of bacon and breakfast meats were frequent. The facility's grievance log and resident council meeting minutes documented ongoing concerns about the absence of bacon and breakfast meats, indicating that the issue was persistent and widely recognized among residents and staff. The dietary manager and registered dietitian confirmed that the decision to remove bacon was based on guidance from the food service provider, who cited nutritional concerns. Despite acknowledging that bacon could be enjoyed in moderation and posed no danger, the facility did not provide it as an option, even though it was previously available and listed on alternative menus. The administrator stated there was no facility policy addressing menu changes or resident preferences, and the current menu cycle did not include bacon or similar breakfast meats.
Failure to Prevent Accidents and Ensure Safe Catheter and Transfer Practices
Penalty
Summary
The facility failed to ensure resident safety and adequate supervision in three separate incidents involving residents with urinary catheters and fall risks. In the first case, a cognitively intact resident with a urinary catheter was injured when a CNA attempted to dress her by pulling the catheter system through her pants, causing a plastic clip attached to the catheter bag to lacerate her leg. The resident required emergency care and nine sutures to close the wound. The CNA later acknowledged that the catheter bag and tubing should have been managed differently to prevent contact with the resident's skin. In the second incident, a resident with a history of falls and confusion, also with a urinary catheter, was observed during therapy with her catheter drainage bag hanging from her wheelchair while she ambulated with a walker. As the resident walked, the catheter tubing was pulled taut, creating tension and pulling on her leg, as the drainage bag remained attached to the wheelchair behind her. The DON confirmed that the standard of care would be to use a leg bag or to hang the catheter bag from the walker to avoid tension on the tubing during ambulation. The third incident involved a resident with repeated falls, hearing and vision loss, and impaired mobility. During a shower, an agency CNA, who had been told the resident was independent, left her in a wheelchair while retrieving a shower chair. The resident attempted to stand on her own, lost her balance, and was lowered to the floor by the CNA. The CNA was unsure if the resident could hear or see her instructions. The DON stated that staff should verify a resident's transfer status and assistance needs using the care plan or information posted in the resident's room.
Staff Cell Phone Use During Care Undermines Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, as evidenced by staff using personal cell phones while providing care and during resident interactions. Three residents reported that CNAs were on their cell phones during showers, with one resident stating the aide was on her phone and using earphones throughout the shower, making the resident feel unimportant and not attended to. Another resident described a similar experience, where the CNA answered a phone call and engaged in conversation during the shower, leading the resident to feel that her care was less important than the staff member's personal call. A third resident observed staff frequently using their phones in hallways and the dining room, expressing concern about staff availability if assistance was needed. Review of the facility's Resident Council Meeting minutes from April to June indicated ongoing resident concerns about staff cell phone use during work hours. The Director of Nursing confirmed that staff are not permitted to use personal phones while at work, especially during resident care, and acknowledged that this has been an ongoing issue. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of treating residents with respect and focusing attention on them during care, which was not adhered to in these instances.
Failure to Provide Required Showers for Dependent Resident
Penalty
Summary
A resident who required staff assistance and supervision for showering or bathing, as indicated in their care plan, did not consistently receive the required showers. Interview and record review revealed that the resident reported sometimes receiving only one shower per week or none at all, despite being supposed to receive at least two showers weekly. Shower records from 5/1/25 to 7/21/25 showed a gap of 13 days between showers, with the resident receiving a shower on 6/27/25 and not again until 7/11/25. The DON confirmed that staff are expected to offer or provide showers or baths twice a week, but also stated that the facility did not have a policy specifying the frequency of showers or baths.
Failure to Arrange Ophthalmology Appointment for Visually Impaired Resident
Penalty
Summary
A resident with a history of visual impairment, who required eyeglasses, had a physician order for an ophthalmology consult and treatment as indicated. The resident reported that his vision had worsened recently, even while wearing his glasses, and stated that he had not been seen by an ophthalmologist or had his vision tested in over a year. The resident recalled having an appointment scheduled with an eye doctor, but it was canceled, and he was unaware of the reason for the cancellation. Record review showed that the ophthalmology appointment was canceled because the provider did not accept the resident's insurance, and no subsequent appointment was scheduled from the time of cancellation through the review period. The DON confirmed awareness of the canceled appointment and acknowledged that a new appointment had not been arranged. Facility policy required social services to coordinate and arrange for physician-ordered services in a timely manner, but this was not followed in the resident's case.
Failure to Follow Physician's Wound Care Orders for Surgical Incision
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician's orders for a resident who was admitted with multiple complex medical conditions, including recent cardiac surgery. The resident's hospital discharge instructions specifically ordered daily cleansing of a surgical incision with soap and water, monitoring for signs of infection, and avoiding lotions or ointments on the site. However, upon review of the resident's electronic Treatment Administration Record (eTAR) and medical record, there was no evidence that an order to wash the incision daily was entered or carried out during the resident's stay. The only documented intervention was monitoring the incision site, with no record of actual cleansing as directed by the physician's order. Interviews with facility staff revealed that the wound care nurse overlooked the order to wash the incision daily and did not ensure the order was entered or followed. The Director of Nursing was unaware of the wound care order and stated that such orders are typically managed by the wound care nurse, who coordinates with the facility's wound care physician or nurse practitioner. The facility's policy requires that treatment orders specify the treatment, frequency, and duration, and that a current list of orders be maintained in each resident's clinical record. This process was not followed, resulting in the omission of the required wound care for the resident.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications as ordered by the physician for one resident. The resident, who had multiple diagnoses including fibromyalgia, heart disease, hypothyroidism, and major depressive disorder, had a physician's order for levothyroxine to be given at 7:00 AM and acetaminophen 500 mg, one tablet by mouth four times daily. During a morning medication pass, an LPN administered the levothyroxine later than the prescribed time and gave two tablets of acetaminophen instead of the ordered one tablet. The resident later stated that she needs to take her levothyroxine at 7:00 AM because she has to wait to eat. The facility's policy requires staff to follow prescribed medication times until reviewed by the facility pharmacist and discussed with the resident or responsible party.
Failure to Provide and Document Ordered Wound Care and Weekly Skin Checks
Penalty
Summary
The facility failed to provide wound and skin treatments as ordered and did not consistently perform or document weekly skin checks for multiple residents. Four out of five residents reviewed for improper nursing care were affected. For example, one resident with skin infections, morbid obesity, and congestive heart failure reported receiving leg wound care only one to two times per week, despite orders for more frequent treatments. Treatment Administration Records (TARs) for this resident showed missed documentation of both wound care and weekly skin checks on several ordered dates. Another resident with non-pressure wounds to the right upper buttock and left lower leg stated that wound care was only provided once a week during physician rounds, even though daily and three-times-weekly treatments were ordered. Documentation for this resident also showed missed skin checks and wound treatments on multiple dates. Additional residents had orders for protective skin preparations to be applied to their heels twice daily, but the TARs indicated numerous missed or undocumented applications and weekly skin checks. Staff interviews confirmed that the purpose of weekly skin checks is to identify skin concerns early and that wound care is essential for healing and infection prevention. The facility's own policy required weekly general skin checks with documentation in the medical record, but records showed this was not consistently done. The findings demonstrate a pattern of missed or undocumented wound care and skin checks, contrary to physician orders and facility policy.
Failure to Report Missing Controlled Substance
Penalty
Summary
The facility failed to identify and report the diversion of a resident's controlled substance, specifically lorazepam. According to the medication administration record and controlled drug count sheet, a discrepancy of 4.0 ml of lorazepam was noted during a routine count, with two nurses signing off on the correction. Despite this discrepancy, there was no documentation or evidence that the missing medication was reported to facility administration or to the appropriate authorities. Interviews with nursing staff revealed that one nurse believed the other would report the issue, but neither confirmed that a report was made. The Assistant Director of Nursing confirmed that the missing lorazepam had not been reported, and the new Administrator, who also serves as the abuse coordinator, stated she was not made aware of the incident. The facility's policy requires prompt reporting of any suspected abuse, neglect, or misappropriation of resident property, including controlled substance discrepancies, to local, state, and federal agencies. The failure to report the missing lorazepam as required by policy and regulation resulted in a deficiency related to the timely reporting of suspected theft or diversion of a resident's medication.
Failure to Document and Provide Ordered Pressure Ulcer Care
Penalty
Summary
The facility failed to provide and document ordered wound care treatments for a resident with a stage four pressure injury located above the buttocks. Review of the resident's Treatment Administration Records (TAR) for April and May showed that several evening wound care treatments were not documented as completed, specifically on 4/29, 4/30, and 5/10. The wound care nurse confirmed that if wound care is not documented, it is considered not done, and any refusals or absences should be noted in the TAR. The facility's policy requires that the date and time of dressing changes be recorded in the resident's medical record or treatment sheet. At the time of observation, the wound appeared as previously described, with a red wound bed and no active drainage.
Failure to Maintain Accurate Controlled Substance Records and Procedures
Penalty
Summary
The facility failed to maintain accurate records and procedures for controlled substances, specifically lorazepam and morphine, for one resident. The medication administration record showed that lorazepam was to be administered as needed, and the controlled drug count sheet indicated a discrepancy of 4 ml, with the count being corrected from 28.0 ml to 24.0 ml by two nurses. One nurse stated she noticed the discrepancy during the shift count and signed off on the correction, believing the other nurse would report it, but was unaware of what happened to the missing medication. The Assistant Director of Nursing confirmed that the nurse should not have signed off on the count and should have notified a nurse manager, and was not aware of the discrepancy until it was brought to her attention during the survey. Additionally, the physical bottle of lorazepam had unclear graduation marks, making it difficult for staff to accurately measure the remaining medication. For the same resident, the morphine count sheet showed a dose was documented as given without a date, time, amount left, or nurse signature. The nurse on duty stated she had not dispensed any morphine and that discrepancies should be reported to administration. The Assistant Director of Nursing was not aware of the incomplete documentation and stated it should have been identified and addressed at shift change. The facility's policy required controlled substances to be counted at each shift change, with discrepancies reported to the Director of Nursing or designee, and for the outgoing nurse to remain until the issue was resolved.
Failure to Safely Reposition Resident Leads to Injury
Penalty
Summary
The facility failed to safely reposition a resident in bed, leading to the resident experiencing multiple fractures and requiring hospitalization. The resident, who was admitted with diagnoses including fibromyalgia, morbid obesity, spinal stenosis, cervical spine fusion, major depressive disorder, repeated falls, and pain, required substantial assistance for bed mobility. Despite this, a CNA attempted to reposition the resident alone on a low air loss mattress, contrary to the facility's policy requiring two staff members for such tasks. This resulted in the resident falling off the bed and sustaining significant injuries, including a humerus shaft fracture, a laceration on the leg, and a pubic ramus fracture. Interviews revealed that the CNA was unaware of the policy requiring two staff members for repositioning residents on low air loss mattresses. The Assistant Director of Nursing confirmed that the incident could have been prevented if the policy had been followed. The resident expressed that the CNA was in a hurry and that the accident was unnecessary, indicating that the CNA's actions were not in line with the required care plan. The incident highlights a lapse in adherence to safety protocols, which directly contributed to the resident's injuries.
Failure to Maintain Patency of Central Venous Catheter
Penalty
Summary
The facility failed to provide physician-ordered interventions to maintain the patency of a Central Venous Catheter (CVC) for a resident, resulting in the occlusion and subsequent need for replacement of the catheter. The resident, who is cognitively intact, reported that the catheter was not being flushed as required, leading to repeated clogging. Observations revealed that the catheter had dark red blood in the tubing, and the resident confirmed that the line had not been flushed on the day of observation. Interviews with nursing staff indicated a lack of consistent practice in flushing the CVC, with some staff members not performing the procedure and others documenting flushes that were not actually conducted. The Medication Administration Records for November and December showed multiple instances where the prescribed Normal Saline flushes and Heparin locks were not administered as ordered. A narrative from a medical doctor confirmed that the catheter was filled with clots, indicating improper flushing and locking practices. The Director of Nurses acknowledged the absence of specific training for CVC flushing, relying instead on a computer program for instruction. This lack of training and adherence to protocol contributed to the catheter's occlusion and the need for its replacement.
Failure to Ensure Proper Texture of Pureed Diets
Penalty
Summary
The facility failed to ensure that pureed Swiss steak was prepared to a smooth, uniform texture as required for residents on a pureed diet. During an observation, the cook, identified as V11, was seen pureeing Swiss steak for lunch but did not achieve the desired consistency similar to mashed potatoes. The pureed Swiss steak appeared slightly chunky, and V11 did not perform a taste test to verify the texture. A test tray provided by the facility revealed that the pureed Swiss steak was gritty with small granules, necessitating chewing before swallowing. The Dietary Manager, V6, confirmed the gritty texture and noted that staff should taste test the product every time before completing the puree. The facility's policy on Modified Texture Foods states that foods requiring modification to a puree texture should have a smooth texture.
Improper Sanitation Practices in Pureed Diet Preparation
Penalty
Summary
The facility failed to ensure proper sanitation practices were followed in the preparation of pureed diets for four residents. During an observation, a cook was seen using a spatula and food processor components without adequately washing, rinsing, and sanitizing them between uses. The cook used the same spatula to transfer different food items, such as Swiss steak, mashed potatoes, and broccoli, without proper cleaning, which could lead to cross-contamination. The Dietary Manager confirmed that the cook should have used either new containers with lids and blades for each food item or should have washed, rinsed, and sanitized each component before reuse. The facility's policy on cleaning food and nonfood contact surfaces requires that kitchenware and food-contact surfaces be washed, rinsed, and sanitized after each use to prevent cross-contamination. This policy was not adhered to during the preparation of pureed diets for the residents.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat a resident, identified as R9, in a dignified manner, as observed during a survey. R9, who was admitted with diagnoses including Parkinson's disease, chronic obstructive pulmonary disease, and generalized anxiety disorder, was noted to have emotional and spiritual distress due to hopelessness and lack of family support. The care plan for R9 emphasized the need for staff to approach her warmly, positively, and calmly, offering reassurance before initiating care. However, on December 9, 2024, R9 was observed moaning and asking to go to bed, with her moans audible across the hall. When two CNAs, V8 and V9, entered her room, V8 told R9 to stop moaning, stating, "Nobody wants to hear that," while V9 loudly informed R9 that they were going to replace her incontinence brief, causing R9 to wince. The Director of Nursing (DON), identified as V2, confirmed that R9 was not hard of hearing and could hear without someone speaking close to her ear. V2 acknowledged that the responses from V8 and V9 were inappropriate and not in line with the facility's policy on dignity, which requires staff to speak respectfully to residents at all times. The facility's Quality of Life-Dignity policy, revised in December 2021, mandates that each resident be cared for in a manner that promotes dignity, respect, and individuality, and that staff should address residents by their name of choice rather than by room number, diagnosis, or care needs.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to safely transfer a resident by not using a gait belt during a transfer, as required by the resident's care plan. The care plan specified that a gait belt should be used for all transfers with the assistance of one person. On December 9, 2024, a Certified Nursing Assistant (CNA) assisted the resident from a wheelchair to a bed without applying a gait belt, instead lifting the resident under the arm and guiding their hips with her hands. This action was contrary to the facility's policy and the resident's care plan, which both mandated the use of a gait belt for safety during transfers. Interviews with another CNA and the Director of Nursing confirmed that the use of a gait belt is necessary for the resident's safety during transfers.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility failed to administer medications as ordered, resulting in a medication error rate of 10.81%, which is above the acceptable threshold of 5%. This deficiency was observed in one of the three residents during a medication pass. Specifically, a Licensed Practical Nurse (LPN) did not administer Diltiazem to a resident with hypertension, despite the absence of hold parameters in the order. The LPN decided to withhold the medication due to the resident's pulse being less than 70, but failed to notify the physician about this decision. Additionally, the LPN administered Timolol Maleate eye drops incorrectly by applying them to both eyes instead of just the left eye as ordered. The LPN also administered Milk of Magnesia on a day it was not due and gave a double dose. Furthermore, the LPN did not administer Vitamin D3 as ordered. The Director of Nursing confirmed that all medications should be given as ordered and that any deviations should be communicated to the physician for approval.
Significant Medication Error Due to Incorrect Insulin Transcription
Penalty
Summary
The facility failed to ensure that a resident received the correct insulin medications as prescribed by their endocrinologist, resulting in a significant medication error. The resident, who has Type 1 diabetes mellitus with polyneuropathy, reported that the facility did not accurately transcribe her insulin orders following an endocrinology appointment. The After Visit Summary from the endocrinologist specified changes to the resident's insulin regimen, including adjustments to the doses of Basaglar (long-acting insulin) and Novolog (short-acting insulin). However, the facility's September Medication Administration Record (MAR) showed that incorrect insulin types and dosages were ordered and administered to the resident until the error was identified and corrected at the end of the month. The Director of Nursing acknowledged that the nurses should have followed the medication orders on the After Visit Summary when transcribing new orders. It was noted that Novolog and Novolin N are different types of insulin and are not interchangeable, highlighting the importance of accurate transcription and understanding of medication types. The Licensed Practical Nurse responsible for medication audits discovered the error during her end-of-month review, which led to the correction of the resident's insulin orders. This incident underscores the critical need for precise medication management and adherence to prescribed treatment plans in the facility.
Resident Fall Due to Improper Transfer Procedure
Penalty
Summary
The facility failed to safely transfer a resident, resulting in a fall and head injury. The incident involved a resident who was being assisted by a CNA to transfer from a bed to a wheelchair. The resident, who had a history of chronic kidney disease, morbid obesity, anxiety, insomnia, persistent atrial fibrillation, congestive heart failure, chronic obstructive pulmonary disease, generalized weakness, and gait abnormalities, required partial to moderate assistance for transfers. Despite the care plan indicating the use of a gait belt and walker, the CNA did not maintain a hold on the gait belt during the transfer, leading to the resident losing balance and falling. The resident fell forward and hit her head on an oxygen concentrator, resulting in a laceration that required emergency medical attention, including 6 staples and 2 sutures. The CNA admitted to not having a hold on the gait belt at the time of the fall, which is against the facility's procedures that require staff to maintain contact with the gait belt to assist residents safely. The incident report inaccurately documented that a gait belt was used during the transfer, although the CNA's account and the resident's statement indicated otherwise. Interviews with facility staff, including a nurse, occupational therapist, nurse practitioner, and the Director of Nursing, confirmed the expectation that gait belts should be used and held during transfers to prevent falls and reduce injury risk. The facility's procedures emphasize the importance of using gait belts to ensure resident safety during transfers, highlighting a failure in adherence to these protocols in this incident.
Deficiency in Dementia Care Leads to Resident Agitation
Penalty
Summary
The facility failed to provide appropriate care to a resident with dementia, leading to escalating agitation. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was involved in an incident where four staff members attempted to assist him in the bathroom. The resident's family expressed concerns about the number of staff involved and the manner in which care was provided, noting that the resident became overwhelmed and agitated due to the loud and multiple instructions given by the staff. The resident was found with bruises and a bump on his head the following day, which the family believed were related to the incident. On another occasion, video footage showed two CNAs providing incontinence care to the resident, who was visibly agitated and in pain. The CNAs continued to provide care despite the resident's resistance and complaints of pain, without giving him time to calm down. The resident's care plan indicated that he required a calm approach and time to process instructions, but these guidelines were not followed during the care provided. The facility's staff did not document the incidents in the resident's progress notes, and there was no dementia care policy in place. The resident's psychiatric provider noted that he had been experiencing agitation and aggression since moving to the facility, with attempts at redirection often escalating his agitation. The facility's Director of Nursing and Administrator acknowledged that the presence of multiple staff members during care was overwhelming for the resident and that additional dementia care training was needed. Despite the facility's efforts to provide dementia care in-services, the incidents highlighted a deficiency in the care provided to the resident with dementia.
Resident Injury Due to Unsafe Transfer
Penalty
Summary
The facility failed to ensure a safe transfer for a resident, resulting in a fractured femur. During a transfer from bed to chair, the resident's knees buckled, and the CNA lowered her to the floor. The CNA did not use a gait belt and was unfamiliar with the resident's transfer needs, assuming she required only one-person assistance. The resident was lowered to the floor and later assessed by an RN, who noted the resident's ability to move her legs, albeit weakly, and reported some pain in the right leg. Despite these observations, the resident was placed in a chair without further immediate intervention. The resident was later diagnosed with a periprosthetic fracture of the distal femur at a local hospital. The radiologist noted that the fracture pattern suggested a twisting motion and some energy involved, which typically results from a fall rather than causing one. The resident had a history of osteopenia, which may have contributed to the injury. The RN on the following shift noted the resident's discomfort and limited knee movement, indicating a potential injury. The resident's condition deteriorated, and she eventually expired under hospice care in the facility.
Failure to Assess and Document Skin Damage
Penalty
Summary
The facility failed to properly assess, treat, and document skin damage for a resident, identified as R1, who was part of a sample reviewed for skin alterations. On July 31, 2024, during a perineal care session, certified nursing assistants (CNAs) V4 and V5 discovered foam patches on R1's coccyx, left anterior thigh, and outer left knee, which were swollen with urine. R1 was unaware of the patches and expressed a preference to be changed only once per shift, which contributed to her brief and liner being saturated with urine. The CNAs did not remove the patches, as they were unsure of what was underneath and did not want to expose R1's skin. The registered nurse (RN) responsible for wound care, V6, was also unaware of the patches and noted that R1 had returned from the hospital recently, with her skin previously in good condition. Upon further assessment, V6 found no open areas under the patch on R1's buttocks but identified a dried fluid blister under the patch on her left knee and moisture-associated skin damage (MASD) on her right inner thigh. The facility's records, including R1's electronic medical record and admission skin assessment sheet, did not document any open areas on R1's inner thigh or left knee at the time of her readmission from the hospital. The facility's policy on skin identification and monitoring requires licensed nursing staff to evaluate skin integrity upon admission and when significant changes occur, but this was not adequately followed, leading to the deficiency.
Failure to Follow Resident's Medication Choice
Penalty
Summary
The facility failed to ensure a resident's medication choice was followed, specifically for melatonin administration. The resident's family had requested that the scheduled melatonin dose be discontinued and only given as needed upon family request. Despite this, the resident continued to receive the scheduled dose. The Director of Nursing (DON) was unaware of who printed or reviewed the medication orders with the family, and the Nurse Practitioner (NP) was not informed of the family's request. The resident's Medication Administration Record (MAR) showed that the resident received melatonin on multiple occasions, contrary to the family's instructions. The resident's Power of Attorney (POA) confirmed that they had communicated the request to discontinue the scheduled melatonin to the nurse on duty, who assured them that the doctor would be informed and the orders would be changed. However, this change was not implemented, and the resident continued to receive the medication, leading to increased sleepiness and decreased eating and drinking. The facility's Resident Rights Policy states that residents are entitled to exercise their personal and legal rights, which was not upheld in this case.
Failure to Treat Residents with Dignity
Penalty
Summary
The facility failed to treat residents in a dignified manner during care, as evidenced by the experiences of three residents (R1, R2, and R3). R1, who has vascular dementia, anxiety, depression, type 2 diabetes mellitus, and difficulty walking, reported that CNA V9 threw her shoes under her bed where she could not reach them. This incident was corroborated by another CNA, V6, who found the shoes under the bed and reported the incident to the administrator, V1. R2, who has anxiety disorder, depression, chronic pain, and weakness, and is assessed as a moderate fall risk, reported that V9 was rude and unhelpful when she requested assistance to use the bathroom. R2 stated that V9 initially refused to help her and only assisted after she insisted on her need for help due to her fall risk. R3, who has arthritis, cellulitis of the lower extremities, and muscle weakness, reported that V9 frequently used inappropriate language, including swearing, while at work, which she found undignified and unprofessional. The facility's dignity policy and procedure, revised in April 2024, emphasizes that each resident should be cared for in a manner that promotes dignity, respect, and individuality. The policy specifically states that associates should not handle or move a resident's personal belongings without permission. The care plans for R1 and R2 highlight their need for additional attention, reassurance, and assistance with activities of daily living due to their medical conditions. Despite these guidelines, the actions of CNA V9, as reported by the residents and corroborated by staff, indicate a failure to adhere to the facility's dignity policy, resulting in undignified treatment of the residents involved.
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What surveyors actually found near you
We read the 140 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Freeport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stephenson Nursing Center | 1.9 mi | ★★★★★ | 9 | 0 |
| Pearl Pointe Nursing Rehab & Care | 3.3 mi | ★★★★★ | 29 | 0 |
| Manor Court Of Freeport | 5.4 mi | ★★★★★ | 31 | 0 |
| Serenity Estates Of Lena | 12.8 mi | ★★★★★ | 3 | 0 |
| Medina Nursing Center | 17.6 mi | ★★★★★ | 23 | 0 |
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.