Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Haven Of Paris during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, described as frail and small-framed, was standing at a bathroom sink brushing teeth when the sink detached from the wall and struck the resident’s right forearm. The resident reported that maintenance had worked on the sink about a week earlier and denied touching the sink when it fell. Nursing documentation and CNA observations described a large, discolored, swollen area from wrist to elbow, with pain on movement of the fingers and wrist. An RN later observed the sink dangling from the wall supported only by plumbing, and an MD and ER documentation confirmed a traumatic hematoma involving most of the forearm.
A resident with moderate cognitive impairment sustained a traumatic hematoma to most of her forearm when a bathroom sink detached from the wall and struck her arm while she was brushing her teeth. Nursing documentation and staff interviews described a large, discolored, swollen area from wrist to elbow, associated pain, and EMS transport to an ER for evaluation and treatment. The attending MD confirmed the resident experienced pain and harm from the incident. Despite these findings and the documented traumatic hematoma, the Administrator did not report the alleged accident and injury to the state agency, instead only initiating an internal soft file.
The facility failed to protect resident privacy and personal space when a wandering resident repeatedly entered other residents’ rooms and used their belongings. One cognitively impaired resident with Alzheimer’s disease and vascular dementia became distressed when the wandering resident sat in his recliner and he reported feeling he had no privacy, a concern echoed by his spouse. Another resident with dementia, psychotic and mood disturbances, and anxiety reported that the same wandering resident frequently came into her room, leading her to keep her door closed and post a stop sign to protect her belongings. RNs confirmed that the wandering resident often entered multiple rooms and picked up items, and the administrator acknowledged that staff were struggling to provide adequate supervision to prevent these intrusions.
A cognitively impaired resident with depression, anxiety, insomnia, and documented wandering and exit-seeking behaviors was not adequately supervised, despite a care plan noting risks for elopement, intrusion into others’ rooms, and rummaging through belongings. Nurses’ notes and multiple interviews with residents, a family member, CNAs, an activity aide, and RNs described the resident frequently wandering hallways, entering other residents’ rooms uninvited, sitting or lying on their beds and chairs, and upsetting them. One resident reported having to keep her door closed and post a stop sign to protect her privacy and possessions, while a family member stated staff were not doing enough to prevent these intrusions. The administrator acknowledged the difficulty staff had in supervising this resident while also caring for other residents.
Two residents with pressure ulcers and impaired skin integrity did not receive properly documented wound and skin assessments as ordered and as required by facility policy. One resident had multiple pressure ulcers and orders for weekly nurse assessments, daily skin checks, and daily foot checks, yet the TAR showed missing entries on several days, open areas and edema were recorded without corresponding progress notes or physician notification, and internal skin observation tools lacked wound measurements or detailed descriptions. Another resident had physician orders for wound care, daily foot exams, weekly skin checks, and coccyx prevention, with a physician wound note documenting specific wound size and exudate, but the EMR contained no nursing skin assessments despite an observed dressing change showing the wound closed. The DON reported that nurses were not documenting wounds as they should and that staff relied on uploading external wound clinic notes instead of completing individualized nursing documentation, contrary to the facility’s pressure/skin breakdown protocol.
A resident with dementia and a high risk for falls was not adequately supervised and was placed in a dark bedroom despite ongoing restlessness. Staff did not maintain frequent safety checks or ensure sufficient lighting, contrary to the care plan and facility policy. The resident was later found on the floor with serious injuries after an unwitnessed fall, which ultimately led to death.
A resident with constipation and stomach pain repeatedly requested to be sent to the emergency room, but experienced a significant delay after informing a CNA and later an LPN, who stated a physician's order was needed. The transfer did not occur until several hours after the initial request, despite facility policy and the medical director's statement that such requests should be promptly honored.
A resident with a history of constipation and neurological impairment did not have bowel movements consistently monitored or documented, despite physician orders and complaints of abdominal pain. Nursing staff failed to assess or notify the physician after several days without a bowel movement, contrary to facility policy and expectations.
A resident with dementia and behavioral issues repeatedly entered other residents' rooms, took assistive devices, and made inappropriate comments due to inadequate supervision and inconsistent implementation of safety interventions. This led to multiple falls and injuries, including lacerations and a hematoma, as well as significant distress among several residents who reported feeling unsafe and disturbed by the ongoing incidents.
Two residents were involved in an incident where one, with a history of dementia and aggressive behavior, physically grabbed and struck another while waiting to go outside. Despite known behavioral risks and prior interventions like increased supervision, the facility did not consistently implement all care plan measures, leading to repeated aggressive incidents and failure to protect residents from abuse.
A resident with Lewy Body Dementia and a history of severe cognitive impairment, wandering, and previous falls was not adequately supervised according to facility policy, which required frequent checks for high-risk individuals. Staff failed to perform and document the necessary 15-minute checks, resulting in the resident falling and sustaining a left hip fracture.
A resident with severe cognitive impairment and multiple comorbidities experienced a fall and subsequently reported ongoing severe right hip pain. Initial ED evaluation did not include hip imaging, and later X-rays were improperly positioned. Despite persistent pain and increased use of narcotic analgesics, further diagnostic imaging was not pursued until the family requested an MRI nearly two weeks later. The MRI was scheduled with significant delay and, when completed, revealed an acute hip fracture. There was also a delay in obtaining and acting on the MRI results, resulting in continued pain and delayed surgical intervention.
Two residents with dementia and high fall risk suffered serious injuries after one accessed an unsecured bathroom and fell, and another fell from a shower chair with malfunctioning wheels. The facility failed to maintain a safe environment and did not ensure equipment was in safe, operable condition, leading to a traumatic fall with head and chest injuries for one resident and a hip fracture requiring surgery for another.
A resident who suffered a fall and required an MRI for a hip fracture did not have proper documentation of their departure and return for the procedure. Additionally, there were discrepancies between the narcotic count sheet and the MAR regarding Tramadol administration, and pain assessments were not fully documented as ordered. The DON confirmed these lapses in record-keeping after reviewing the records.
Survey Results Book Not Properly Posted or Identified: A facility failed to accurately post the location of the survey inspection results book and failed to identify the book itself. Three residents said they did not know where the book was located, and observation found the posted location did not match the actual placement of the notebook, which was unlabeled and stored in a cabinet in the resident and family lounge.
Unsafe food handling, storage, and sanitation practices: A resident with moderate cognitive impairment was observed eating meals from trays that had been left out for extended periods, including high-protein, high-water-activity foods and milk-based supplements. Staff stated the resident takes a long time to eat and does not want to give up his tray. Surveyors also observed a foam cup being used as a scoop in bulk sugar and soiled kitchen, pantry, and dish room floors with debris and food buildup.
A facility failed to protect the dignity of two residents with indwelling urinary catheters by leaving their urine collection bags uncovered and visible in rooms, hallways, and even outdoors. Both residents had severe cognitive impairment, used wheelchairs, and had orders requiring their catheter bags to always have a cover in place, but surveyors repeatedly observed transparent bags partially filled with urine without privacy covers.
Respiratory equipment was not maintained in a clean, sanitary, and ordered condition for two residents. One resident with COPD had no oxygen order or respiratory care plan interventions for oxygen monitoring, and staff used a visibly soiled nebulizer mask with undated tubing, an empty humidifier bottle, and undated nasal cannula/tubing. Another resident receiving oxygen had a totally dry humidifier bottle and undated tubing, despite an order for weekly changes.
Medication administration errors exceeded the allowed rate after staff failed to follow pharmacy directions for ordered meds. An LPN gave iron and cefdinir together despite an order to separate iron/antacids by 2 hours, did not ensure a resident rinsed after Trelegy Ellipta, and an RN could not find ordered Florastor for another resident during the med pass.
A facility failed to store a resident’s refrigerated controlled substance in a locked compartment and failed to ensure two residents’ opened Lantus insulin pens were properly labeled with pharmacy information, directions, and open dates. An LPN found the controlled medication in an unlocked refrigerator door and the insulin pens in the med cart with only handwritten last names, while the facility’s policies required locked storage for refrigerated controlled substances and proper labeling before storage.
Failure to use enhanced barrier precautions for two residents with indwelling urinary catheters. Both residents had severe cognitive impairment, were wheelchair-bound, and had orders and care plans for EBP due to chronic catheter use. Observations found no EBP signage, no PPE, and no ABHR at or near the rooms, and an LPN stated one resident should be on EBP when asked.
A resident receiving IV ertapenem for an ESBL wound infection had an order for Florastor 250 mg BID for prophylaxis, but the facility did not have the house-stock probiotic available. The RN checked the cart, med room, and stock room and found no Florastor 250 mg capsule to give, and the ADON stated the correct dose could not be purchased, so it was not administered as scheduled.
The facility did not have a full-time DON or an Acting DON to oversee and coordinate nursing services, as confirmed by the Administrator. This deficiency affected oversight for all 83 residents in the facility.
The facility did not consistently notify family representatives or POAs about physical abuse allegations involving multiple residents. Although records indicated notifications were made, interviews revealed that POAs were either not contacted or not fully informed about the incidents, with some only learning of the events from the residents themselves. This failure to provide timely and accurate information was contrary to the facility's abuse prevention policy.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not notify the Ombudsman of multiple abuse allegations, despite documentation stating otherwise. Investigation reports for several incidents of physical abuse between residents and one involving a nursing staff member indicated that the Ombudsman was informed, but the Ombudsman confirmed he received no such notifications, contrary to facility policy.
The facility did not properly notify the local police department or the physician about multiple incidents of alleged abuse and injuries involving several residents, despite documentation stating otherwise. Interviews and record reviews confirmed that neither the police nor the physician were aware of these events, and the administrator could not provide proof of notification as required by facility policy.
The facility did not interview families or other residents who may have had knowledge of several alleged abuse incidents, including resident-to-resident physical altercations and a report of rough handling by staff. Despite the facility's policy requiring such interviews, investigations were deemed complete without this step.
The facility did not timely review or revise care plans for several residents after multiple incidents of resident-to-resident physical abuse. Despite documentation in investigation reports that care plans were reviewed, the actual care plans lacked timely updates or new interventions addressing the abuse events, as confirmed by record review and staff interviews.
A resident's medical records contained repeated documentation errors, with the Medical Director inaccurately recording bruising on multiple assessment dates when no such bruising was present. This resulted in incomplete and inaccurate records for the resident.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to compliance with care planning requirements.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with severe cognitive impairment and multiple medical conditions was found with a large, dark abdominal bruise. Although the injury was promptly reported internally by a CNA to an LPN and then to the DON and administrator, the required report to the State Agency was delayed by several days, contrary to facility policy for reporting Injuries of Unknown Origin.
A resident with severe cognitive impairment and multiple medical conditions developed a large, unexplained abdominal bruise. Staff observed and reported the injury, but the DON did not conduct a thorough investigation, failing to review key records such as skin assessments, shower sheets, and insulin administration sites, and did not rule out abuse as a possible cause.
A resident with a history of falls and multiple medical conditions was left unattended during a shower, and the shower chair's wheels were not locked, causing the chair to move on a sloped, wet floor. The resident fell and sustained pain and bruising. Staff and resident interviews confirmed that the shower chair was unstable and that not all CNAs consistently locked the wheels or provided direct assistance during transfers.
A resident assessed as high risk for falls experienced a fall in the shower room, but the incident was not documented in the medical record and the care plan was not updated until months later. Required follow-up assessments and documentation were not completed by nursing staff, contrary to facility policy.
A resident with multiple chronic conditions and a history of skin ulcers developed signs of infection in a toe wound, including redness, swelling, and pain. Although an LPN reported the changes to the wound nurse, the physician was not notified as required by policy and physician orders. This led to a four-day delay in treatment, with antibiotics only started after the resident was seen at a scheduled wound clinic visit, at which time cellulitis was diagnosed.
A resident with multiple chronic conditions and a history of skin ulcers developed new signs of infection in a toe wound, which were observed by an LPN and reported to the wound nurse. The wound nurse did not notify the physician as required, resulting in a delay in treatment until the resident's next wound clinic visit, when an antibiotic was finally ordered.
A resident with multiple chronic conditions continued to receive daily wound treatments for pressure wounds on the buttocks, but weekly wound assessments and measurements were not documented as required by facility policy. The wound nurse was not informed that the wound had reopened, resulting in a lack of weekly assessments for several weeks.
The facility did not follow its bedbug prevention policy when a bedbug was found in a resident room. Although staff observed and reported the pest, the pest control company was not notified and the room was not treated, as confirmed by the pest control representative and maintenance director. This failure affected all residents in the facility.
A mushy, sloping, and unstable floor with an unattached transition piece was found in a shower area used by multiple residents, creating fall and trip hazards. The Maintenance Director acknowledged the unsafe condition, and the DON confirmed the area is regularly used for resident care.
Two residents in the dementia unit were not protected from physical abuse, as one resident with a known history of aggression was involved in multiple altercations, including taking another resident's walker and shoving another resident. Staff confirmed the need for increased supervision and acknowledged understaffing in the unit.
A resident with dementia accessed unsecured Morphine left on a medication cart in a dementia care unit, leading to an overdose. The resident, known for wandering and drinking from unattended containers, was found with the Morphine bottle up to their lips. The incident occurred after an LPN left the medication unsupervised, resulting in the resident becoming unresponsive and requiring Narcan and hospital transport.
A resident with Diabetes Mellitus Type II did not receive their prescribed insulin for eight days due to the medication being unavailable, and the facility failed to notify the physician promptly. The resident's blood glucose levels were affected during this period. Facility policies require notifying the prescriber and documenting medication errors, which were not followed.
Two residents with Diabetes Mellitus Type II were not provided with their physician-ordered diets. One resident was admitted with instructions for a Diabetic diet but received a regular diet due to a transcription error. Another resident was served a regular diet instead of a Consistent Carbohydrate diet, despite the correct order being in the EMR. These errors were acknowledged by facility staff and could have led to adverse health outcomes.
A facility failed to report a resident's change of condition to a nurse before conducting a COVID-19 test and did not ensure qualified staff performed the test. A CNA tested a resident for COVID-19 without notifying the nurse of the resident's condition change, which is against the facility's policy. The resident's temperature increased significantly, and the incident was confirmed by an LPN and the interim DON.
A facility failed to protect a resident's right to unrestricted access without clinical justification, leading to fear and threats of seclusion. Another resident, requiring supervision for smoking due to severe cognitive impairment, was not consistently assisted to smoke breaks, contrary to facility policy. These actions violated resident rights and demonstrated a lack of dignity and respect.
A resident was subjected to mental abuse by the facility's Administrator, who raised her voice and threatened the resident with a move back to the Dementia unit. The incident, witnessed by several staff members, left the resident feeling humiliated and fearful, leading to a withdrawal from activities. The facility's policy on abuse was not followed, and the Medical Director emphasized the seriousness of verbal and mental abuse.
A resident with severe cognitive impairment was left exposed during incontinence care when a CNA failed to close the bathroom or room door and did not use the privacy curtain. Another resident and a CNA observed the incident, and the CNA did not change gloves throughout the procedure. The Director of Nursing confirmed that privacy should have been provided.
The facility failed to respect the rights of two residents to refuse electronic monitoring devices. Both residents, who were cognitively intact and their own responsible parties, expressed a desire to have the devices removed, citing feelings of imprisonment and mistreatment. Despite their requests, the devices were not initially removed, and there was no documentation of consent or assessment for their use. The devices were eventually removed after the residents' complaints were acknowledged by the facility's Regional Clinical Nurse.
Sink Detachment Causes Traumatic Forearm Hematoma
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment free from accident hazards when a bathroom sink detached from the wall and struck a resident’s right forearm. The facility’s Safety and Supervision Guideline, revised 1/30/25, states a commitment to maintaining an environment as free from accident hazards as possible and identifies resident safety, supervision, and assistance to prevent accidents as facility-wide priorities. The resident, described as very thin, small-framed, and frail, with moderate cognitive impairment per the Minimum Data Set, reported that she was standing at the bathroom sink brushing her teeth when the sink suddenly fell off the wall and hit her right forearm. She stated she did not touch the sink at the time and that maintenance had worked on the sink about a week prior to the incident. Nursing documentation in the EHR recorded that the resident was washing her hands and brushing her teeth when the sink detached from the wall and struck her right forearm, resulting in a 12-inch hematoma, pain with movement of the fingers and wrist, and subsequent EMS transport to a local ER. A CNA reported that the resident and another CNA came out of the room stating the sink had fallen, and observed the resident’s right forearm as discolored and puffed up, with the resident complaining of pain; the CNA also relayed the resident’s statement that maintenance had worked on the sink approximately one week earlier. The RN who assessed the resident described the injury as unusual, with purplish discoloration from wrist to elbow and a raised area resembling a blood blister about one inch off the arm, and later observed the sink dangling from the wall supported only by plumbing. The attending MD confirmed familiarity with the incident, noted a large dark purple area from wrist to elbow on examination, and identified the injury as related to the sink fall, while the ER record documented a traumatic hematoma covering 70% of the right forearm.
Failure to Report Traumatic Sink-Related Injury to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report to the state agency an alleged accident with a traumatic injury involving one resident. The resident, who has moderate cognitive impairment and is described as very thin and of small stature, reported that while she was standing at the bathroom sink brushing her teeth, the sink suddenly detached from the wall and struck her right forearm. A nursing note in the EHR dated 4/1/26 documented that the resident was washing her hands and brushing her teeth when the bathroom sink detached and hit her right forearm, resulting in a 12-inch hematoma, pain with movement of her fingers and wrist, and subsequent EMS transport to a local emergency room for evaluation and treatment. The emergency room record documented that the resident sustained a traumatic hematoma covering 70% of her right forearm. Staff interviews corroborated the unusual nature and severity of the incident and injury. A CNA stated she was working when the sink detached from the wall and that she observed the resident’s right forearm as discolored and puffed up, with the resident complaining of pain. The RN who cared for the resident at the time described the injury as unusual, with purplish discoloration from wrist to elbow and a raised area resembling a blood blister about one inch off the arm, and confirmed the resident was sent to the emergency room immediately. The physician stated he was familiar with the incident, observed a large dark purple area from wrist to elbow, and confirmed the resident experienced pain and harm related to the incident. The Administrator acknowledged starting a soft file on the incident but stated she did not report it to the state agency because she believed the emergency room treatment was only basic first aid and no major injury was identified, despite documentation of a traumatic hematoma involving most of the resident’s forearm.
Failure to Protect Resident Privacy From Wandering Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect residents’ rights to privacy and a dignified existence by not adequately preventing one resident from repeatedly entering other residents’ rooms. One resident with Alzheimer’s disease and vascular dementia with behavioral disturbances, who was severely cognitively impaired and required assistance with transfers, reported that another resident frequently entered his room and used his recliner. A progress note documented an incident in which this resident yelled at the wandering resident to leave his room and expressed feeling that he had no privacy anymore. His wife stated that the wandering resident was constantly in his room, sitting on his bed or in his recliner, and also going into other residents’ rooms, and she felt staff were not doing enough to protect residents from these intrusions. A RN confirmed that the wandering resident was always going into this resident’s room and that the wife no longer wanted to visit because of these repeated intrusions. Another resident, diagnosed with cognitive communication deficit, dementia, psychotic disturbance, mood disturbance, and anxiety, and who was mildly cognitively impaired and independent with a walker, stated she was tired of the same wandering resident coming into her room. She reported having to place a stop sign on her door and keep it closed to protect her belongings and maintain privacy. Staff had attempted to remove her soaps and lotions to keep the wandering resident from accessing them, but later returned these items. Two RNs stated that the wandering resident frequently entered other residents’ rooms and picked things up as she went, and that the second resident, who had many personal items, became very upset when the wandering resident was in her room. The administrator acknowledged that staff were having difficulty providing adequate supervision for the wandering resident, who often entered other residents’ rooms, affecting their privacy and personal possessions.
Inadequate Supervision of Wandering Resident Intruding Into Others’ Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision for a cognitively impaired resident who frequently wanders and intrudes into other residents’ rooms. Facility policy states that each resident shall receive nursing care and supervision to attain and maintain the highest practicable well-being, based on assessments and care plans. The resident in question has diagnoses of major depressive disorder, generalized anxiety disorder, and insomnia, and is documented on the Minimum Data Set as severely cognitively impaired, independent with transfers, and requiring supervision with walking. The resident often wanders and has exhibited physical behavioral symptoms toward other residents, such as hitting, pushing, and grabbing. The care plan identifies the resident as at risk for elopement due to exit-seeking behavior, a history of elopement and wandering, and notes that the resident wanders into other residents’ rooms where they are not welcome, invades others’ space, rummages through belongings, and is physically vulnerable with dementia, confusion, poor judgment, and frequent wandering. Nurses’ notes document that the resident wandered into another resident’s room several times and that the other resident threatened to throw the wandering resident out if she entered again. Multiple interviews with staff and residents confirm that the resident is “constantly wandering” the halls and entering other residents’ rooms, sitting on their beds or in their recliners, and sometimes lying in other people’s beds. A resident’s spouse reported that the wandering resident repeatedly comes into her husband’s room and that staff are not doing enough to protect residents from these intrusions. Staff, including an activity aide, CNAs, and RNs, consistently stated that the resident wanders up and down the halls, goes into other residents’ rooms, upsets them, and picks up items as she moves through rooms. Another resident reported being tired of these intrusions and resorted to placing a stop sign on her door and keeping it closed to protect her belongings and privacy. The administrator acknowledged that it is difficult for staff to care for other residents while trying to provide adequate supervision for this wandering resident and that the facility needs to find a better way to supervise her.
Failure to Document Required Wound and Skin Assessments for Residents With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to complete and document required wound and skin assessments for two residents with pressure ulcers and impaired skin integrity. One resident had a care plan identifying high risk for pressure ulcers and multiple existing pressure ulcers on the sacrum, ischial areas, heels, ankle, gluteal folds, and foot, with instructions for weekly licensed nurse assessments and daily monitoring for infection and physician notification if wounds were not healing. Treatment Administration Records for this resident showed missing documentation for ordered daily foot checks and daily skin checks on multiple dates, and when edema and open areas were documented, there were no corresponding progress notes describing edema, open areas, treatment, or physician notification. Skin Observation Tools listed multiple pressure areas and other skin issues but lacked wound measurements or descriptive details. Wound clinic notes on two separate visits contained detailed measurements and descriptions, including staging, presence of fibrin, exposed bone, and tunneling, but these details were not mirrored by facility nursing documentation. During observed wound care, multiple wounds were measured and described, but the report does not show that such assessments were routinely documented by facility staff. The second resident had an undated care plan for impaired skin integrity and risk for injury related to dementia, with physician orders for wound care to the left lateral ankle, daily foot exams, weekly skin checks, and preventive measures for coccyx skin breakdown. A physician wound visit documented a left lateral ankle wound with specific measurements, moderate exudate, and erythema, but the electronic medical record contained no nursing skin assessments. An observed dressing change showed the wound was closed and the resident denied pain or issues at the site, yet there was still no documented nursing assessment in the record. The DON stated that staff do not write individualized wound documentation and instead only upload wound clinic notes, and acknowledged that nurses were not documenting on wounds as required. These practices were inconsistent with the facility’s Pressure/Skin Breakdown-Clinical Protocol, which requires nurses to assess and document a full skin assessment including location, stage, dimensions, exudate, necrotic tissue, signs of infection, and impact of comorbid conditions on wound healing.
Failure to Provide Adequate Supervision and Lighting Resulting in Resident Fall and Injury
Penalty
Summary
The facility failed to ensure sufficient lighting in a resident's bedroom and did not provide adequate supervision for a resident with dementia who was known to be restless and at high risk for falls. The resident had a documented history of falls, severe cognitive impairment, and behavioral disturbances, including agitation and restlessness. The care plan included interventions such as walking with the resident when restless and providing adequate lighting, but these were not consistently implemented. On the night of the incident, the resident was observed to be agitated and repeatedly attempting to stand and walk independently. Staff had previously walked with the resident using a walker and gait belt, but later put the resident to bed with the bedroom lights off. The resident was left unsupervised, and staff did not continue frequent safety checks, despite the resident's high fall risk and recent history of falls. The resident was later found on the floor in the dark room, with injuries including a hematoma to the head and multiple skin tears, and was entangled in television cords. Interviews with staff revealed that the decision to put the resident to bed was made despite ongoing restlessness, and that agency staff felt their input regarding the resident's care would not be well received. The facility's own policy required individualized fall prevention interventions and ongoing monitoring, but these were not adequately followed. The resident ultimately died from complications related to the unwitnessed fall, as confirmed by the county coroner.
Delay in Honoring Resident's Request for Emergency Room Transfer
Penalty
Summary
A resident with a diagnosis of constipation reported experiencing stomach pain and repeatedly requested to be sent to the emergency room, beginning early in the morning. The resident informed a CNA multiple times to notify the nurse, but the LPN did not enter the resident's room until approximately two hours later. Upon being seen, the resident again requested to go to the hospital, but the nurse explained that a physician's order was required and that obtaining it could take time. The resident was not transferred to the emergency room until later that afternoon, several hours after the initial request. The facility's own statement of resident rights affirms that residents have the right to exercise their rights, including the right to prompt medical attention, and the medical director confirmed that residents requesting transfer to the emergency room should be sent and the physician notified afterward.
Failure to Monitor and Document Bowel Movements Leads to Unaddressed Constipation
Penalty
Summary
The facility failed to ensure consistent monitoring and documentation of bowel movements for a resident with a diagnosis of constipation, hemiplegia, hemiparesis, unspecified muscle disorder, and difficulty walking. The resident had an active physician order for ferrous sulfate and was being monitored for bowel management. Review of the Bowel Movement Task Sheet over several days showed multiple entries of 'none' or 'not applicable,' with no bowel movements documented on several consecutive days. There were also no nursing progress notes indicating that a bowel assessment was completed on a day when the resident reported abdominal pain. The resident reported to a CNA that he was experiencing stomach pain and requested that the LPN be notified early in the morning, but the LPN did not enter the room until later. Interviews with the Medical Director and Regional Nurse Consultant confirmed that staff are expected to notify the physician if a resident has no bowel movement for three days and to assess residents who report symptoms of constipation. The facility's Bowel Management Program requires prompt documentation by CNAs and daily review by nursing staff, but these procedures were not followed, resulting in unaddressed constipation for the resident.
Failure to Prevent Resident Wandering and Inadequate Supervision Resulting in Resident Harm
Penalty
Summary
The facility failed to develop and implement effective interventions and provide adequate supervision to prevent a resident with dementia and behavioral disturbances from wandering into other residents' rooms, invading their privacy, disturbing their environment, taking assistive devices, and making inappropriate comments. Despite documentation of the resident's history of physical aggression, resistance to care, and impulsivity, the care plan interventions such as 10- or 15-minute checks were inconsistently documented or not performed as required. The resident was observed to have frequent behaviors, including entering other residents' rooms without permission, and staff interviews confirmed that supervision was lacking, especially during night shifts. Multiple residents reported distressing encounters with the wandering resident, including incidents where assistive devices such as walkers were taken, resulting in falls and injuries. One resident, who was independent with ambulation using a walker and had multiple medical diagnoses including heart disease and osteoporosis, suffered two unwitnessed falls after her walker was moved out of reach by the wandering resident. These falls resulted in a laceration to the knee requiring sutures, a laceration to the hand, and a hematoma to the scalp. The affected resident expressed fear and distress due to repeated intrusions and threats from the wandering resident, and reported that her concerns were not believed by staff or her family. Other residents also reported frequent and distressing intrusions into their rooms, including being awakened at night, having personal belongings taken, and experiencing threats or attempted physical aggression. Staff interviews corroborated that the resident with dementia was not adequately supervised, particularly during evening and night shifts, and that interventions such as doorway sensors and increased checks were either not implemented or not consistently followed. Documentation gaps and lack of effective supervision contributed to ongoing incidents affecting the safety and well-being of multiple residents.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse by another resident, resulting in an incident where one resident with dementia and a history of aggressive behavior physically grabbed and struck another resident. The incident occurred while residents were waiting in line to go outside to smoke, when the resident with dementia approached from behind and grabbed the other resident's shoulder, causing the latter to yell and express fear. Witnesses confirmed the aggressive behavior, and it was noted that this was not the first time the resident had exhibited such conduct toward others, including attempts to hit and invade personal space of multiple residents. The resident who committed the abuse had a documented history of dementia, behavioral disturbances, and post-traumatic stress disorder, with care plans indicating episodes of physical aggression and resistance to care. Interventions such as increased supervision and 10-minute checks had been implemented previously due to these behaviors. Staff interviews revealed ongoing concerns about the resident's confusion, anger, and tendency to enter other residents' rooms, as well as difficulties in redirecting the resident and managing their impulsivity and poor safety awareness. Despite these known risks and behavioral patterns, the facility did not consistently implement or update all interventions in the care plan, such as the use of a doorway sensor, and staff reported challenges in maintaining adequate supervision. The failure to prevent the incident resulted in a resident experiencing physical abuse and fear, with staff and other residents acknowledging ongoing issues with the aggressive resident's behavior.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Fall and Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident diagnosed with Lewy Body Dementia, resulting in a fall and acute left hip fracture. The resident had a documented history of severe cognitive impairment, wandering, and previous falls, and was identified as high risk for both falls and elopement. The care plan specified the need for frequent monitoring, with staff and policy indicating that high-risk residents should be checked every 15 minutes. However, on the day of the incident, documentation showed the resident was last repositioned at 8:22 AM, with the fall occurring at 3:50 PM, and there was no evidence of the required frequent checks being performed or documented. Interviews with staff confirmed that the resident frequently got up without assistance and that the expectation was for high-risk residents to be checked every 15 minutes. Despite this, staff were unable to provide documentation that these checks occurred as required. The resident was found by a CNA after losing balance and falling, and subsequent medical evaluation confirmed a left hip fracture. The facility's failure to implement and document the required supervision and monitoring directly led to the resident's fall and injury.
Delayed Diagnostic Imaging and Result Follow-Up After Fall
Penalty
Summary
The facility failed to promptly schedule and obtain results for a physician-ordered MRI of a resident's right hip following a witnessed fall during an assisted shower. The resident, who had severe cognitive impairment and multiple comorbidities including dementia, hemiplegia, and was on blood thinners, experienced a fall and was initially sent to the emergency department (ED) for evaluation. The ED performed CT scans of the head and spine, but no imaging of the right hip was conducted at that time. Upon return to the facility, the resident began to complain of right hip and shoulder pain, refused to get out of bed due to pain, and required increased administration of narcotic pain medication. Subsequent evaluation at the ED included X-rays of the right hip and shoulder, which were reported as showing no acute fracture or dislocation, but the hip X-ray was noted to be improperly positioned, potentially limiting diagnostic accuracy. Despite ongoing severe pain and a recommendation to consider a non-contrasted CT scan if symptoms persisted, there was no documentation that further imaging was pursued until the resident's family requested an MRI nearly two weeks later. The MRI was ordered and scheduled eleven days after the order, and when finally performed, revealed an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema. There was an additional delay in obtaining and acting upon the MRI results, with the facility not receiving the finalized report until approximately 36 hours after the MRI was completed. The resident was then transferred to the hospital for surgical intervention. Throughout this period, the resident experienced continued severe pain and immobility, as evidenced by increased use of narcotic pain medication and family observations of the resident's inability to move her leg. The delay in both scheduling the MRI and obtaining the results directly contributed to the delay in diagnosis and surgical repair of the hip fracture.
Failure to Prevent Accidents Due to Unsafe Environment and Equipment
Penalty
Summary
The facility failed to provide a safe environment and adequate supervision to prevent accidents for two residents with dementia and high fall risk. In the first instance, a resident with moderately impaired cognition, a history of wandering, and high risk for falls and elopement was left unsupervised when a normally secured bathroom door was left ajar and unlatched. The resident accessed the bathroom independently, resulting in an unwitnessed fall that caused a large hematoma, rib fracture with a partially collapsed lung, and two brain bleeds, requiring emergency hospitalization and trauma surgery. Staff interviews revealed that the bathroom door had a malfunctioning keypad lock and was routinely left open due to difficulty in operation, and maintenance requests for repair were either not submitted or not acted upon in a timely manner. In the second instance, another resident with severe cognitive impairment, hemiplegia, and multiple comorbidities experienced a fall during an assisted shower. The fall occurred when the wheel of a small, white shower chair became stuck on a floor drain, causing the chair to tip and the resident to fall, resulting in a hip fracture that required surgical repair. Staff and maintenance interviews confirmed that the shower chair was old, had worn and malfunctioning wheels, and was known among staff to be unsafe. Despite this, the chair remained in use, and only partial repairs were made after the incident. The resident continued to experience severe pain for weeks following the fall, and diagnostic imaging confirming the fracture was delayed. Both incidents demonstrate a failure to identify and address environmental hazards and to ensure that equipment used for resident care was maintained in safe, operable condition. The facility's own policies required the environment to be free from hazards and for appropriate supervision to be provided, but these were not followed, resulting in significant injuries to both residents.
Failure to Maintain Accurate and Complete Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident who experienced a fall and subsequently required medical attention. The resident underwent an MRI at a local hospital, which revealed an acute, impacted subcapital hip fracture with lateral displacement and extensive soft tissue edema. However, there was no documentation in the resident's medical record indicating the departure from or return to the facility for the MRI. Additionally, there was a gap in documentation between a nurse practitioner's note and a later transfer note, with no record of the MRI event or related care during that period. Further review of the resident's records revealed discrepancies in the administration and documentation of Tramadol, a narcotic analgesic. The narcotic count sheet indicated that several doses were removed from the supply on specific dates, but these administrations were not recorded on the Medication Administration Record (MAR). Pain assessments, as ordered to be completed every shift using a 1-10 scale, were also not properly documented, with nurses signing off on completion but failing to record the actual pain scores. The Director of Nursing confirmed these documentation failures after reviewing the records and speaking with the involved nurses.
Survey Results Book Not Properly Posted or Identified
Penalty
Summary
The facility failed to post an accurate notice for the location of the survey results book and failed to identify the survey book. During a resident group interview, three residents stated they had no knowledge of where the survey results book was located and said no facility staff had informed them of its location. Observation showed an 8.5 x 11 inch sign in the front hallway stating the survey inspection results book could be found in a plastic holder outside the front office, but no plastic holder was present outside the administrative office, reception office, or conference room. A plastic holder outside the human resources office was empty. The Administrator later located a 4-inch-thick black notebook inside the glass doors of a small cabinet in the resident and family lounge room, and the notebook was not labeled as the survey results book. The facility's Medicare and Medicaid application documented 81 residents.
Unsafe food handling, storage, and sanitation practices
Penalty
Summary
The facility failed to observe and implement controlled temperature safeguards for potentially hazardous foods served to residents. On 9/16/25, R13 was observed in bed actively eating breakfast from a tray that had been delivered to the North Hall around 7:15 AM and was still in front of him at 11:48 AM; the tray contained scrambled eggs, oatmeal, and a milk-based nutritional supplement. Later that day, R13 was again observed actively eating lunch from a tray that had been out for an extended period and contained a hot dog, baked beans, and a milk-based nutritional supplement. Staff stated that trays delivered to residents in rooms are served before dining room trays, that North Hall trays go out early in the morning, and that R13 takes a long time to eat and does not want to give up his tray. R13’s MDS documented a BIMS score of 9 out of 15, indicating moderate cognitive impairment. On 9/18/25, R13 was again observed with breakfast tray items including crumbled pork sausage and gravy and a milk-based nutritional supplement, and the tray remained in front of him until 10:50 AM. The facility also failed to prevent potential physical cross-contamination of stored food and failed to maintain sanitary dietary service floor areas. On 9/16/25, a disposable foam cup was observed being used as a food scoop inside a bulk dry storage bin of sugar, with the cup resting in contact with the stored sugar. In addition, the kitchen, pantry, and dishwashing room floors were observed to be soiled with dark accumulations of food deposits at baseboards, floor junctions, and threshold areas, with plastic and paper debris scattered on the dish room floor, including beneath racks of clean dishes, and multiple dishwashing scrub pads on the floor. These floor conditions remained soiled on 9/18/25. The facility application documented 81 residents residing in the facility.
Uncovered urinary catheter bags visible to others
Penalty
Summary
The facility failed to maintain residents’ rights to dignity by not keeping urinary catheter collection bags inside privacy covers for two residents, both of whom had indwelling urinary catheters and severe cognitive impairment. R1’s record documented diagnoses including hemiplegia, hemiparesis, epilepsy, history of traumatic brain injury, parkinsonism, and vascular dementia with agitation, and noted that R1 used a wheelchair, was dependent on staff for activities of daily living, and had impaired upper and lower extremity range of motion. R1 also had a physician order for an indwelling urinary catheter and urine collection bag, with an order to ensure the urine collection bag always had a cover in place. Survey observations showed R1’s urine collection bag attached to the wheelchair was repeatedly uncovered and partially filled with yellow urine while R1 was visible from the hallway, seated in the room with the door open, in the hallway, and outdoors on the front porch. R12’s record documented diagnoses including hemiplegia, hemiparesis, dementia, and seizures, severe cognitive impairment, wheelchair use, dependence on staff for activities of daily living, and an indwelling urinary catheter with an order to ensure the urine collection bag always had a cover in place. Survey observations showed R12’s urine collection bag was also repeatedly uncovered and visible from the hallway while R12 was seated in the room with the door open and while seated in the hallway. The facility’s Dignity policy stated staff shall promote dignity and assist residents as needed by helping residents keep urinary catheter bags covered.
Respiratory Equipment Not Maintained in Clean, Ordered Condition
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents. For one resident with COPD and shortness of breath when lying flat, the physician order sheet documented head-of-bed elevation and nebulized Ipratropium-Albuterol, but did not include an order for oxygen administration or monitoring. The care plan did not document compromised respiratory status, respiratory interventions for monitoring oxygen administration, positioning to prevent shortness of breath, blood oxygen level measurements, or safe and sanitary care of respiratory equipment. On observation, the resident’s nebulizer mask was visibly soiled with opaque white splatter and beige sticky material, the tubing was undated and dangled close to the floor, the oxygen concentrator had an empty humidifier bottle dated 8/31/25, and the nasal cannula/tubing was undated. An RN used the soiled nebulizer mask to administer treatment, then confirmed the mask should not have been used and that the mask, tubing, oxygen tubing, nasal cannula, and humidifier bottle were undated or empty when they should have been changed weekly and dated. A second resident was observed receiving oxygen through a concentrator at 4 liters per minute with a humidifier bottle that was totally dry and dated 9/8/25, and the nasal tubing was undated. The resident stated the bottle runs dry all the time, and the dry humidifier bottle remained unchanged on a later observation. The resident’s physician order sheet directed that the oxygen tubing and humidifier bottle be changed every week on Sunday nights. The facility policy stated oxygen is to be administered in accordance with physician orders and that humidifier bottles, masks, and tubing are needed equipment for oxygen administration; it also stated humidifier bottles are changed as needed and that oxygen tubing not in use is placed inside a plastic bag.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to follow pharmacy instructions for medication administration, resulting in three medication errors out of 32 opportunities and a 9.38 percent medication error rate. During observation and record review, R3’s physician orders included Ferrous Sulfate 324 mg twice daily and Cefdinir 300 mg twice daily with the instruction, “No iron/antacids within 2 hours.” On 9/19/25 at 8:00 a.m., an LPN administered the iron and Cefdinir at the same time, contrary to the physician order and the pharmacy label. The LPN confirmed that Cefdinir was given with Ferrous Sulfate and that the two-hour separation was not observed. R3’s physician orders also included Trelegy Ellipta inhalation powder once daily with directions to rinse the mouth thoroughly after each use. During the same medication pass, after R3 had taken oral medications, the LPN administered the Trelegy Ellipta inhaler but did not provide water or ensure that R3 rinsed the mouth afterward. R3 stated that no one had ever told them to rinse after using the inhaler, and the LPN acknowledged that the mouth-rinsing instruction should have been followed. In a separate event, R43’s order included Florastor 250 mg twice daily, but on 9/18/25 at 9:21 a.m. the RN found no supply available in the medication room or facility stock room and did not administer the ordered Florastor.
Controlled Substance and Insulin Labeling/Storage Deficiencies
Penalty
Summary
The facility failed to store a resident’s scheduled IV controlled substance, Lorazepam Intensol Oral Concentrate, in a locked refrigerator compartment. During medication storage observation, the unopened 30 mL bottle was found in the refrigerator door of the South Hall medication room, and the refrigerator did not have a lock to secure the controlled substance. The LPN stated the medication should have been in a locked box in the refrigerator and noted there may have been confusion among staff about storage, with the key kept on a different key ring than the medication room key. The facility also failed to ensure two residents’ opened insulin injection pens were properly labeled. In the South Hall medication cart top drawer, Lantus insulin quick-injection pens for two residents were observed with only the residents’ last names handwritten in permanent marker. The pens had no open dates and no pharmacy labels showing directions for administration, the prescribing physician, the dispensing pharmacy, or a prescription number. The LPN stated the pens came in bags without resident information or directions and that staff matched them to the MAR and wrote the resident name on the pen. The report identified that the facility’s controlled substance storage policy required Schedule II through V medications requiring refrigeration to be stored within a locked box inside the refrigerator, and its medication storage policy required drug containers with missing, incomplete, improper, or incorrect labels to be returned to the pharmacy before storage. These observations involved three residents reviewed during medication storage observation: one resident receiving hospice care with a PRN Lorazepam order for anxiety, restlessness, and agitation, and two residents receiving daily Lantus insulin for diabetes mellitus.
Failure to Use Enhanced Barrier Precautions for Residents With Indwelling Urinary Catheters
Penalty
Summary
The facility failed to ensure enhanced barrier precautions were used for two residents with indwelling urinary catheters. R1 had diagnoses including hemiplegia, hemiparesis, epilepsy, history of traumatic brain injury, parkinsonism, vascular dementia with agitation, infection due to indwelling urinary catheter, and sepsis. R1’s assessment documented severe cognitive impairment, wheelchair use, dependence on staff for activities of daily living, an indwelling urinary catheter, and impaired upper and lower extremity range of motion. R1’s orders and care plan included an indwelling urinary catheter, urine collection bag, and enhanced barrier precautions due to risk for infection from chronic catheter use. During observations, R1 was seated in a wheelchair in the room with the catheter and collection bag attached, but no enhanced barrier precaution signage was posted at the room entrance, no PPE was present in or near the room, and no ABHR was present in or immediately adjacent to the room. V15 reported R1 had recently finished antibiotics for a UTI, and the infection log documented treatment completed for a UTI. R12 had diagnoses including hemiplegia, hemiparesis, dementia, and seizures, with severe cognitive impairment, wheelchair use, dependence on staff for activities of daily living, and an indwelling urinary catheter. R12’s orders and care plan also included an indwelling urinary catheter, urine collection bag, and enhanced barrier precautions due to high risk for UTI from chronic catheter use. Observations showed R12 seated in a wheelchair with the catheter and collection bag present, but no enhanced barrier precaution signage, no PPE, and no ABHR were present in or near the room. An LPN stated R12 should be on enhanced barrier precautions when asked.
Failure to Maintain Ordered Probiotic Stock
Penalty
Summary
The facility failed to maintain a supply of the house-stock probiotic Florastor (Saccharomyces boulardii) for a resident who had a physician order for Florastor 250 mg by mouth twice daily for prophylaxis while also receiving Ertapenem 1 gram intravenously every 24 hours for 14 days. The resident’s physician order sheet also documented contact isolation for ESBL related to a wound involving an acquired absence left above-knee amputation infected surgical site. The medication administration record for the month documented Florastor 250 mg scheduled at 8:00 am and 8:00 pm, but the RN recorded the medication as not available on 9/18/25. During medication preparation, the RN checked the medication cart, medication room, and stock room and found no Florastor 250 mg capsule in stock to administer. The ADON stated the Florastor 250 mg capsules should have been available in stock, later stated the facility was not able to purchase the correct 250 mg dose, and that this was why it was not given as scheduled. The ADON also stated the facility was working on obtaining an order for a different probiotic since the Florastor 250 mg capsule could not be obtained.
Lack of Full-Time Director of Nursing
Penalty
Summary
The facility failed to provide a full-time Director of Nursing (DON) to oversee and coordinate nursing services. During the survey conducted from 8/19/25 through 8/22/25, it was observed that there was no DON present in the building. The Administrator/Abuse Prevention Coordinator confirmed that the previous DON's last day was 8/15/25 and that no Registered Nurse had been hired for the DON position, nor was there an Acting DON in place to provide oversight of nursing services. At the time of the survey, the facility's resident roster documented 83 residents residing in the facility.
Failure to Notify POAs of Abuse Allegations
Penalty
Summary
The facility failed to properly notify family representatives or Powers of Attorney (POA) regarding allegations of physical abuse involving five residents. In several documented incidents, the facility's records indicated that POAs were notified as per policy, but interviews with the POAs and family members revealed that they were either not informed at all or were not given accurate or complete information about the nature of the incidents. For example, in one case, a POA was told that two residents were arguing, with no mention of physical contact, despite documentation of a physical altercation. In other cases, POAs stated they were unaware of any calls from the facility regarding abuse allegations, and only learned of the incidents from the residents themselves. Additionally, in an incident where a resident was handled roughly by staff resulting in a bruise, the POA was only informed about the presence of a bruise with no explanation of the alleged rough handling or abuse. The facility's abuse prevention policy requires immediate and accurate notification to POAs, physicians, and authorities, but the documentation and interviews indicate a pattern of incomplete or absent communication. The administrator acknowledged that nurses are responsible for accurate documentation and timely notification, but the evidence shows this was not consistently done.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Ombudsman of Abuse Allegations
Penalty
Summary
The facility failed to operationalize its abuse prevention policy by not notifying the Ombudsman of multiple abuse allegations, despite documentation indicating that such notifications had occurred. Specifically, investigation reports for several incidents of resident-to-resident physical abuse and an incident involving a nursing staff member causing a bruise to a resident's arm all stated that the Ombudsman was notified, as required by the facility's policy. These reports were documented by the Administrator/Abuse Prevention Coordinator. However, during an interview, the Ombudsman confirmed that he had not been notified of any of the abuse allegations listed in the reports. The Ombudsman reviewed his records, including notes, emails, and phone calls, and found no evidence of notification from the facility. He also stated that he was present in the facility during the relevant period and was not informed in person about any of the incidents. The facility's abuse policy requires immediate reporting of all abuse allegations to the Administrator and timely notification to authorities, including the Ombudsman, but this procedure was not followed.
Failure to Report Abuse Allegations to Police and Physician
Penalty
Summary
The facility failed to report allegations of abuse, neglect, or injuries of unknown origin to the local police department and the physician as required by its own abuse prevention policy. Specifically, five residents were involved in incidents of resident-to-resident physical abuse, staff-to-resident physical abuse, and injuries of unknown origin. Although facility documentation indicated that the police and physician were notified for each incident, interviews with the local police department and the facility's medical director revealed that neither party had any record or knowledge of these reports. The administrator responsible for abuse prevention admitted to not having proof of contacting the police and relied on nursing staff documentation for physician and family notifications, which could not be substantiated. The incidents included one resident smacking another's face, another swatting a resident's back, a resident grabbing another's wrist, and a staff member allegedly handling a resident roughly, resulting in a bruise. Despite the facility's policy requiring immediate reporting to authorities, the lack of verifiable communication with the police and physician was confirmed through interviews and record reviews. The administrator acknowledged the absence of documentation to support that proper notifications were made, and the medical director confirmed that neither he nor the on-call physicians were informed of the abuse allegations.
Failure to Interview Key Witnesses During Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations into multiple alleged abuse incidents by not interviewing families who frequently visit the facility or other residents who may have had knowledge of the alleged events. Specifically, in several cases involving resident-to-resident physical abuse and an incident where a resident reported being handled roughly by unidentified nursing staff, the facility determined the allegations to be unfounded without seeking input from potential witnesses such as family members or other residents. The administrator confirmed that these investigations were considered complete despite not including these interviews. The facility's own abuse policy requires that investigations include interviews with residents, staff, visitors, and vendors, but this was not followed in the reviewed cases.
Failure to Timely Review and Revise Care Plans After Resident-to-Resident Abuse
Penalty
Summary
The facility failed to timely review and revise care plans for four of nine residents following incidents of resident-to-resident physical abuse. Multiple abuse investigation reports documented physical altercations between residents, such as one resident smacking another's face, swatting another's back, and grabbing a wrist. Although the investigation reports indicated that the involved residents' care plans were reviewed or revised, the actual care plans did not reflect timely updates or new interventions related to the abuse incidents. For example, care plans for residents with histories of dementia, psychiatric diagnoses, and aggressive behaviors were not updated to address the specific abuse events as required. Record review and staff interviews confirmed that the care plans for the involved residents had not been updated as they should have been after each abuse allegation. The facility's own abuse policy requires prompt investigation and necessary changes to prevent future occurrences, but documentation showed that care plans remained unchanged or were not revised in a timely manner following the incidents. The lack of timely care plan review and revision was acknowledged by facility leadership during the survey.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one of nine residents reviewed for abuse or injury of unknown origin. Multiple physician notes for this resident, signed by the Medical Director, documented the presence of bruises on the left cheek and left lower rib cage across several assessment dates. Upon review, the Medical Director acknowledged that these entries were inaccurate, as the resident had experienced bruising only following a fall in a previous month and did not have bruising on the dates documented. The Medical Director confirmed these were documentation errors, resulting in inaccurate medical records for the resident.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required by regulations.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an Injury of Unknown Origin for one resident who was severely cognitively impaired and required significant assistance with daily activities. The resident, who had multiple medical diagnoses including dementia, diabetes, and heart failure, was found to have a large, dark purple bruise on the left lower abdomen. The bruise was first observed by a CNA during the early morning hours and was immediately reported to an LPN, who then informed the Director of Nursing (DON). The DON was notified of the injury the same morning, and the administrator was also informed. Despite the immediate internal reporting, the facility did not submit the required initial report to the State Agency until four days after the injury was discovered. The facility's policy requires that such incidents, especially those classified as Injuries of Unknown Origin, be reported to the State Agency immediately after assessment. Interviews with staff and review of records confirmed that the injury met the criteria for immediate reporting, but this was not done in accordance with policy.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to conduct a thorough investigation into an injury of unknown origin for a resident with multiple medical diagnoses, including severe cognitive impairment, diabetes, and heart failure. The resident was found to have a large, dark purple bruise on the left lower abdomen, which was not present during a prior skin assessment and was first observed by a CNA, who reported it to an LPN. The bruise was subsequently reported to the DON and the physician, but the resident was unable to explain the cause of the injury, and no fall or other incident was noted. Documentation showed that insulin had been administered in the same area, but this information, along with shower sheets and daily skin assessments, was not reviewed as part of the investigation. Interviews with staff confirmed that the investigation did not adequately consider all relevant information or rule out abuse as a possible cause of the injury. The DON acknowledged that the investigation was incomplete, and the administrator confirmed that important records were not reviewed to determine the etiology of the bruise. The facility's abuse policy defines injuries of unknown source and outlines the need for thorough investigation, which was not followed in this case.
Failure to Provide Adequate Supervision and Safe Equipment During Shower Resulting in Resident Fall
Penalty
Summary
A deficiency occurred when a resident with multiple medical conditions, including a history of falls, diabetes with polyneuropathy, and a left artificial hip joint, was not provided adequate assistance and safe equipment during a shower, resulting in a fall. The resident was assessed as high risk for falls and required partial to moderate assistance with bathing, meaning staff should provide less than half the effort but still assist with lifting, holding, or supporting as needed. During the incident, the resident was left unattended while the CNA retrieved a towel, and the shower chair's wheels were not locked, causing the chair to move on the sloped, wet floor. The resident reported that the shower chair wobbled due to the uneven floor and that the brakes were not engaged, which allowed the chair to move abruptly when the resident attempted to stand. The CNA was not within arm's reach at the time, and the resident fell forward, landing on the same hip previously fractured before admission. The resident experienced pain and bruising following the fall, and later required an X-ray to rule out a new fracture. The resident also described previous falls, including one at home and others in the facility, but specifically noted that this shower fall was due to equipment instability and lack of staff assistance at the critical moment. Observations and interviews with other staff and residents confirmed that the shower chair was unstable even when locked, and that not all CNAs consistently locked the wheels or provided direct assistance during transfers. The shower room's design, with a sloped floor and a lightweight, wheeled shower chair, contributed to the hazard. Staff acknowledged the potential for falls under these conditions and indicated that locking the chair and providing hands-on assistance were not always standard practice.
Failure to Maintain Complete and Accurate Medical Record After Resident Fall
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident following a fall in the shower room. The resident, who had no cognitive impairment and was assessed as high risk for falls, experienced a fall during a transfer in the shower room. The fall was documented in the facility's fall incident log and a fall investigation report, but there was no corresponding documentation in the resident's medical record. The care plan was not updated with an intervention for the fall until more than two months later, during the survey. The resident confirmed the fall and described circumstances that differed from the staff account, including the staff member's distance at the time of the incident and the condition of the shower area. Interviews with facility staff, including the DON and Regional Director of Operations, confirmed the absence of required documentation in the resident's chart, such as the initial incident report and follow-up nursing assessments. The facility's own policy requires immediate investigation, documentation, and follow-up charting for 72 hours after an incident, as well as timely updates to the care plan. These procedures were not followed, resulting in incomplete and inaccurate medical records for the resident after the fall.
Failure to Notify Physician of Wound Changes Resulting in Delayed Treatment
Penalty
Summary
Facility staff failed to notify a resident's physician of significant changes in a vascular wound, specifically increased redness, swelling, and pain in the resident's right second toe. The resident had a history of atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections, and had physician orders for daily foot checks with instructions to notify the physician of any changes. On the day the wound changes were observed, the LPN notified the facility wound nurse, but the physician was not contacted as required by policy and physician orders. The wound nurse acknowledged being informed of the changes but did not notify the physician, mistakenly planning to do so later and forgetting that the wound was under the care of a vascular wound physician. As a result, no treatment for potential infection was initiated until the resident's next scheduled wound clinic appointment four days later, at which point the wound was diagnosed as cellulitis and antibiotics were ordered. The delay in physician notification and treatment resulted in a delay in addressing the wound infection.
Failure to Notify Physician of Wound Infection Signs
Penalty
Summary
The facility failed to notify a resident's physician of signs of a wound infection, as required by policy. A resident with diagnoses including atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections had an order for daily foot checks and physician notification of any changes. On one occasion, an LPN observed that the resident's right second toe was swollen, red, and painful to touch, and reported these changes to the facility wound nurse. However, the wound nurse did not notify the resident's physician or wound care physician about the change. The wound nurse acknowledged being informed of the wound changes but did not contact the physician, intending to do so later but ultimately forgetting. As a result, no treatment for a potential infection was initiated until the resident's next scheduled wound clinic appointment, at which time an antibiotic was ordered for cellulitis. The lack of timely physician notification delayed the initiation of appropriate treatment for the resident's wound infection.
Failure to Complete Weekly Pressure Wound Assessments
Penalty
Summary
The facility failed to complete weekly pressure wound assessments and measurements for one resident who was being treated for pressure wounds on the buttocks. According to the facility's Pressure Ulcer policy, weekly documentation and assessment of pressure ulcers are required until the wound is healed, including details such as wound characteristics, treatment, and progress. The resident, who had diagnoses including atherosclerotic heart disease, diabetes mellitus type II, dementia, and local skin infections, continued to receive daily wound treatments after the wounds were initially deemed healed. However, there was no documentation of weekly wound assessments for the pressure wounds after they were considered healed, despite ongoing treatment. The wound nurse confirmed she was not informed that the wound had reopened and, as a result, had not performed weekly assessments for the past four weeks.
Failure to Follow Bedbug Prevention Policy
Penalty
Summary
The facility failed to follow its bedbug prevention and management policy, which requires that if evidence of bedbugs is found, a specimen should be collected and the pest control company notified. Documentation showed that 82 residents resided in the facility at the time. A Terminex inspection report confirmed treatment for bedbugs in one room, but staff interviews revealed that a bedbug had recently been seen in another room and was reported to the Assistant Director of Nursing. A CNA was aware of bedbugs being found in two residents' room but did not believe the room had been treated. The Maintenance Director stated that if only one bedbug is found, the facility does not spend the money to spray the room. The Terminex representative confirmed that he only treats rooms when notified by the facility and emphasized the importance of being called even if only one bedbug is found, as this could lead to an outbreak. There was no evidence that the pest control company was notified or that treatment occurred in the room where the bedbug was recently seen.
Unsafe and Unhomelike Shower Room Environment Due to Damaged Flooring
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for 28 residents, as evidenced by the poor condition of the south shower hall ante-room floor. The floor was observed to be sloping, mushy, and unstable, creating a risk of falling or sliding, and the transition piece between the old and new flooring was not attached, presenting a trip hazard. Staff, including a Certified Nursing Assistant, were observed using the shower room for resident care despite these hazards. The Maintenance Director acknowledged the unsafe and unhomelike condition of the floor and stated he was unaware of the extent of the problem prior to the observation. The Director of Nursing confirmed that the affected shower is used by multiple residents. The facility's job description for the Maintenance Director specifies responsibility for maintaining a safe and comfortable environment.
Failure to Prevent Resident-to-Resident Physical Abuse in Dementia Unit
Penalty
Summary
The facility failed to protect two residents from physical abuse, as evidenced by documented altercations between residents in the dementia unit. One resident was involved in two separate incidents: in the first, the resident took another resident's walker, requiring staff intervention; in the second, the same resident purposefully shoved another resident after a dispute involving a walker. Staff interviews confirmed that the resident has a history of aggression toward others and requires close supervision. Facility staff, including the Administrator and Assistant Director of Nursing, acknowledged that the dementia unit was understaffed at the time of the incidents and lacked a dementia unit coordinator.
Unsecured Morphine Leads to Resident Overdose
Penalty
Summary
The facility failed to store a Schedule II Controlled medication, Morphine Sulfate, in a locked location, leaving it on top of a medication cart in plain view and unsupervised on a dementia care unit. This oversight allowed a resident, who had a history of wandering and drinking from unattended containers, to access the medication. The resident was found with the bottle of Morphine up to their lips, and upon retrieval, the bottle was empty. This incident led to the resident becoming unresponsive with a decreased respiration rate, necessitating the administration of Narcan and emergency transport to the hospital. The resident involved had a medical history that included dementia with psychotic disturbance, major depressive disorder, and other conduct disorders. The resident was known to wander the facility and had previously ingested non-food substances, such as fingernail polish remover, which required emergency intervention. On the day of the incident, the resident was observed wandering near the nurses' station where the medication cart was located, and later found with the Morphine bottle. The incident occurred when a Licensed Practical Nurse inadvertently left the Morphine bottle on the medication cart after administering a dose to another resident. The nurse placed the bottle in a biohazard bag on top of the cart and left the unit. The resident accessed the bottle during this time, leading to the overdose. The facility's investigation confirmed that the Morphine was not spilled, as no evidence of the liquid was found on the resident or in the surrounding area, indicating that the resident ingested the entire contents of the bottle.
Removal Plan
- R1 was evaluated and sent to the Local emergency room for evaluation. When EMS personnel arrived, they attempted to administer Narcan to R1 prior to transferring R1 to the local emergency room.
- V4, Licensed Practical Nurse, was suspended pending a comprehensive investigation of the incident.
- Upon Return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with hourly vital signs/Level of Consciousness for eight hours and then every shift times two days.
- Upon Return to facility, R1 had a change in condition. V6, Registered Nurse, administered Narcan to R1, called 911, and sent R1 back to the Local emergency room for Evaluation.
- R1 returned from the hospital. Upon return to the facility, R1 was placed on 15-minute checks and increased assessment and monitoring with every 4 hour vital signs for 2 days.
- All licensed nursing staff were educated on Storage of Controlled Substances, Medication Administration, Accidents and Incidents, and Change of Condition Policies prior to their next scheduled shift either in person or via phone by V31 (former Director of Nursing), V2 (former Nurse and current Director of Nursing), (former Registered Nurse and current Director of Nursing), and V36 (Licensed Practical Nurse).
- V2 (former Registered Nurse and current Director of Nursing) contacted V37 (R1's Power of Attorney) for notification.
- V2 (former Registered Nurse and current Director of Nursing) contacted V12 (R1's Physician) for notification, V31 (former Director of Nursing), and the facility pharmacy provider for assistance with Medication Audits.
- V30 (Maintenance Director) completed a sweep of the Dementia Unit to ensure that all items that are liquid and hazardous products were locked up or put away out of reach.
- The Facility Corporate team (V32 Chief Nursing Officer, V33 Regional Clinical Consultant, V34 Chief Executive Officer, V35 Regional Director of Operations) reviewed and revised policies and procedures related to Medication Administration, Medication Storage, Accidents and Incidents, and Change of Condition.
- The Director of Nursing or designee will complete audits three times weekly for a period of 8 weeks in the following categories: Medication Administration Policy, Storage of controlled substances, Accidents and Incidents, and Change of Condition. Results of the above reviews will be discussed at a weekly quality assurance meeting for a period of 4 weeks and will provide additional education as needed and implement interventions for improvement until resolution.
Failure to Administer Insulin and Notify Physician
Penalty
Summary
The facility failed to administer a resident's physician-ordered insulin for eight days and did not notify the resident's physician of the medication error. The resident, who was moderately cognitively impaired, had a medical history including Diabetes Mellitus Type II, Dementia, and other conditions. The physician had ordered Levemir insulin to be administered every bedtime, but it was not given from January 21 to January 28 due to the medication not being available. During this period, the resident's blood glucose levels ranged from 166 to 562. The facility's Director of Nurses stated that the Levemir insulin was not administered because it was no longer manufactured, and the facility pharmacy had notified them on January 27. However, the physician was not informed until January 28, which delayed the change to Lantus insulin. The facility's policies require nursing staff to contact the prescriber when medication is unavailable and to document and report medication errors. The physician expressed that the facility should have notified him sooner to adjust the resident's diabetic management.
Failure to Follow Physician-Ordered Diets for Diabetic Residents
Penalty
Summary
The facility failed to adhere to physician-ordered diets for two residents, R4 and R9, both of whom have Diabetes Mellitus Type II. R4 was admitted with a hospital discharge instruction to receive a Diabetic diet, but due to a transcription error, the dietary department was instructed to serve a regular diet instead. This error persisted from R4's admission, as confirmed by the Certified Dietary Manager and the Director of Nurses, who acknowledged the incorrect entry of R4's diet order. Similarly, R9, who also has Diabetes Mellitus, was ordered a Consistent Carbohydrate diet with pureed texture and thin liquids. However, R9 was served a regular diet with a full portion of dessert, contrary to the physician's order, as observed by a Certified Nurse Aide and confirmed by an Agency Registered Nurse. The Regional Registered Dietician noted that the facility should have ensured the correct transcription of hospital discharge orders into the Electronic Medical Record (EMR) and communicated the correct diet to the dietary department. The Director of Nurses admitted that R4's diet order was entered incorrectly, and R9's diet was served incorrectly despite being transcribed correctly into the EMR. These failures in following physician-ordered diets could have led to adverse health outcomes for the residents, such as high blood sugar or hospitalization, as stated by the Regional Registered Dietician.
Failure to Report Change of Condition and Improper COVID-19 Testing
Penalty
Summary
The facility failed to report a resident's change of condition to the nurse before conducting a COVID-19 test and did not ensure that qualified staff performed the testing. A Certified Nursing Assistant (CNA) conducted a COVID-19 test on a resident, identified as R2, without notifying the nurse of the resident's change in condition. The CNA reported that the resident was not acting right and subsequently tested positive for COVID-19. However, the CNA did not inform the nurse about the resident's condition change, which is necessary for the nurse to assess the resident before any testing. The incident was documented in the nursing progress notes, where it was noted that the resident's temperature had increased from 98.2 to 101.4 degrees Fahrenheit. The Licensed Practical Nurse (LPN) and the interim Director of Nursing (DON) both confirmed that it is not within a CNA's scope of practice to conduct COVID-19 tests without first notifying a nurse. The facility's Acute Change of Condition Policy requires nursing assistants to communicate any changes in a resident's condition to the nurse, which was not followed in this case.
Resident Rights Violations and Inadequate Smoking Assistance
Penalty
Summary
The facility failed to protect a resident's right to be free from restricted access without clinical justification, affecting one resident out of three reviewed for seclusion. The resident, identified as R9, was cognitively intact and used a walker for ambulation. The facility's administrator restricted R9's movement within her own hallway due to a complaint from another resident's family member, which led to R9 expressing fear of being yelled at and threatened with a move to a locked Dementia unit. This restriction was enforced despite R9's medical history, which included conditions such as Cerebral Infarction, Alzheimer's Disease, and a recent hip replacement, necessitating mobility for recovery. The report also highlights the facility's failure to ensure that another resident, R6, was assisted to smoke breaks as required. R6, who was severely cognitively impaired and required supervision while smoking, was not consistently offered the opportunity to smoke at designated times. The facility's policy stated that residents had to reach the smoking area independently, which was not feasible for R6 due to his condition. As a result, R6 expressed frustration over not being able to smoke as frequently as allowed, which was an intervention for his behavioral issues. The facility's policies on resident rights and abuse were not adhered to, as evidenced by the actions of the administrator and the lack of staff support for R6's smoking needs. The administrator's actions towards R9 were described as mental abuse, involving threats and humiliation, while the lack of assistance for R6's smoking breaks demonstrated a failure to treat residents with dignity and respect. These deficiencies highlight significant lapses in the facility's adherence to resident rights and care standards.
Resident Subjected to Mental Abuse by Administrator
Penalty
Summary
The facility failed to protect a resident, identified as R9, from mental abuse by a staff member, V1, the Administrator. This incident involved V1 raising her voice and threatening R9 with a move back to the Dementia unit, which R9 found distressing and humiliating. The incident was witnessed by other staff members, including the Director of Nurses (V2) and the Social Service Director (V4), who confirmed that V1 raised her voice at R9, causing her to become visibly upset and cry. R9 expressed feelings of humiliation and fear, stating that she was yelled at for walking down her own hallway and was threatened with being moved back to a unit she disliked. R9, who has a history of cerebral infarction, Alzheimer's disease, and other medical conditions, was described as cognitively intact and using a walker for ambulation. The incident occurred after a complaint from another resident's family member about R9 walking past their room. Despite R9's explanation that she was merely admiring the room, V1's response was to confront R9 in a manner that was perceived as abusive by witnesses. R9 reported feeling humiliated and expressed a desire to avoid the hallway in the future to prevent further incidents. The facility's policy on abuse, which includes mental abuse such as humiliation and threats, was not adhered to in this situation. The Medical Director, V43, emphasized that staff should never raise their voices at residents and that verbal and mental abuse is a serious issue. The incident led to R9 withdrawing from activities she previously enjoyed, indicating a significant impact on her well-being. The report highlights a failure in the facility's responsibility to ensure residents are free from abuse and mistreatment.
Failure to Provide Privacy During Incontinence Care
Penalty
Summary
The facility failed to provide privacy for a resident, identified as R5, during incontinence care. R5, who has severe cognitive impairment and multiple medical diagnoses including hemiplegia, Parkinson's disease, and vascular dementia, was assisted by a CNA, V8, to the toilet. During this process, V8 did not close the bathroom or room door, nor did they pull the privacy curtain, leaving R5 exposed from the waist to ankles. This lack of privacy was observed by another resident, R14, who walked by and looked into the bathroom, and by another CNA, V12, who entered the room unannounced and stood outside the bathroom watching the procedure. V8 also failed to change gloves during the entire procedure. The Director of Nursing, V2, confirmed that staff should always provide privacy during perineal care and acknowledged that V8 should have closed the doors and changed gloves. V2 also noted that V12 should not have entered the room unannounced. The incident was described as embarrassing and contrary to the basic principles of CNA care, which emphasize the importance of privacy.
Failure to Honor Residents' Right to Refuse Electronic Monitoring Devices
Penalty
Summary
The facility failed to honor the rights of two residents, identified as R11 and R16, to refuse treatment, specifically the use of electronic monitoring devices. R11, who is cognitively intact and his own responsible party, expressed a desire to have the electronic monitoring device removed, stating that it made him feel imprisoned and restricted his freedom to go outside. Despite his request, the device was not removed, and staff continued to check its placement as per physician orders. R11's medical history includes conditions such as Hemiplegia, Diabetes Mellitus Type II, and Vascular Dementia, but he is noted to be independent in certain activities and requires only moderate assistance in others. Similarly, R16, also cognitively intact and his own responsible party, repeatedly removed the electronic monitoring device, expressing frustration and feeling treated like an animal. The facility's records did not document a Physical Restraint Assessment or consent for the use of the device on R16. Both residents were described as alert, oriented, and ambulatory, and the facility's Regional Clinical Nurse acknowledged that there was no reason for them to wear such devices, as the facility only had one door with the electronic monitoring system. The devices were eventually removed after the residents' complaints were acknowledged.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 142 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Paris
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Lakes Extended Care | 1.1 mi | ★★★★★ | 4 | 0 |
| Pleasant Meadows Senior Living | 12.6 mi | ★★★★★ | 13 | 1 |
| Providence Health Care Center | 14.2 mi | ★★★★★ | 1 | 0 |
| Clinton Gardens | 15.3 mi | ★★★★★ | 10 | 0 |
| Vermillion Convalescent Center | 15.8 mi | ★★★★★ | 11 | 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 July 2026) and official state health department websites.