Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Harbor Health & Rehab during CMS and state inspections, most recent first.
The facility failed to keep care plans current and comprehensive for several residents with dementia, schizophrenia, behavioral issues, fall risk, and abuse/neglect risk. One resident with Alzheimer’s and psychotic disorder had incidents involving other residents, including a verbal altercation that led to pain and hospital transfer, yet elopement, abuse/neglect, and fall care plan interventions had not been revised for many months. Another resident with schizophrenia and multiple comorbidities had repeated verbally aggressive behaviors, was placed on frequent safety checks, and was twice sent to the hospital, but behavior care plan interventions were not updated to reflect these events until much later. Additional residents with suicidal ideation, psychotic disorder, paranoid schizophrenia, and hemiplegia were involved in aggressive or maladaptive interactions, while their abuse/neglect and behavior-related care plan interventions remained outdated despite later revision dates on the care plans themselves.
A resident with Alzheimer’s disease, psychotic disorder, HTN, depression, anemia, and COPD, who was documented as cognitively impaired for daily decision making on the MDS, experienced a change in roommate. A nurse’s progress note indicated the resident was adjusting well to the new roommate, confirming the change occurred, but there was no documentation that the resident’s Responsible Party was notified. During interview, the DON acknowledged that the Responsible Party had not been informed of the roommate change, as she believed notification was only required for a room change.
A resident with Alzheimer's disease, psychotic disorder, HTN, depression, anemia, and COPD, identified on the MDS as cognitively impaired for daily decision making, did not have ongoing care plan meetings conducted and documented as required. A social services note showed that a care plan meeting was arranged with the resident's daughter and held on the same day, but records indicated this was the last documented care plan meeting, with no further meetings recorded. During interview, a nurse consultant confirmed there was no documentation of any subsequent scheduled or rescheduled care plan meetings, despite the expectation that any cancelled meetings be documented as rescheduled.
A resident with schizophrenia, dementia, depression, anxiety, HIV, alcohol abuse, and a history of verbal and physical aggression exhibited escalating behaviors, including unprovoked verbal abuse and striking staff and another resident, leading to multiple hospital and psychiatric evaluations. Despite physician orders for 15‑minute safety checks and a behavior care plan citing aggression toward staff and peers, the record lacked required safety check documentation over an extended period, and behavior interventions were not updated for many months despite repeated aggressive incidents. Staff interviews confirmed the resident’s unpredictable aggression, absence of effective de‑escalation techniques, and that ordered close monitoring was not consistently implemented after returns from behavioral health hospitalizations.
A resident with multiple psychiatric, cognitive, and medical diagnoses, including schizophrenia, dementia, depression, anxiety, HIV, and alcohol abuse, had a physician’s order for 15-minute safety checks every shift. Review of safety logs showed that the ordered 15-minute checks were not signed out for a one-hour period. An LPN reported that the checks had been done but not yet charted, and the DON stated that staff are expected to complete all ordered 15-minute checks and sign off each time, acknowledging that the documentation for that hour should have been completed.
The facility failed to electronically submit required PBJ staffing data to iQIES based on payroll records. The CMS PBJ report showed the data was not submitted, and the VP of Operations reported a connection error caused files to fail to send. The VP, HR Director Consultant, and a nurse consultant reviewed and finalized the quarterly PBJ, but the nurse consultant did not verify that the submission went through.
A facility failed to maintain resident dignity during activities and in resident rooms. One resident with dysphagia and vascular dementia was given coffee, had it removed because it was not thickened, and was then not offered another drink while others continued drinking coffee; another resident asking for coffee was told only juice was available and staff did not call the kitchen. In addition, swallow precaution signs were posted in plain view above the beds of two residents with dysphagia and cognitive impairment.
A resident’s privacy was not respected when staff searched his room and personal belongings for smoking materials without informing him beforehand or giving him the chance to be present. The resident, who had quadriplegia, trauma, depression, and PTSD, was cognitively intact and later told the DON he was upset that staff went through his belongings after a holiday event. His smoking consent allowed searches of his clothing, bags, and room for smoking materials, but did not say searches could occur without his knowledge or presence.
Failure to Provide Hair Washing Assistance: A resident who needed substantial to maximal assistance with bathing and showering was repeatedly observed with greasy hair and dandruff, and stated her hair had not been washed. Although the MAR showed Selsun Blue shampoo was signed out and shower sheets documented complete bed baths, there was no documentation that her hair was washed during those baths or that she refused hair washing; the DON stated the current shower sheets had no place to document hair washing.
A resident with dementia and other chronic conditions had a witnessed fall, but the fall follow-up documentation was incomplete and vital signs were not documented each shift for the required 72 hours. Another resident with bilateral lower extremity edema and multiple psychiatric and medical diagnoses was repeatedly observed without the ordered compression bandages/ace wraps, despite a care plan and MD order for daily application.
Inadequate supervision with hot beverages, thickened liquids, and vaping. A resident with dysphagia and vascular dementia was given unthickened hot coffee without a lid despite an order for nectar-thick liquids and a care plan requiring supervision for eating; due to tremors, the coffee spilled before staff removed it. Another resident with COPD and impaired decision making was observed vaping in her room while staff watched, even though the smoking policy allowed smoking only in designated areas and prohibited smoking materials inside the building for residents requiring supervision.
Foley catheter and nephrostomy care were not properly managed for two residents. An LPN and other staff observed a Foley bag and tubing on the floor multiple times for a resident with a Foley catheter and UTI, and a wound nurse found a nephrostomy StatLock and collection bag undated with missing documentation for bag changes and output monitoring for another resident.
Improper PEG Tube Placement Check Before Medication Administration: An RN prepared meds for a resident with a gastrostomy tube and, before verifying placement by aspiration, flushed 30 cc of water through the PEG tube and then attempted to check residual. She obtained less than 5 cc from each port and stated she expected to withdraw 30 cc. The resident’s order and facility policy both directed staff to verify placement by aspirating gastric contents first.
Implanted Port Not Monitored per Order: A resident with vulva cancer, COPD, CHF, and an implanted right chest port-a-cath was observed with the device visible under a white bandage. Record review showed prior orders to monitor the port and report abnormalities, but after a hospital return there were no monitoring orders in place until a later order was written. The DON stated nurses should have been monitoring the device, and the facility policy required assessment, flushing per order, and documentation of all procedures.
Improper Storage of Pre-Filled Saline Syringes: An LPN left multiple pre-filled normal saline syringes in a resident’s room during IV antibiotic administration for a resident with an implanted port. Syringes were observed on the over-bed table and nightstand, and the LPN later returned with another syringe, leaving it on the over-bed table before using it to flush the line. The LPN stated she was unaware the syringes had been left in the room.
Food Served at Unappetizing Temperature: A meal observation found lunch trays delivered on a non-insulated cart to a dining room, with test tray temperatures showing chicken at 104 degrees and rice and black beans at 120 degrees. The Kitchen Manager questioned the thermometer, then could not use a digital thermometer because batteries were unavailable, and the food was tasted and found not hot. Residents also reported that the food was bad and often cold, and one CNA said she passed all room trays and got drinks by herself.
Failure to Provide Ordered PT: A resident with CKD and post-surgical T11-L1 laminectomy was ordered PT 5x/week, then 3x/week, for therapeutic exercise, gait, bed mobility, and transfer training. The resident was seen on some scheduled days, but missed multiple ordered sessions, including an unavailable visit with no documented reason and a canceled session by another staff member. The resident reported going many days without therapy, and the Rehab Director said staffing was limited to one full-time therapist with PRN staff who were only in the building intermittently.
Incomplete and inaccurate tube feeding documentation. A resident with CHF, dysphagia, and a gastrostomy tube had a physician order to check residuals each shift and hold feedings if residuals were over 100 ml, but the MAR documented several residuals above that limit without narrative notes showing intolerance or physician notification. The DON stated the nurses documented incorrectly, and an NP note in the record contained another resident’s information.
Failure to monitor antibiotic use: A resident with a suprapubic catheter and recurrent UTI concerns was started on ciprofloxacin for presumed UTI after reporting pain and discomfort with urination. The urine culture later showed Proteus mirabilis resistant to ciprofloxacin, yet the resident still received the full 5-day course, and there was no documentation that the physician was notified of the culture results; the DON stated the antibiotic should not have been given once resistance was known.
A resident with COPD and other medical conditions was observed receiving oxygen therapy at a flow rate below the physician-ordered 2 liters per minute on multiple occasions. The nasal cannula was not always properly positioned, and an LPN initially failed to verify the correct flow rate before adjusting it. The care plan and physician's orders specified the need for 2 liters of oxygen via nasal cannula as needed, but this was not consistently provided as required.
A resident, dependent on staff for mobility, fell and fractured her leg during a Hoyer lift transfer when only one staff member assisted, contrary to the facility's two-person policy. The resident, with a history of osteoporosis and neuromuscular weakness, was transferred by a CNA who could not find additional help. The CNA attempted to prevent the fall, but the resident's leg was injured during the incident.
The facility's first floor had several environmental deficiencies, including marred walls, loose baseboards, and missing bolts around toilets, affecting multiple residents. The Maintenance Director confirmed the need for repairs.
A cognitively impaired resident was repeatedly observed wearing a hospital gown during the day, with no care plan indicating this preference. The resident, with multiple health conditions, had an incomplete Activity Assessment and lacked a care plan addressing clothing needs. The DON confirmed the absence of personal clothes and a related care plan.
Two residents in the facility did not receive adequate assistance with ADLs, including nail care, oral hygiene, and mobility. One resident had long, dirty fingernails and expressed a need for nail care, which had not been performed since late July. Another resident was observed with long fingernails and dried mucous around the lips, indicating a lack of oral care, and was not assisted out of bed despite no bed rest order. Staff interviews confirmed these deficiencies, and the DON acknowledged that care tasks should have been completed as needed.
The facility failed to provide personalized activity programs for two cognitively impaired residents. One resident, in a persistent vegetative state, received minimal engagement despite a care plan for 1:1 visits and music stimulation. Another resident, with multiple diagnoses, was observed in bed without access to activities or proper stimulation, and the care plan did not reflect the resident's current status. The Activity Director and DON acknowledged these deficiencies.
The facility failed to provide appropriate treatment and documentation for two residents with non-pressure related skin conditions. One resident did not receive consistent treatment for a finger wound as ordered, and another resident's arm discoloration was not documented or communicated among staff. The facility's Wound Management policy was not effectively followed.
The facility failed to provide necessary vision and hearing services to residents. A resident with diabetes and renal disease did not receive new glasses recommended after an eye exam, and another resident with hearing loss did not receive a hearing aid despite a recommendation. Additionally, a third resident with chronic conditions did not receive glasses as advised. The Social Service Director was unaware of these issues, and Medicaid coverage was a barrier for one resident's glasses.
A resident with multiple health conditions, including a pressure ulcer, did not receive the necessary treatment as ordered by the physician, leading to a deficiency in care. Observations revealed the absence of a bandage on the ulcer, which had worsened with necrotic tissue. Staff interviews indicated a lack of adherence to the treatment plan, and the Wound Nurse confirmed the treatment was not completed as ordered, resulting in the wound's deterioration.
A resident with a suprapubic catheter did not receive the required catheter care, as evidenced by an outdated bandage with dried blood. The resident, who has multiple medical conditions, was assessed to need assistance with personal hygiene. Despite physician orders for catheter care every shift, the facility failed to comply, as confirmed by the DON.
A resident with a PEG tube was improperly positioned during enteral feeding, contrary to the care plan requiring the head of the bed to be elevated 30-45 degrees. CNAs lowered the bed and put the feeding on hold, which was not allowed. The resident had multiple health issues and was dependent on staff for care.
A resident with COPD and other health conditions was observed receiving oxygen at 1.5 liters instead of the prescribed 2 liters. The care plan and physician orders both indicated the need for a 2-liter flow rate, but this was not followed, as confirmed by the DON.
A facility failed to maintain accurate documentation for narcotic medications, leading to a suspected diversion by a nurse. A resident prescribed Morphine Sulfate had discrepancies in the narcotic log, with doses inaccurately recorded. The issue was not reported until later, despite the medication being signed out as given twice daily. The nurse involved refused a drug screen and terminated employment.
A facility failed to document blood pressure readings for a resident receiving Hydralazine, despite a physician's order to hold the medication if systolic blood pressure was below 110. Staff interviews revealed that blood pressures were checked but not documented due to system limitations, and nursing leadership acknowledged the oversight.
A resident with Alzheimer's disease was prescribed Seroquel for behavior management without adequate documentation of its necessity or an attempt at gradual dose reduction. The resident's care plan included antipsychotic medication, but there was no approved diagnosis for its use, and the resident had not been seen by the behavioral health NP. Seroquel is not FDA-approved for dementia-related psychosis, and there is a black box warning about increased mortality in such cases.
A resident with decayed and broken teeth did not receive routine dental services due to a lack of follow-up after a dental exam in April 2024. The exam indicated non-restorable teeth and inflamed gums, but no care plan was documented. The MDS Coordinator was unaware of the issues, and the resident had not seen a dentist since the facility changed providers. The resident was reluctant to restart the dental process with the new provider.
The facility did not follow recipes for pureed diets, affecting two residents. A cook prepared pureed barbeque chicken and broccoli without using additional ingredients as specified in the recipes, such as sauce and margarine. The Dietary Manager confirmed that the recipes should have been followed, indicating a failure to adhere to dietary protocols.
The facility failed to maintain accurate clinical records for two residents. A resident with end-stage renal disease had inconsistent documentation of their dialysis access site condition, while another resident, who was NPO, had incorrect medication administration routes documented as oral instead of via peg tube. The DON and ADON acknowledged these documentation errors.
The facility failed to address a repeated deficiency related to pest control, specifically gnats in resident rooms, affecting all 60 residents. Despite regular meetings of the QAA Committee, no action plans or Performance Improvement Plans were developed. The Administrator was aware of the issue and engaged pest control services weekly, but treatments did not always target gnats.
A resident with pressure ulcers was found in a room infested with gnats, which were observed on their bed linen and wound dressing. The Wound Nurse confirmed the presence of gnats during wound care, despite pest control measures being in place for other pests. The facility's pest control program did not address gnats, contrary to its policy of maintaining a pest-free environment.
A resident with a history of falls was observed with a low bed and floor mat, but these interventions were not documented in the care plan. Despite a previous fall, the care plan only included a reach assist bar and lacked specific interventions like the low bed and mat. The DON confirmed the care plan update post-fall but acknowledged the missing documentation.
A facility failed to notify a physician of a resident's elevated blood glucose levels, despite multiple readings above 400 mg/dL. The resident, who was receiving insulin for diabetes, had no specific parameters in place for physician notification. Interviews with staff confirmed the expectation to notify physicians of such levels, but documentation was lacking.
Failure to Maintain Current, Comprehensive Care Plans for Residents With Behaviors, Falls, and Abuse Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and update comprehensive, measurable care plans with current interventions for multiple residents with behaviors, falls, schizophrenia, and abuse/neglect risk. For one resident with Alzheimer’s disease, psychotic disorder, depression, COPD, and cognitive impairment, the record showed two facility-reported incidents: a candy-related interaction with another resident where no injuries occurred, and a later verbal altercation with a different resident that resulted in the resident being found on the floor with right leg and hip pain and being sent to the hospital. Despite these events and existing care plans for elopement/wandering, abuse/neglect risk, and falls, the interventions within these care plans had not been revised for many months, with the elopement/wandering interventions last revised in June of the prior year, the abuse/neglect interventions unchanged since May of the prior year, and the fall interventions last updated in July of the prior year. Another resident with schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse had multiple documented episodes of verbally aggressive behavior toward staff and residents over several dates. Nursing notes documented the use of 30‑minute checks and later 15‑minute safety checks, as well as two separate hospital transfers for evaluation and behavioral health care. The resident had a behavior care plan that included interventions such as praising progress, protecting the rights and safety of others, minimizing disruptive behaviors, and 15‑minute safety checks. However, the interventions in this behavior care plan were not updated after the series of aggressive behaviors and hospitalizations in December and January; the last intervention prior to the February incident was from September of the previous year, and the care plan interventions were only updated after a later psychiatric hospitalization. A third resident with suicidal ideations, dementia, anxiety, hypertension, major depressive disorder, and psychotic disorder was involved in the candy-related incident when another resident offered candy and this resident swatted at it, knocking it to the floor, with no injuries noted. This resident had an abuse/neglect risk care plan and a separate care plan for socially inappropriate and maladaptive behavior, but the interventions for abuse/neglect had not been revised since early August of the prior year, and the socially inappropriate/maladaptive behavior interventions had not been revised since mid‑September of the prior year. A fourth resident with hemiplegia, hypotension, paranoid schizophrenia, aphasia, epilepsy, dysphagia, and a right hand contracture was involved in an aggressive incident toward the third resident, after which both residents were assessed and one was sent to the hospital. This fourth resident had an abuse/neglect risk care plan and a schizophrenia care plan, but the abuse/neglect interventions had not been revised since May of the prior year, and the schizophrenia care plan interventions had not been updated since early May of the prior year, despite the later aggressive incident and subsequent care plan revision dates that did not include updated interventions.
Failure to Notify Responsible Party of Roommate Change
Penalty
Summary
The facility failed to notify a resident’s Responsible Party of a change in roommate, as required for situations that affect the resident. Resident B’s record, reviewed on 2/23/26, showed multiple diagnoses including Alzheimer’s disease, psychotic disorder, hypertension, depression, anemia, and COPD, and a Quarterly MDS dated 11/4/25 documented that the resident was cognitively impaired for daily decision making. A nurse’s progress note dated 1/22/26 at 12:46 a.m. stated that the resident appeared to be adjusting well to a new roommate, confirming that a roommate change had occurred. However, there was no documentation that the resident’s Responsible Party had been notified of this new roommate, and during interview the DON acknowledged that the Responsible Party was not notified of the roommate change, as she believed notification was only required for a room change. This deficiency was cited under 3.1-5(b)(1) and related to Intake 2739564.
Failure to Conduct and Document Ongoing Care Plan Meetings
Penalty
Summary
The facility failed to ensure required care plan meetings were conducted and documented for a resident, as mandated to be developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by an interdisciplinary team. Record review for Resident B, who had diagnoses including Alzheimer's disease, psychotic disorder, hypertension, depression, anemia, and COPD, showed that a Quarterly MDS dated 11/4/25 identified the resident as cognitively impaired for daily decision making. A Social Services note dated 9/23/25 documented that the Social Service Director contacted the resident's daughter to schedule a care plan meeting, and the daughter agreed to have the meeting when she arrived at the facility that day, with the SSD indicating availability to conduct it. The record showed the last care plan meeting occurred on 9/23/25, with no documentation of any subsequent care plan meetings after that date. During interview, the Nurse Consultant reported contacting the previous social worker and confirmed there was no documentation of a scheduled or rescheduled care plan meeting, and stated that any cancelled meeting should have been documented as rescheduled. This citation relates to Intake 2739564 and regulatory reference 3.1-35.
Failure to Provide Adequate Behavioral Health Interventions and Monitoring
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services to a resident with a history of significant psychiatric and behavioral issues. The resident’s diagnoses included schizophrenia, dementia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, alcohol abuse, and dysphagia. A quarterly MDS showed the resident was cognitively intact for daily decision-making but had worsening verbal behaviors. On one day, multiple behavior notes documented verbal aggression toward staff and residents, and the resident was placed on 30‑minute safety checks for 72 hours. Subsequently, the resident was sent to the hospital for evaluation and later returned to the facility. Following the resident’s return, a physician ordered 15‑minute safety checks every shift with completion of a safety log, and nursing documentation indicated the resident was verbally aggressive and placed on 15‑minute checks before being sent again to a hospital behavioral health unit. However, the record lacked documentation of 15‑minute safety checks from late December through early February, despite ongoing behavior issues. During this period, multiple nurse’s notes documented repeated verbally aggressive behaviors on numerous dates. The behavior care plan, which identified aggression toward staff and residents related to mental illness, contained general interventions such as administering medications, assessing coping skills, and assessing understanding of the situation, but behavior interventions were not updated after the December incidents and hospitalizations. On a later date in February, nurse’s notes documented verbal and physical aggression toward staff and another resident, leading to the resident being isolated from others and sent to the hospital for psychological evaluation. A facility‑reported incident described staff overhearing a verbal altercation between two residents, after which one resident was found on the floor with pain in the leg and hip and was sent to the hospital, while the aggressive resident was sent for psychiatric evaluation. A physician again ordered 15‑minute safety checks for 72 hours. The behavior care plan, originally dated in 2023 and revised in early February 2026, noted a history of verbal and physical aggression and included interventions such as praising progress, protecting the rights and safety of others, and placing the resident on 15‑minute safety checks, but the interventions had not been updated between September 2024 and mid‑February 2026 despite multiple aggressive incidents and hospitalizations. Interviews with the ADON, CNAs, and DON confirmed the resident’s unpredictable, unprovoked verbal and physical aggression, the lack of effective de‑escalation techniques, and that the resident was not on 15‑minute safety checks when returning from earlier psychological evaluations.
Failure to Accurately Document 15-Minute Safety Checks
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete clinical records for a resident on physician-ordered 15-minute safety checks. Resident C had multiple diagnoses, including schizophrenia, dementia, dysphagia, depression, anxiety, mild cognitive impairment, mild intellectual abilities, restlessness and agitation, HIV, and alcohol abuse. A Quarterly MDS dated 11/4/25 documented that the resident was cognitively intact for daily decision-making and exhibited verbal behaviors that were worse than on the previous assessment. A physician’s order dated 2/16/26 directed staff to initiate 15-minute safety checks every shift for monitoring. On 2/24/26, review of the safety logs on the second floor showed that the 15-minute safety checks for Resident C were not signed out from 3:00 p.m. to 4:00 p.m. During interview, an LPN stated she should have charted the 15-minute checks after performing them but had not yet done so. In a separate interview, the DON stated she expected nursing staff to complete all ordered 15-minute safety checks and sign off in the logs each time, and acknowledged that the checks for the previous hour should have been signed off.
Failure to Submit PBJ Staffing Data
Penalty
Summary
The facility failed to ensure mandatory direct care staffing information, based on payroll and other verifiable and auditable data, was electronically submitted to iQIES. Review of the CMS Payroll Based Journal (PBJ) Staffing Data report for FY Quarter 4 2025 showed the facility did not submit the required data. During interview, the VP of Operations stated he could access the PBJ submission log and that iQIES showed a connection error and that files failed to send. He also stated that he, Nurse Consultant 1, and the HR Director Consultant reviewed schedules quarterly before submission. Nurse Consultant 1 stated she contacted iQIES and was told it was the facility's responsibility to ensure the PBJ was transmitted and submitted, and she acknowledged that although the HR Director, VP of Operations, and she met to finalize the 4th quarter PBJ before it was due, she did not check to confirm the submission went through.
Dignity concerns with beverage access and swallowing signs posted in view
Penalty
Summary
The facility failed to maintain resident dignity by not offering appropriate beverages during activities and by posting personal care signs in resident rooms in plain view. Resident 2, who had dysphagia following a stroke and vascular dementia and was cognitively impaired for daily decision making, was observed in the Second Floor dining room participating in an activity and was given a cup of coffee. After the coffee was removed because it was not thickened, the resident was not given anything else to drink while other residents continued drinking their coffee. On a later observation, activity staff were passing out cups of coffee in the dining room, but Resident 2 was not offered anything to drink. The ADON stated the resident should have been provided a thickened drink after the coffee was removed. Resident 20 entered the dining room and asked the Activity Aide for coffee, but was told there was no coffee and only juice available. The resident stated it was the coldest day of the year and asked about coffee, but the Activity Aide did not call the kitchen to see if coffee could be obtained. In addition, a sign reading "Swallow Precautions" was observed posted above Resident 1's bed on multiple observations; Resident 1 had dysphagia, stroke, dementia, moderate impairment in daily decision making, and was on a mechanically altered diet. A similar swallowing instruction sign was also observed above Resident 43's bed on multiple observations; Resident 43 had vascular dementia, dysphagia, moderate cognitive impairment, and was dependent in ADLs and transfers. The DON stated the signs should not be posted in plain view and indicated speech therapy would be educated.
Resident Privacy Not Respected During Room Search
Penalty
Summary
The facility failed to ensure a resident’s privacy was respected when staff completed a room search of the resident’s personal belongings for smoking materials without the resident’s permission or presence. The resident was observed lying in bed and appeared visibly upset when he later stated that staff had made him attend the resident Christmas party and that he watched other residents exchange gifts while he received nothing. He then reported that, after staff returned him to his room, the DON told him staff had gone through his belongings looking for smoking materials, and he stated he was upset that he had not been informed the sweep was going to happen and was not given the opportunity to be there. The resident had diagnoses including quadriplegia, trauma, depression, and PTSD. The admission MDS indicated he was cognitively intact for daily decision making and dependent in ADLs and transfers. A nurse’s note documented that sweeps were performed because the resident was an active smoker and that smoking materials were confiscated. The resident’s signed smoking consent stated that his clothing, bags, and room could be searched for smoking materials, but it did not state that searches could be conducted without his knowledge or presence. During interview, the DON stated she had been told the social worker was going to inform residents that staff would go through their belongings looking for smoking materials, and she acknowledged that it should not have happened that way.
Failure to Provide Hair Washing Assistance
Penalty
Summary
The facility failed to ensure a dependent resident received assistance with ADLs related to hair washing. Resident 24 had diagnoses including major depressive disorder, anxiety, and osteoarthritis, and the 8/31/25 Quarterly MDS indicated she was cognitively intact for daily decision making and needed substantial to maximal assistance with bathing and showering. Her care plan, revised on 12/11/25, identified that she required assistance with ADLs including bed mobility, transfers, and bathing, and also noted she was resistive to care related to ADL refusal. During an interview on 12/12/25, the resident stated she preferred a bed bath, did not like going into the shower room, and did not remember the last time her hair was washed. She was observed on multiple occasions with greasy hair and a large amount of dandruff flakes, and she stated her hair had not been washed. The physician’s order directed Selsun Blue shampoo to be applied to her hair on Tuesday and Friday evenings for dandruff, and the MAR showed the shampoo was signed out on multiple dates in November and December 2025. However, the Skin Shower Sheets documented complete bed baths on several dates but did not document that her hair was washed during those baths, and there was no documentation that she refused hair washing. The DON stated there was no place on the current shower sheets to document hair washing.
Failure to complete post-fall follow-up documentation and apply ordered compression wraps
Penalty
Summary
The facility failed to ensure follow-up documentation after a fall was completed for a resident with diagnoses including stroke, major depressive disorder, dementia, and high blood pressure. The resident’s quarterly MDS indicated he was not cognitively intact for daily decision making and needed substantial to maximal assistance for transfers. Records showed a witnessed fall out of a wheelchair on 10/28/25, with a post-fall observation form completed that day. However, the fall follow-up assessments documented on 10/28/25 late evening and on 10/29/25 showed the most recent vital signs as 10/29/25 at 8:43 a.m., while the vital signs section of the clinical record contained only one entry for that date. A nurse consultant stated there was no fall follow-up completed for the evening shift on 10/29/25 and that nursing staff were to document every shift for 72 hours after a fall. The facility also failed to apply compression wraps as ordered for another resident with bilateral lower extremity edema. This resident had diagnoses including chronic kidney disease, stroke, anxiety disorder, schizophrenia, bipolar disorder, dementia, and high blood pressure, and the admission MDS indicated moderate impairment in daily decision making. The care plan identified risk for impaired circulation related to dependent edema and directed compression bandages for bilateral lower extremity edema, on in the morning and off at night. The physician’s order dated 12/4/25 also directed compression bandages to both lower extremities daily for edema. During multiple observations, the resident was seen with edema to both ankles and was not wearing compression socks or ace wraps on the legs.
Inadequate supervision with hot beverages, thickened liquids, and vaping
Penalty
Summary
The facility failed to provide adequate supervision related to the serving of hot beverages and thickened liquids for a resident with dysphagia and cognitive impairment. Resident 2 had diagnoses including dysphagia following stroke and vascular dementia, and the quarterly MDS indicated he was cognitively impaired for daily decision making and required supervision or touching assistance for eating. His care plan directed that he eat only with supervision, and the physician’s order required a pureed diet with nectar thickened liquids. During observation, he was given a cup of coffee that was not thickened and had no lid while participating in an activity in the dining room. Because of his tremors, the coffee spilled on the table and his hands, and he was able to drink some of it before staff removed the cup several minutes later. The facility also failed to ensure adequate supervision related to a resident vaping in her room. Resident 63, who had diagnoses including COPD, anxiety disorder, heart failure, and high blood pressure, was observed vaping in her room while seated in her wheelchair, with a restorative CNA watching and the housekeeping director present in the room. Her roommate was in bed with her eyes closed. The resident’s significant change MDS indicated she was moderately impaired for decision making. Her care plan identified her as a tobacco user and directed her to adhere to the smoking policy. A smoking risk assessment indicated she actively smoked and was able to vape with one-to-one supervision, while the facility’s smoking policy stated smoking was permitted only in designated areas and that possessing, carrying, or holding smoking materials by residents who required supervision was prohibited inside the building.
Foley Catheter and Nephrostomy Care Not Properly Managed
Penalty
Summary
The facility failed to keep an indwelling Foley catheter bag and tubing off the floor for a resident with chronic kidney disease, stroke, anxiety disorder, schizophrenia, bipolar disorder, dementia, and neuromuscular dysfunction of the bladder. The resident’s MDS indicated he was moderately impaired for daily decision making and frequently incontinent of urine. During multiple observations, the Foley catheter bag and tubing were seen on the floor next to the bed and later on the floor by the wheelchair. The resident’s record showed a Foley catheter order and a urine culture positive for greater than 100,000 colonies of Klebsiella-ESBL, with an antibiotic ordered for the urinary tract infection. The DON stated the Foley catheter bag and tubing should not have been on the floor. The facility also failed to ensure appropriate nephrostomy tube care for another resident with a urinary tract infection, stage 4 sacral pressure ulcer, and an artificial opening of the urinary tract. The resident’s MDS indicated he was cognitively intact and required substantial assistance with ADLs. During observation, the nephrostomy dressing was removed, a StatLock was in place with edges coming up, and the tubing was connected to a collection bag that was not dated; neither the StatLock nor the collection bag was dated. The wound nurse stated she did not normally perform the nephrostomy care and was not sure when the StatLock or collection bags were changed. The record lacked documentation of nephrostomy bag changes, instructions for StatLock use or change, and output documentation for multiple shifts, with no documentation that the physician was notified of no urine output.
Improper PEG Tube Placement Check Before Medication Administration
Penalty
Summary
The facility failed to check for PEG tube placement properly before medication administration for one resident observed receiving medications through a PEG tube. During a medication administration observation, an RN prepared medications for the resident, placed the enteral tube feeding on hold, removed the connection device, and inserted a syringe into one of the PEG tube ports. She poured 30 cc of water down the tube by gravity and then placed the piston in the syringe to pull back stomach contents to check for residual. When she attempted to aspirate, she obtained less than 5 cc of fluid from each port and stated she was supposed to be able to pull back 30 cc of residual and would notify the physician. The resident’s record showed diagnoses including gastrostomy tube, and the physician’s order directed staff to check enteral feeding tube placement by aspirating 30 ml and then returning it, and to hold feeding and notify the physician if placement could not be verified by aspiration. A nurse consultant stated the RN should have checked for residual by aspirating fluid first before flushing the tube with 30 cc of water, and the facility policy also directed staff to use the aspiration method first.
Implanted Port Not Monitored per Order
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for one resident with an implanted port device. Resident 63 had diagnoses including vulva cancer, adult failure to thrive, COPD, anxiety disorder, heart failure, and high blood pressure, and the 9/26/25 MDS indicated she was moderately impaired for decision making. During an observation on 12/12/25 at 2:00 p.m., she was seen sitting in a wheelchair by the elevator with her shirt falling off her shoulder, and an implanted port device with a white bandage over it was visible on her chest. Record review showed the resident had a right chest port-a-cath noted in the care plan and admission assessment, with physician orders from 8/2/25 and 8/20/25 to monitor the central venous access port and report abnormalities to the provider. The record also indicated the resident was admitted to the hospital and, after her return, there were no orders to monitor the PAC until a new order was written on 12/12/25 to monitor the right chest port and report swelling, drainage, or pain. During interview, the DON stated nurses should have been monitoring the device, but a new physician order had not been put into place after the most recent hospitalization. The facility policy stated ports must be flushed per physician order, the site assessed for signs of infection prior to each use, and all procedures documented in the medical record.
Improper Storage of Pre-Filled Saline Syringes
Penalty
Summary
The facility failed to ensure proper medication storage related to pre-filled normal saline syringes used to flush an implanted port for Resident 74. During a medication pass observation, an LPN entered the resident’s room with an IV antibiotic and two pre-filled normal saline syringes to flush the resident’s line before administration. At that time, a pre-filled normal saline syringe was already laying on the resident’s over-bed table, and two more pre-filled normal saline syringes were on top of the nightstand. After using the two syringes she brought into the room, the LPN placed the other three syringes on top of the nightstand before leaving the room. Later, the LPN returned with another pre-filled normal saline syringe to take the IV down, but the antibiotic had not completely infused, so she left the syringe on the over-bed table and exited the room. When she returned again after the IV antibiotic had infused, she used the syringe on the over-bed table to flush the line and left the room. The other three pre-filled normal saline syringes remained on the nightstand. During interview, the LPN stated she was unaware the syringes were left in the room and said she would remove them. The DON had no additional information, and the facility’s medication storage policy stated medications and biologicals should be stored in an orderly manner and locked in cabinets, drawers, carts, and refrigerators.
Food Served at Unappetizing Temperature
Penalty
Summary
The facility failed to ensure food was served at a palatable temperature for one meal observation involving Residents 4, 24, and 42. During interviews, Resident 4 stated the facility's food was bad and that he did not want to eat it most of the time. Resident 24 stated the food was often cold, and Resident 42 stated in resident council that food taste and temperature had been a concern and that food was often cold when received. During a lunch meal observation, trays were brought to the second floor dining room on a non-insulated cart. When the Kitchen Manager checked test tray temperatures, the chicken was 104 degrees, the rice was 120 degrees, and the black beans were 120 degrees using a manual thermometer. The Kitchen Manager stated she thought there was something wrong with the thermometer, covered the food, and went to get a digital thermometer, but later returned unable to find batteries for it. The food was tasted and was not hot. CNA 1 stated she passed all of the room trays and got drinks for residents by herself. The facility policy stated residents are to receive food that is palatable, attractive, and served at a safe and appetizing temperature.
Failure to Provide Ordered Physical Therapy
Penalty
Summary
The facility failed to ensure a resident received PT as ordered by the physician. The resident was admitted with diagnoses including chronic kidney disease and post-surgical T11 through L1 laminectomy. The admission MDS indicated the resident was cognitively intact for daily decision making and was receiving speech, OT, and PT. A physician’s order dated 11/1/25 directed PT five times a week for 30 days for therapeutic exercises, activity tolerance training, gait training, bed mobility training, and transfer training, and a PT certification and evaluation also dated 11/1/25 reflected that schedule. The resident was seen by PT on 11/1, 11/5, 11/6, and 11/7/25, then a new physician’s order dated 11/11/25 changed PT to three times a week for four weeks. The resident was seen on 11/11 and 11/12/25, was unavailable on 11/14/25 with no reason documented, and was seen again on 11/19 and 11/21/25. PT notes indicated a session was canceled by another staff member on 11/20/25, and the resident was not picked up for a third day of PT during the weeks reviewed. During interview, the resident stated he did not receive therapy and sometimes went many days without it. The Rehab Director stated she was the only full-time staff member due to census and that PRN staff were only in the building sometimes for three hours at a time because they worked at other sister facilities. The Administrator stated residents should receive therapy as ordered by the physician.
Incomplete and inaccurate tube feeding documentation
Penalty
Summary
The facility failed to ensure the medical record was complete and accurate for one resident with CHF, dysphagia, and a gastrostomy tube. The resident’s Significant Change MDS indicated moderate cognitive impairment, substantial assistance with ADLs, and enteral feeding. A physician’s order required verification of enteral feeding residuals every shift and to hold the feeding and notify the physician if residuals were more than 100 ml. However, the December MAR documented multiple residual amounts over that limit, including 300 ml, 250 ml, and 560 ml, with no narrative notes showing that the resident had residuals over 100 ml, was not tolerating feedings, or that the physician was notified. During interview, the DON stated the nurses had documented incorrectly and that an NP note in the resident’s record actually contained the wrong resident’s information.
Failure to Monitor Antibiotic Use and Respond to Resistant Culture Results
Penalty
Summary
The facility failed to promote antibiotic stewardship for a resident with an indwelling suprapubic catheter by continuing ciprofloxacin therapy even after the urine culture showed the organism was resistant to that medication. Resident 8 was cognitively intact and had diagnoses including chronic kidney disease, renal dialysis, and obstructive and reflux uropathy. The resident had a suprapubic catheter in place related to obstructive uropathy with urinary retention, and the care plan directed staff to monitor and report signs and symptoms of a UTI. After the resident complained of pain and discomfort with urination, the physician was notified and a urinalysis with culture and sensitivity was ordered. The resident was then prescribed ciprofloxacin 500 mg daily for five days for a UTI. The urine culture later identified Proteus mirabilis and showed resistance to ciprofloxacin, but the resident still received the full five-day course. There was no documentation that the physician was notified of the culture results, and the DON stated the resident should not have received ciprofloxacin because it was resistant and the physician should have been notified.
Failure to Ensure Correct Oxygen Flow Rate for Resident
Penalty
Summary
A deficiency was identified when a resident requiring oxygen therapy for conditions including COPD, heart failure, and dementia was observed with their oxygen flow rate set incorrectly on multiple occasions. On two separate days, the oxygen flow meter was set slightly above 1.5 liters per minute, rather than the physician-ordered 2 liters per minute via nasal cannula. During one observation, the nasal cannula tubing was not properly positioned under the resident's nose. An LPN, when questioned, initially stated the oxygen was set at 2 liters but upon verification, acknowledged the flow rate was incorrect and adjusted it to the prescribed level. The resident's care plan specified oxygen therapy as needed for shortness of breath, with instructions to administer oxygen as ordered by the physician. The resident's medical record confirmed the order for 2 liters of oxygen via nasal cannula as needed. The DON confirmed that nursing staff had been previously in-serviced on the correct method for checking oxygen flow rates, which involves viewing the flow meter at eye level to ensure accuracy. Despite these instructions, the oxygen was not set at the correct rate as ordered.
Inadequate Supervision During Hoyer Lift Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance and supervision during a mechanical lift transfer, resulting in a fall and injury for a dependent resident. The incident involved a single staff member assisting the resident during a Hoyer lift transfer, contrary to the facility's policy and the manufacturer's recommendation of requiring two staff members. This lapse in protocol led to the resident falling and sustaining a fracture to her leg. The resident involved in the incident was cognitively intact but dependent on staff for mobility and transfers. She had a history of conditions that increased her risk for falls, including osteoporosis and neuromuscular weakness. Despite these risk factors, the resident was transferred by only one staff member, which was insufficient to ensure her safety during the transfer process. The incident was witnessed by a CNA who admitted to transferring the resident alone because she could not find another staff member to assist, and the resident was insistent on being moved. The CNA attempted to prevent the fall by getting under the resident, but the resident's leg may have hit the lift, contributing to the injury. The facility's failure to adhere to the two-person transfer policy directly led to the resident's fall and subsequent injury.
Environmental Deficiencies on First Floor
Penalty
Summary
The facility failed to maintain a safe and well-maintained environment for residents on the first floor, as observed during an environmental tour. Several deficiencies were noted, including marred walls, loose baseboards, and missing bolts around toilets in multiple rooms. Specifically, the cove base was pulling away from the wall near the entrance of one room, and the walls were marred under the chair rail. Another room had a marred and gouged wall behind the bed. In a different room, the door frame was marred by the closet, and the cove base was loose in the entryway. Additionally, the bathroom walls were marred. In another instance, the bathroom door frame was marred, and the paint on the walls was chipped, with exposed bolts at the base of the toilet. These conditions affected several residents who shared these rooms and bathrooms. The Maintenance Director acknowledged the need for repairs during the interview.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain the dignity of a cognitively impaired resident, identified as Resident 58, who was observed wearing a hospital gown during the day on multiple occasions. The resident, who was moderately impaired in daily decision-making due to conditions such as stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, and restlessness, did not have a care plan indicating a preference for wearing a hospital gown. Additionally, an Activity Assessment for the resident was incomplete, lacking information on recreation interests, habits, and preferences. During an interview, the Director of Nursing acknowledged that the resident had no clothes but confirmed there was no care plan addressing this issue.
Deficiency in ADL Assistance for Two Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for two residents, specifically in the areas of nail care, oral hygiene, and mobility. Resident 45 was observed multiple times with long and dirty fingernails, despite expressing a need for nail care. The resident's care plan indicated a need for assistance with personal hygiene, but nail care had not been performed since 7/29/24. Interviews with staff revealed that nail care was not provided as needed, and the Director of Nursing confirmed that nail care should be done as required. Resident 58 was also observed with long fingernails and dried mucous around the lips, indicating a lack of oral care. The resident was dependent on staff for personal hygiene and oral care due to a recent stroke, as noted in the care plan. Despite this, there was no documentation of oral care being performed daily. Additionally, the resident was not being assisted out of bed, although there was no physician's order for bed rest. Staff interviews confirmed the lack of oral care and mobility assistance, and the Director of Nursing acknowledged that these care tasks should have been completed as needed.
Failure to Provide Personalized Activity Programs for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide a personalized activity program for two residents, both of whom were cognitively impaired and dependent. Resident 24, diagnosed with conditions including stroke and major depressive disorder, was observed multiple times over several days in a persistent vegetative state, lying in bed with no television or radio present for stimulation. The resident's care plan indicated the need for 1:1 visits and music stimulation, yet the resident only received minimal engagement, such as listening to music on two occasions and being read a story twice in early August. The Activity Director acknowledged the lack of ongoing stimulation and the absence of a radio in the resident's room. Resident 58, who had diagnoses including stroke and diabetes, was observed in bed with the television turned off and positioned in a way that the resident could not see it. The resident's care plan required encouragement for activities, but the resident had not participated in any group activities since June and had limited 1:1 visits. The Activity Director noted that the care plan did not reflect the resident's current status, and there was no radio for continuous music. The Director of Nursing mentioned that the resident was not being moved out of bed due to restlessness, although there was no care plan or physician's order for bed rest.
Failure to Provide Proper Skin Care and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with non-pressure related skin conditions. Resident 13, who has multiple diagnoses including COPD, diabetes, and heart disease, was observed with dry, flaky skin on her feet and an open area on her right ring finger that was not covered. The resident reported that the treatment for her finger was last done on a previous Friday and was supposed to be done every Monday, Wednesday, and Friday. However, the treatment was not completed as scheduled on 8/6/24. The Wound Physician had ordered daily treatment with betadine, but the Treatment Administration Record indicated it was not consistently administered. The Wound Nurse acknowledged the treatment was to be done daily, and the Director of Nursing confirmed the treatment should have been completed as ordered. Resident 57, who has Alzheimer's disease and other conditions, was observed with a large red and purple discoloration on his left forearm. Despite this visible condition, there was no documentation in the clinical record regarding the discoloration from 8/1-8/7/24. Staff members, including an LPN and an RN, were unaware of the discoloration, and the Director of Nursing only assessed it after being informed. The resident mentioned that such discolorations occur frequently. The facility's Wound Management policy was intended to assist in the care and documentation of wounds, but it was not effectively implemented in this case.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure that residents received necessary vision and hearing services as ordered. Resident 2, who has diagnoses including type 2 diabetes and end-stage renal disease, reported needing new glasses, which were recommended after an eye exam on 12/19/23. Despite being cognitively intact and having a care plan that included arranging consultations with an eye care practitioner, there was no documentation indicating that the resident received the new glasses. The Social Service Director, who had been employed for 95 days, acknowledged the issue and noted that Medicaid would not cover the cost of the glasses, leaving the resident with a $215 out-of-pocket expense. Resident 45, with multiple diagnoses including spinal cord infarction and major depressive disorder, indicated he had been fitted for a hearing aid months ago but had not received any follow-up. An audiology exam from 9/6/23 recommended a hearing aid due to moderate to severe sensorineural hearing loss, but there was no care plan addressing hearing difficulties, and the Social Service Director was unaware of the need for a hearing aid. Similarly, Resident 34, with diagnoses including chronic kidney disease and depressive disorder, had an eye exam on 12/19/23 recommending new glasses, but had not received them. The Social Service Director confirmed that the resident should have received glasses following the recommendation.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatment and services for a resident with a pressure sore, leading to a deficiency in care. During an observation, it was noted that a resident with a pressure ulcer did not have a bandage covering the affected area, and the ulcer showed signs of necrotic tissue. The resident, who was dependent on staff for repositioning and had multiple health conditions including stroke and diabetes, was observed with several ulcers on the buttocks and sacral area, which were not properly treated as per the physician's orders. The treatment plan included the application of a hydrocolloid dressing three times a week, but this was not adhered to, resulting in the deterioration of the wound. Interviews with staff revealed a lack of awareness and execution of the prescribed treatment plan. A CNA indicated the resident was last changed hours before the observation, and an LPN was unsure of the treatment required. The Wound Nurse confirmed that the treatment was not completed as ordered, and the wound had worsened since the last assessment. The resident's condition had declined, with the wound evolving into an unstageable pressure ulcer, and additional new wounds were noted. The Director of Nursing acknowledged that the treatment should have been completed as ordered.
Failure to Provide Adequate Catheter Care for a Resident
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic foley catheter, as observed during a survey. Resident 45, who has a suprapubic catheter, was found with a bandage around the stoma that was dated three days prior and had dried brown blood on it. This observation was made during a random check while the resident was in bed. The resident's medical history includes conditions such as infarction of the spinal cord, heart disease, high blood pressure, type 2 diabetes, major depressive disorder, anxiety disorder, urine retention, and neuromuscular issues of the bladder. The resident was assessed to be cognitively intact and required partial to moderate assistance with personal hygiene. The care plan for the resident, revised in July, indicated that the resident was attention-seeking regarding catheter care, with an approach to provide catheter care as ordered. However, the physician's orders from July required catheter care every shift, which was not adhered to, as evidenced by the outdated bandage. The facility's policy on suprapubic site care, dated February 2021, outlines the procedure to decrease the risk of infection, including cleaning the area around the stoma and evaluating it for any signs of infection. Despite these guidelines, the facility did not ensure that the resident received the necessary catheter care, as confirmed by the Director of Nursing, who had no additional information to provide.
Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper positioning of a resident during enteral feeding, which is a deficiency in care. During an observation, two CNAs were asked to reposition a resident with a PEG tube to examine a pressure ulcer. One of the CNAs lowered the head of the bed to 5 degrees while the enteral feeding was infusing, which is against the care plan that requires the head of the bed to be elevated 30-45 degrees during and thirty minutes after tube feeding. The CNA then put the feeding on hold, claiming that nurses allowed them to do so, which was not appropriate according to the Director of Nursing. The resident involved had a history of stroke, obesity, dysphagia, type 2 diabetes, high blood pressure, heart disease, restlessness, and agitation, and was dependent on staff for various activities. The resident was moderately impaired in daily decision-making and received more than half of their nutrition through the PEG tube. The physician's orders specified that the resident was NPO and required enteral feeding at specific times. The deficiency was identified through observation, record review, and interviews, highlighting a lapse in following the care plan and physician's orders.
Failure to Maintain Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that oxygen was set at the correct flow rate for a resident requiring respiratory care. During observations on multiple occasions, the resident was seen wearing oxygen via nasal cannula at 1.5 liters, despite physician orders specifying a flow rate of 2 liters. The resident's medical record indicated a history of chronic obstructive pulmonary disease (COPD), chronic respiratory failure, and other significant health conditions. The care plan, revised on two separate occasions, also specified the need for oxygen therapy at 2 liters. However, the observed flow rate did not align with these orders, as confirmed by the Director of Nursing during an interview.
Narcotic Documentation Discrepancy and Diversion Investigation
Penalty
Summary
The facility failed to maintain an accurate system for accounting, reconciling, and ensuring the disposition of controlled drugs, specifically narcotics, for a resident. This deficiency was identified during an investigation into a suspected narcotic diversion involving a previously employed nurse. The investigation revealed discrepancies in the documentation of narcotic medications for a resident who was prescribed Morphine Sulfate for pain and shortness of breath. The narcotic log showed inconsistencies in the recorded remaining doses, particularly on 7/6/24, where the remaining dose was inaccurately documented as higher than expected. This discrepancy was not reported until 7/31/24, despite the medication administration record indicating the medication was signed out as given twice daily throughout July. The resident involved had multiple diagnoses, including hemiplegia, a stage 4 sacral wound, and anxiety, and was using hospice services. The care plan highlighted the risks associated with opioid use, such as constipation and respiratory failure. During interviews, it was revealed that the nurse who administered the morphine on 7/6/24 did not report the discrepancy to the Director of Nursing or the Administrator. The nurse consultant acknowledged that a diversion issue likely existed before the report was filed. The nurse involved in the discrepancy refused a drug screen and subsequently signed a voluntary termination.
Failure to Document Blood Pressure Monitoring for Medication Administration
Penalty
Summary
The facility failed to appropriately monitor and document blood pressures for a resident receiving Hydralazine, a medication used to lower blood pressure. The resident, who was admitted with multiple diagnoses including stroke, obesity, type 2 diabetes, and high blood pressure, had a physician's order to hold Hydralazine if the systolic blood pressure was less than 110. However, the Medication Administration Record (MAR) for July and August 2024 showed no documented blood pressure readings prior to the administration of the medication, with the last recorded blood pressure being on July 28, 2024. Interviews with facility staff revealed that blood pressures were checked but not documented due to a lack of a designated place in the computer system. The LPN responsible for administering the medication confirmed that she checked the blood pressure but did not document it. Both the Assistant Director of Nursing and the Director of Nursing acknowledged that blood pressures should have been recorded in the clinical record before administering Hydralazine, indicating a lapse in following proper documentation protocols.
Inadequate Documentation for Antipsychotic Medication Use
Penalty
Summary
The facility failed to document an adequate indication for the use of an antipsychotic medication for a resident diagnosed with Alzheimer's disease, high blood pressure, anemia, and osteoarthritis. The resident, who was moderately impaired in daily decision-making and exhibited wandering behavior, was prescribed Seroquel, an antipsychotic medication, for behavior management without a documented attempt at gradual dose reduction (GDR). The resident's care plan indicated the use of antipsychotic medication, but there was no documentation of behaviors or an adequate indication for its use in the clinical record. The resident was initially prescribed Seroquel 25 mg at bedtime for insomnia, which was later increased to 50 mg at bedtime and 25 mg in the morning for restlessness. Despite these changes, there was no approved diagnosis for the use of Seroquel, and the resident had not been seen by the contracted behavioral health Nurse Practitioner. The FDA-approved uses for Seroquel do not include treatment for dementia-related psychosis, and there is a black box warning about increased mortality in elderly patients with dementia-related psychosis treated with antipsychotic drugs.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for a resident with decayed and broken teeth. The resident, who was cognitively intact and required assistance with personal hygiene, had not received dental care since a dental exam in April 2024. This exam revealed root tips, non-restorable teeth, and inflamed gums, with recommendations for further x-rays and a treatment plan. However, no care plan for dental issues was documented, and the resident had not been seen by a dentist since the facility switched dental providers. Interviews revealed that the MDS Coordinator was unaware of the resident's dental issues, relying on the MDS look-back assessment rather than direct observation. The Social Service Director confirmed the resident had not seen a dentist since April 2024, despite visits from a new dental company in June and August 2024. The resident expressed reluctance to see the new dentist, not wanting to restart the process. This lack of follow-up and coordination resulted in the resident's continued dental issues.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that food was prepared in a form to meet individual needs, specifically for residents on a pureed diet. During an observation, it was noted that a cook prepared pureed barbeque chicken and broccoli without following the provided recipes. The cook did not use any additional ingredients as specified in the recipes, such as sauce for the chicken or margarine for the broccoli, resulting in a mixture that was pudding thick and even, but not prepared according to the guidelines. The Dietary Manager confirmed that the recipes should have been followed, indicating a lapse in adherence to dietary protocols.
Documentation Errors in Dialysis and Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for two residents, leading to deficiencies in documentation. For Resident 2, who had diagnoses including type 2 diabetes and end-stage renal disease, the facility did not correctly document the condition of the resident's dialysis access site. The care plan required the site to be assessed every shift for signs of infection, with abnormalities noted using specific symbols. However, the July Medication Administration Record (MAR) showed both positive and negative symbols documented on several dates, indicating inconsistencies in recording the site's condition. The Director of Nursing confirmed that the MAR should have been coded correctly. For Resident 58, who had multiple diagnoses including stroke, obesity, and dysphagia, the facility failed to accurately document the administration route for medications. Despite the resident being NPO and receiving nutrition through a peg tube, the physician's orders incorrectly indicated that medications were to be given by mouth. An LPN acknowledged awareness of the resident's NPO status but was unsure why the orders specified oral administration. The Assistant Director of Nursing confirmed that the orders should have reflected administration through the peg tube.
Failure to Address Repeated Pest Control Deficiency
Penalty
Summary
The facility failed to address unresolved quality deficiencies related to pest control, specifically concerning gnats in resident rooms. This issue was previously cited in an annual survey, indicating a repeated deficiency. The Quality Assessment and Assurance (QAA) Committee, which includes various key personnel such as the Medical Director, Administrator, and Director of Nursing, met regularly but did not develop or implement action plans to address the pest control issue. The lack of a Performance Improvement Plan (PIP) for the prevention of gnats was noted, despite the Administrator's awareness of the problem and the engagement of a pest control company. The deficiency had the potential to affect all 60 residents residing in the facility. During an interview, the Administrator acknowledged the ongoing gnat problem and mentioned that pest control services were being utilized weekly, although they did not always treat for gnats. The Administrator was in the process of reviewing the pest control contract to make necessary revisions. However, there was no evidence of continuous monitoring or corrective actions being taken to resolve the issue effectively.
Facility Fails to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, as evidenced by the presence of gnats in a resident's room. On the morning of August 5, 2024, a resident was observed in bed with gnats flying around the room and landing on their bed linen and wound dressing. The Wound Nurse, upon entering the room to perform wound care, noted gnats in the air, on the resident's gown, and within the bandages covering the resident's open ulcerations on the right lower leg. The Wound Nurse acknowledged the presence of gnats and mentioned that a work order had been submitted for pest treatment. Despite the presence of gnat strips in the room, the gnats continued to be a problem during the wound care process. The resident's medical record indicated diagnoses of pressure ulcers and hemiplegia following a cerebral infarction, with hospice services being provided. A review of the facility's pest control documentation revealed that while fruit flies, bed bugs, and cockroaches had been treated in various areas of the facility, gnats had not been addressed. The facility's policy on maintaining a safe environment stated that the facility should be free of pests and rodents, yet this was not achieved in the case of the resident's room. The Administrator later confirmed that the resident was moved to a different room, and the original room was deep cleaned.
Failure to Document Fall Interventions in Care Plan
Penalty
Summary
The facility failed to ensure that fall interventions were adequately care planned for a resident with a history of falls. Resident E, who was admitted with diagnoses including dysphagia, Diabetes Mellitus, and hypertension, was observed in bed with the bed in a low position and a mat on the floor next to him. Despite these observations, the resident's care plan did not include these specific interventions. The resident had previously fallen on 6/8/24 while trying to reach for something, although no injury occurred. The care plan was updated to include a reach assist bar, but it lacked the interventions of a low bed and a mat on the floor. The Director of Nursing confirmed during an interview that the care plan had been updated post-fall to include a grabbing tool, but it still did not reflect the use of a low bed or floor mat as interventions. This oversight was identified during a review of the resident's care plan, which indicated the resident was at risk for injury related to falls. The care plan included general interventions such as continuing existing interventions, educating the resident and caregivers about safety, a pharmacy consult, and physical therapy evaluation, but failed to document the specific interventions observed during the survey.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to provide necessary care and services for a resident with diabetes by not having blood glucose parameters in place and failing to notify the physician of elevated blood glucose levels. The resident, who was cognitively intact and diagnosed with Diabetes Mellitus, heart failure, and hypertension, was receiving insulin as per physician orders. However, there were no specific parameters set for when to notify the physician of abnormal blood glucose levels. Despite having several instances of blood glucose levels exceeding 400 mg/dL, there was no documentation indicating that the physician had been notified. Interviews with the RN and the Director of Nursing revealed that the general rule was to notify the physician if blood glucose levels were less than 60 or above 400, in the absence of specific physician orders. The facility's policy on Diabetes Mellitus Guidelines also required that abnormal lab or blood glucose results be communicated to the physician and recorded in the nurse's notes. The deficiency was identified during a complaint investigation, highlighting a lapse in following the facility's policy and ensuring proper communication with the physician regarding the resident's elevated blood glucose levels.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near East Chicago
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Munster Med-inn | 4.3 mi | — | 44 | 2 |
| Bria Of River Oaks | 4.6 mi | ★★★★★ | 15 | 0 |
| Rehabilitation Center At Hartsfield Village | 4.9 mi | ★★★★★ | 11 | 0 |
| Hammond-whiting Care Center | 4.9 mi | ★★★★★ | 32 | 0 |
| Tri-state Village Nrsg & Rhb | 5.6 mi | ★★★★★ | 5 | 0 |
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