Below average — CMS composite of the measures below.
The next survey window likely opens 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 Harcourt Terrace Nursing And Rehabilitation during CMS and state inspections, most recent first.
Dementia care and supervision failure led to a resident-to-resident altercation after a resident with severe dementia was moved into and then out of a locked memory care unit without a documented reason. The resident had a history of aggression, routine dependence, and a need for personal space, while the other resident had severe cognitive impairment, intrusive wandering, and poor spatial awareness. The wandering resident attempted to enter the other resident’s room, both fell, and the wandering resident sustained a right intertrochanteric femur fracture requiring surgery.
A resident with severe dementia, anxiety, and psychotic disorder was moved from a skilled unit to a locked memory care unit and then back again without a documented relocation planning conference with his RP and the ED. The resident’s son said he was not told why the move occurred and only learned later that his father had been transferred; the record lacked documentation of required notification details, a unit tour offer, or clear consent/waiver information for the non-emergent room changes.
A bedbound resident with chronic respiratory failure, anxiety, and depression was repeatedly subjected to verbal abuse, cursing, and threats from another resident who lived across the hall and had a documented history of alcohol abuse and aggressive behavior. The aggressor resident frequently stood in the doorway, yelled insults, and threatened to beat the bedbound resident, including during trach care, while staff were present. Staff and the resident’s family reported multiple incidents and expressed safety concerns, including fears that the aggressor, who came and went freely and sometimes returned intoxicated, could bring a weapon into the building. Despite prior documented behavior issues, the facility did not consistently document key altercations, including one requiring police involvement, did not implement a documented behavior contract or safety plan, and leadership minimized the events by asserting that the behavior did not constitute abuse because the victim did not admit psychosocial distress, resulting in ongoing exposure to verbal abuse and intimidation.
Two residents did not receive care according to physician orders and documented needs. One resident with diabetes missed a scheduled insulin dose when a unit manager, honoring the resident’s preference not to receive injections from her, attempted to hand off the task to another nurse who was not informed in time, resulting in the dose not being administered and no clear medication administration policy in place. Another resident with a history of stroke, dysphagia, and abnormal labs for calcium, sodium, and ammonia had orders to repeat a comprehensive metabolic panel and ammonia level, but the record showed no evidence these labs were obtained, despite subsequent abnormal labs at hospital admission. The same resident’s rehab discharge instructions for a dysphagia diet with 1:1 supervision, alternating sips and small bites, medications crushed in puree, and no straws were not fully transcribed into admission orders, and the EMR lacked specific orders for 1:1 supervision, alternating sips/bites, routine crushing of medications in puree, or no straws, leading to a reported incident where an RN gave an uncrushed pill instead of crushing it in applesauce.
A resident with chronic respiratory failure and sleep apnea had a tracheostomy with a physician’s order specifying a Bivona XL size 7 trach and directing that both a smaller and the same size tracheostomy cannula be kept at the bedside. During observation and staff interviews, it was determined that only a size 6 cannula was stored at the bedside, and staff were unsure whether a same-size cannula was available there. The DON believed the same-size cannula only needed to be stored somewhere in the facility, later acknowledging the order required it at the bedside, and also reported there was no tracheostomy policy in place.
A resident with neurologic deficits and dysphagia did not receive multiple ordered morning medications, including a Schedule II controlled substance, which were documented as not administered due to the resident’s condition. An RN signed out a controlled medication and reported discarding all of the resident’s medications in the room trash, but only two pills were later found and no liquids were located. The controlled substance was not destroyed with a second nurse or documented as wasted, contrary to facility policy and competency expectations requiring use of a Drug Buster system and witnessed destruction of unused controlled drugs.
A resident with a history of stroke, dysphagia, aphasia, and dysarthria was discharged from a rehab hospital with an order for an IDDSI Level 5 minced and moist dysphagia diet with thin liquids and 1:1 or close supervision due to aspiration risk. On admission, the facility initially ordered a regular diet, then changed it to a soft & bite-sized diet, which per IDDSI requires more chewing than the ordered minced and moist diet. Facility records showed the resident needed assistance with eating, and progress notes documented episodes of coughing, vomiting, and thick secretions during meals. The resident’s daughter reported that the resident was left unattended despite needing close supervision. The SLP stated the facility did not offer a minced and moist diet and considered soft & bite-sized an upgraded diet, while facility policy converted minced and moist orders to puree and required a therapy referral, demonstrating that the diet provided was not comparable or compatible with the diet ordered from the rehab hospital.
A resident with a history of stroke, dysphagia, aphasia, and dysarthria was admitted from a rehab hospital with documented swallowing deficits, an aspiration risk, and orders for a dysphagia diet with 1:1 supervision. On admission, the facility first ordered a regular diet, then a soft bite-sized diet, without notifying speech therapy or obtaining an evaluation, even though facility policy required a nursing-to-therapy referral when a resident admitted on a modified diet. The resident experienced coughing, vomiting, and thick secretions during meals on multiple occasions before speech therapy was finally ordered and the diet changed to pureed. The SLP later stated that a soft bite-sized diet was an upgrade from the ordered minced and moist diet and should not have been implemented without an SLP evaluation, and the resident’s daughter reported that he required close supervision at meals and had been left unattended.
Kitchen refrigerated items were found without required received-date labels and with expired discard dates in 2 of 2 reach-in refrigerators. Five gallons of 2% milk lacked received-date labels, and two cottage cheese containers were not properly labeled; one had a use-by date of 12/29/25 and the other had a best-by date of 12/28/25, and neither had been discarded. The culinary manager acknowledged the labeling and discard issues, and the DON stated there were no residents with an NPO diet.
Staff failed to wear the required PPE when entering rooms under droplet/contact precautions for COVID-19, with a QMA and CNA observed entering isolation rooms without the gown, N95, eye protection, and other PPE required by signage and policy. The facility also failed to properly document a new employee’s 2-step TB test within the required timeframe, and the DON stated the second step was recorded with the wrong date.
Failure to document informed consent for psychotropic medications. The facility did not ensure that residents or their representatives were informed of the risks and benefits, black box warnings, and alternative treatment options before psychotropic medications were started or changed. Records for three residents showed medication changes such as antipsychotics, antidepressants, anxiolytics, and mood stabilizers, but no informed consent documentation could be found. The DON stated the facility used IDT review processes, but could not provide documentation of consent or education for the medication changes.
A resident with dementia, bipolar disorder, depression, anxiety, and other psychiatric diagnoses had psychotropic medications increased and olanzapine added, but the chart did not document psychotic behaviors, dangerous behaviors, hallucinations, delusions, or distress to support the changes. Notes mainly described the resident resting in bed, being at baseline, or making repeated requests for ice or drinks, and the DON said the facility could not provide documentation of increased behaviors or non-pharmaceutical interventions attempted.
Failure to notify the Ombudsman of resident transfers and discharges for two residents. One resident with HTN, Alzheimer’s dementia, and major depressive disorder was discharged to a psychiatric facility, and another resident with dementia, syncope and collapse, and HTN had hospital transfers and returns documented. Neither resident was documented in the clinical record as having Ombudsman notification, and both were absent from the facility’s monthly transfer/discharge notification lists.
A resident with dementia, heart failure, and generalized anxiety died in the facility, but the required MDS tracking assessment for death in facility was not found in the record. The MDS Coordinator stated the assessment needed to be completed within 7 days, and the DON said the facility did not have an MDS policy; the facility used the RAI Manual for guidance.
Oxygen Flow Set Above Ordered Level: A resident with chronic respiratory failure and sleep apnea was observed receiving oxygen at 3 to 3.5 liters, although the physician ordered 2 liters continuously when not on BiPAP. Record review showed multiple entries documenting 3 liters administered, and an LPN and the ADON confirmed the ordered flow was 2 liters.
Surveyors found multiple medication storage and labeling failures in two medication carts, including loose pills, medications without pharmacy labels or open dates, expired medication left in the cart, refrigerated medications not stored or dated correctly, and damaged controlled-medication blister packs taped closed. An LPN, QMA, ADON, and DON were interviewed about the findings, and facility documents stated that unlabeled or expired medications should not be administered and that opened medications with shortened expiration dates should have the date opened recorded.
A dining table in the Men's Memory Care Unit had torn laminate exposing the composite board surface and remained in use while a resident sat at the damaged area and ran his hand over the loose material. An LPN was unsure whether the concern had been reported, another LPN said she would submit another maintenance request, and the Maintenance Supervisor stated he had not been aware of the issue until that morning. The DON said the facility did not have a policy on maintaining furnishings or a homelike environment.
A resident with dementia and multiple health conditions was treated roughly by a QMA during care, including being loudly instructed and physically placed in bed against her refusal, despite care plan interventions for safety and communication. An LPN observed the incident and intervened, and the facility determined the QMA violated the resident's rights to dignity and self-determination.
Two residents with significant mobility and cognitive impairments did not receive safe or comfortable assistance with ADLs. In one case, a QMA transported and transferred a resident without using a gait belt and handled her roughly, while in another, a resident with a recent fracture was provided incontinence care by a single staff member, causing her pain and distress. Both incidents violated facility policy and resident rights.
A room shared by two residents with dementia and incontinence was found to have a strong urine odor, multiple flies (including some on a resident and in a juice cup), unclean bedside commode, and fecal matter on the toilet. Staff interviews revealed lapses in cleaning routines and uncertainty about responsibilities, contributing to the unsanitary and non-homelike conditions.
A facility failed to ensure a resident's privacy during personal care. An LPN left a resident's door open while administering a gastrostomy tube bolus, exposing the resident's abdomen without closing the privacy curtain. The resident had multiple diagnoses, including acute respiratory failure and congestive heart failure. Interviews revealed the facility lacked a policy on providing privacy, despite a Resident Rights policy stating residents have the right to a dignified existence.
A facility failed to develop a comprehensive care plan for a resident with a hand splint, despite multiple observations of the resident wearing the splint. The resident had a history of transient ischemic attack, hypertension, anxiety disorder, and major depressive disorder. The electronic medical record lacked a physician's order or care plan for the splint, and the DON confirmed the absence of a care plan prior to a specific date. The facility's policy required interdisciplinary care plan reviews, which was not followed.
A facility failed to provide timely pharmaceutical services for a resident at risk for seizures, resulting in 26 missed doses of Lacosamide. Despite procedures to address medication unavailability, the medication was delayed for several days, and the facility's policy did not cover missing multiple doses.
The facility failed to conduct AIMS assessments for two residents on antipsychotic medications as per policy. One resident, with Alzheimer's and bipolar disorder, did not receive an assessment between January and August, while another resident with vascular dementia did not have an admission assessment. Both residents were on medications requiring regular monitoring for involuntary movements.
The facility failed to maintain accurate documentation for two residents requiring bedtime snacks due to unavailability, despite physician orders. A nurse improvised by finding alternative snacks, and the facility's competency checklist lacked guidance on accurate documentation.
A facility failed to assess a resident for self-administration of medications. A resident was found with a cup of pills left by a nurse, without a physician's order, care plan, or assessment for self-administration. The facility's policy requires an interdisciplinary team assessment and a physician's order, which were not followed.
The facility failed to ensure cups used for serving drinks were free of film from hard water. Observations revealed that many cups had a white film that could be scraped off, and residents were served drinks in these cups. The Executive Director acknowledged the issue, citing a lack of salt to soften the water, and noted that the film was from the sanitizer.
A facility failed to provide effective dementia care, resulting in an altercation between two residents. One resident, with a history of aggressive behavior, injured another resident, causing a fractured wrist and facial laceration. The aggressive resident had a complex medical history and frequently exhibited combative behavior, which was inadequately managed. Staff shortages and lack of evening activities contributed to the incident.
Dementia Care and Supervision Failure Leading to Resident-to-Resident Altercation
Penalty
Summary
The facility failed to provide effective person-centered dementia care for a resident with severe dementia, behavior disturbances, anxiety disorder, and psychotic disorder with delusions, and the resident was moved into a locked memory care unit and then moved back to the skilled unit without a documented reason. The resident had longstanding care plan interventions related to aggression, agitation with routine changes, and a preference for personal space and being left alone, and staff interviews showed he did not do well with change. Although staff discussed the room change in an IDT morning meeting and one staff member disagreed with the move because of the resident’s need for routine and private space, the resident was moved to the memory care unit anyway. Staff later stated the move was intended to get him out of his room and address increased isolation, but the record did not show a documented reason for the transfer. After the room change, the resident became involved in a resident-to-resident altercation. A behavior event documented that he pushed a wandering resident who attempted to enter his room, and the psychosocial stressor identified was the resident’s new admission to the memory care unit. An IDT note stated the wandering resident walked by the room and attempted to enter it, and the resident pushed him away to redirect him from his room. Staff interviews indicated the resident had been demonstrating increased aggression after returning from the memory care unit, and the resident’s son was told the room change was due to decreased activity and a desire to get him out of his room more often. The other resident involved had dementia and Alzheimer’s disease, severe cognitive impairment, intrusive wandering, poor spatial awareness, and a history of pacing and entering others’ personal space. His care plans addressed wandering, restlessness, and behavioral symptoms, but the fall care plan did not include an approach for safety monitoring or supervision before the incident. On the day of the event, he attempted to enter the other resident’s room without invitation, staff observed the interaction, both residents lost their balance and fell, and the wandering resident complained of right hip and leg pain, could not bear weight, and was sent to the hospital. He was diagnosed with a right intertrochanteric femur fracture and underwent surgical repair. Later interviews indicated the facility investigation determined the fall was unwitnessed, and the Executive Director stated both residents were not provided appropriate supervision or monitoring to prevent the incident.
Failure to Document Required Planning and Notification for Room Transfers
Penalty
Summary
The facility failed to ensure a relocation planning conference was held with the resident’s responsible party and the Executive Director before moving Resident H to a locked memory care unit and before moving him back to the skilled unit. Resident H had diagnoses including severe dementia with behavior disturbances, anxiety disorder, and psychotic disorder with delusions, and he had lived in the same room on the skilled unit since admission in 2020. The record showed an intra-facility transfer on 4/21/26 from the skilled unit to the memory care unit and another on 4/28/26 back to the skilled unit. Resident H’s son, who was the responsible party, stated he was not informed why his father was moved to the dementia unit and did not know his father had later been moved back until speaking with the surveyor. He described finding Resident H’s belongings removed from the room and learning the resident was on the dementia unit only after asking staff. He also reported having to pass through two locked doors to reach the unit and seeing a stop sign across the resident’s room entrance. The facility’s documentation for the first move showed the transfer reason as transitioning to the Cottage memory care unit, but the record did not document the contact number or date of notification, and the ED’s note did not include the reason for the move, whether a unit tour was offered, or whether the responsible party was offered or refused the right to waive 48-hour notice, a relocation planning conference, or written notice. For the second move back to the skilled unit, the transfer form again showed the waiver options checked, but no progress note documenting notification to the responsible party was found in the record. The ED stated she contacted the son by telephone for the first move and left a voice message for the second move. Staff interviews indicated the expected process for non-emergent intra-facility transfers was to notify and explain the reason for the move, answer questions, tour the unit and room, obtain consent before transfer, observe the resident after the move, and document the process, but those steps were not documented for Resident H’s transfers.
Failure to Protect a Bedbound Resident From Ongoing Verbal Abuse and Threats by Another Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse, intimidation, and threats by another resident, despite an ongoing pattern of aggressive behavior. Resident B, who was bedbound with chronic respiratory failure with hypoxia, morbid obesity, anxiety, and depression, reported that Resident C, his former roommate who now lived across the hall, repeatedly came to his doorway, yelled, cursed, and threatened to "kick his a**" without provocation. Resident B stated that these incidents occurred while he remained in bed and that Resident C would position himself in the doorway, sometimes while staff were present providing tracheostomy care. Resident B reported difficulty sleeping because Resident C was allowed to leave and return to the facility at all hours, sometimes intoxicated, and he feared Resident C could bring a weapon into the building or enter his room while he slept. Resident B kept a back scratcher next to him for protection. Staff and family interviews corroborated that Resident C’s behavior was particularly directed toward Resident B and that there had been multiple incidents. An anonymous staff member indicated Resident C yelled and cursed at many staff and residents, but his behavior was especially bad toward Resident B. Resident B’s daughter reported at least three incidents in which Resident C came to her father’s room yelling, cursing, and threatening to beat him up, and she expressed concern that Resident C could bring a weapon into the facility and that staff had no control over him. The Social Service Director documented that after Resident B returned from the hospital and briefly roomed with Resident C, Resident C became angry about having a roommate and later about his TV not working after a room move; since then, every time Resident C passed Resident B’s room there was an altercation, including an event where Resident C yelled from the hallway, causing Resident B to become upset and shout back. The Social Service Director stated she had suggested room changes multiple times in IDT meetings after the first altercation, but these suggestions were rejected. The facility was aware of Resident C’s ongoing disruptive and aggressive behaviors, including documented alcohol abuse, returning intoxicated, yelling at staff and residents, using vulgar language, going in and out of other residents’ rooms, and making it clear he would make any roommate uncomfortable. A behavior event documented that Resident C stated he would not tolerate a roommate and would make it very uncomfortable for anyone placed with him. Another documented event showed Resident C returning intoxicated, yelling at staff, and stopping in Resident B’s doorway to verbally attack him, with staff making several attempts to redirect him. Despite these patterns and the facility’s own abuse policy defining resident-to-resident verbal and mental abuse, there was no documented behavior contract for Resident C, no documented safety plan for Resident B, and no nursing documentation of the 3/29 verbal altercation or the incident requiring police involvement in either resident’s record. Leadership, including the ED and DON, minimized the events by asserting that Resident B did not admit psychosocial distress and therefore the behavior did not meet the definition of abuse, and they believed Resident B or his daughter were aggressors or primarily bothered, even though Resident B’s record reflected anxiety, depression, mood distress, trouble sleeping, and anger. The facility’s failure to implement effective protections, document incidents, and follow its own abuse and resident rights policies led to Resident B being repeatedly subjected to verbal abuse and intimidation by Resident C. Resident B’s clinical record contained care plans for mood distress and risk of depression, with interventions to encourage expression of feelings, concerns, and fears, and to offer validation and support. Progress notes and psychiatric notes documented that Resident B was unhappy since his hospital stay, had issues with Resident C entering his room after moving out, and experienced low mood, trouble sleeping, worry, irritability, depression, and anger. During a follow-up by the Social Service Director, Resident C yelled, cursed, and called Resident B names from the hallway, causing Resident B to become upset until the door was closed and he was calmed. Resident C’s record showed multiple behavior events and progress notes describing irritation, suspected intoxication, disrespectful and vulgar language, encouraging other residents to verbally attack others, and explicit statements that he did not care about facility policy. Despite this, the facility did not document the 3/29 altercation or the police-involved incident in the clinical records, did not implement a documented behavior management plan or contract for Resident C, and did not put a documented safety plan in place for Resident B, contrary to the facility’s abuse prohibition and resident rights policies that require immediate protection, increased supervision, and room or staffing changes when resident-to-resident abuse occurs.
Failure to Follow Physician Orders for Medications, Labs, and Dysphagia Care
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care according to physician orders and resident preferences, specifically related to medication administration and laboratory monitoring. For one resident with type 2 diabetes, anemia, and hypertension, a physician’s order dated 12/2/25 directed that 16 units of lispro insulin be administered three times daily with meals. The MAR showed that the 7:30 a.m. insulin dose on 2/7/26 was not administered. The resident reported that staff did not give his insulin that morning. The unit manager stated that, due to the resident’s preference, he did not want her to administer his insulin, so she attempted to pass the responsibility to another nurse. The LPN reported she was not informed she was supposed to care for this resident until it was too late, and the insulin dose was consequently missed. The DON indicated the facility did not have a medication administration policy, only a skills validation checkoff referencing the 5 rights of medication and timing parameters. Another deficiency involved a resident admitted from a rehabilitation hospital with diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented that the resident had been assessed for hypercalcemia, hyponatremia, and hyperammonemia, and that lab levels should continue to be monitored. A lab report dated 1/16/26 showed low sodium (132) and high calcium (12.5). A physician progress note on 1/19/26 addressed hypercalcemia, hyponatremia, and elevated ammonia, with a plan to repeat a comprehensive metabolic panel in one week, and a corresponding order to repeat ammonia and a comprehensive metabolic panel on 1/26/26. The record contained a lab report dated 1/30/26 indicating insufficient blood for lipid and thyroid tests, but no evidence that the ordered comprehensive metabolic panel or ammonia level was obtained after 1/16/26. The resident was later admitted to the hospital with acute respiratory failure with hypoxia, hypercalcemia, acute renal insufficiency, and hypernatremia, and abnormal lab values including sodium, potassium, and calcium. The same resident from the rehabilitation hospital also had documented dysphagia and communication deficits. The rehab discharge summary specified a dysphagia diet with 1:1 supervision for all meals due to aspiration risk, including 1:1 or close supervision, alternating sips of liquids with small bites, medications crushed in puree, and no straws. Upon admission, a physician’s order allowed staff to crush appropriate medications and mix with applesauce or other food sources as needed. However, the electronic medical record did not include orders for 1:1 or close supervision for meals, alternating sips of liquids with small bites, crushing medications in puree as a standing requirement, or no straws. The resident’s daughter reported that her father had swallowing difficulties from a stroke and that she filed a grievance after an RN placed an uncrushed pill in his mouth instead of in applesauce, despite his need for medications to be crushed in applesauce. The unit manager stated that an order indicating the nurse may crush medications was not the same as an order to always crush them and did not believe the resident received medications crushed. The facility’s Nursing Admission/Return Admission policy required the admitting nurse to review the hospital discharge summary and physician orders and to transcribe admission orders from the original orders, which was not reflected in the resident’s EMR orders for dysphagia-related care.
Failure to Maintain Ordered Same-Size Tracheostomy Cannula at Bedside
Penalty
Summary
The facility failed to follow a physician’s order to keep the same size tracheostomy cannula at the bedside for a resident with a tracheostomy. During observation, the resident was noted to have a tracheostomy, and record review showed diagnoses including chronic respiratory failure and sleep apnea. A physician’s order dated 2/2/26 specified that the resident’s tracheostomy was a Bivona tracheostomy XL size 7 and directed staff to keep both a smaller tracheostomy cannula and the same size tracheostomy cannula at the bedside. However, during interviews, RN 2 and the MDS Coordinator each confirmed that only a size 6 cannula was stored at the bedside and indicated they would need to check whether the same size cannula was stored there. The DON stated that she believed the same size cannula only needed to be stored somewhere in the facility, not specifically at the bedside, and upon reviewing the physician’s order, acknowledged it required the same size cannula at the bedside. The DON also indicated the facility did not have a tracheostomy policy. This resulted in the facility’s failure to ensure the same size tracheostomy cannula was kept at the bedside as ordered for the resident reviewed for respiratory care.
Improper Medication Disposal and Incomplete Controlled Substance Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were disposed of in a secure and safe manner and to follow controlled substance destruction procedures for a resident with multiple neurologic conditions. The resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria, and had been admitted from a rehab hospital where speech-language pathology had recommended medications be crushed in puree form. On a specified morning, the Medication Administration Record showed several medications, including aspirin, vitamin D3, lactulose, methylphenidate (a Schedule II controlled substance), sennosides-docusate sodium, rifaximin, and polyethylene glycol, were marked as not administered due to the resident’s condition. A controlled substance record indicated one tablet of rifaximin was signed out by an RN, but the record did not show that the tablet was disposed of or wasted with a second nurse. During interviews, the unit manager reported that the RN stated none of the medications were given that morning and that she had thrown all of the medications into the trash in the resident’s room, contrary to facility expectations. When the unit manager and a second staff member checked the resident’s room, they found only two pills in the trash can, despite six pills having been ordered for that morning, and no liquid medications were found. The RN later confirmed she did not administer any medications to the resident that morning. Facility documents, including a medication administration competency checklist and the controlled substances policy, indicated that wasted, dropped, or discarded medications were to be disposed of in a Drug Buster disposal system and that all unused controlled medications were to be destroyed with a witnessing licensed nurse and documented on the controlled substance record. These requirements were not followed in this incident.
Failure to Provide Ordered Minced and Moist Dysphagia Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide a diet that was comparable and compatible with the minced and moist dysphagia diet ordered by a rehabilitation hospital for a resident with significant neurologic and swallowing impairments. The resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented mild oral phase deficits with right anterior loss and pocketing, intermittent cough with thin liquids and solids, impulsivity during feeding, and an aspiration risk, and ordered an IDDSI Level 5 minced and moist diet with thin liquids, 1:1 or close supervision, alternate sips and small bites, and no straws. Upon admission, the facility’s admission observation noted swallowing difficulties, but the initial physician order was for a regular diet, which was later changed the same day to a soft and bite-sized diet and remained in place until it was discontinued on a later date. According to IDDSI definitions, the ordered minced and moist diet (Level 5) requires minimal chewing and smaller particle size than the soft and bite-sized diet (Level 6) that requires regular chewing and tongue control. During the period the resident was on the soft and bite-sized diet, the care plan and MDS documented that the resident required assistance with eating related to dysphagia and dysarthria and needed partial to moderate assistance. Progress notes recorded that the nurse was called to the dining room on two separate occasions due to the resident coughing, vomiting, and having thick secretions while eating, yet the resident continued to eat and cough. A subsequent physician order changed the diet to pureed. The resident’s daughter reported that her father had swallowing difficulties from a stroke, that these had worsened, and that she had filed a grievance about him being left unattended while eating despite his need for close supervision. The speech therapist stated that the facility did not offer a minced and moist diet and that a soft and bite-sized diet would be considered an upgraded diet from minced and moist. Facility policy listed available diets as regular, puree, ground meat, and soft & bite-sized, and directed that if a minced and moist diet was ordered, it would be interpreted as puree and that nursing should refer such residents to speech therapy to ensure the most appropriate diet, indicating a discrepancy between the ordered minced and moist diet and the diet actually provided.
Failure to Initiate Speech Therapy and Appropriate Dysphagia Diet Management
Penalty
Summary
The deficiency involves the facility’s failure to initiate and provide ordered speech therapy services and appropriate dysphagia diet management for a resident admitted with a known swallowing disorder. The resident was admitted from a rehabilitation hospital with diagnoses including cerebral infarction, right-sided hemiplegia/hemiparesis, dysphagia, aphasia, and dysarthria. The rehab hospital discharge summary documented mild oral phase deficits, coughing with thin liquids and solids, impulsivity during feeding, and an aspiration risk, with a recommendation for continued dysphagia diet (IDDSI thin liquids and minced and moist/IDDSI 5 solids), 1:1 supervision at all meals, and ongoing monitoring for signs of aspiration or pulmonary compromise. On admission, the resident’s health problems included swallowing difficulties, and the care plan and MDS documented the need for assistance with eating related to dysphagia and dysarthria. Despite this, the facility initially ordered a regular diet, then changed it to a soft bite-sized diet the evening of admission, without a speech therapy evaluation. Over the following days, the resident experienced coughing, vomiting, and thick secretions while eating, as documented in progress notes on two separate occasions, which triggered a therapy evaluation. Only after these events did the physician order a speech therapy evaluation and treatment, along with a change to a pureed diet. Interviews revealed that the DON stated speech therapy was usually ordered upon admission for residents with worsening dysphagia or modified diets but believed this resident’s dysphagia was stable or improving. The speech therapist stated that when a resident is admitted with dysphagia and on a modified diet, speech therapy should be notified to evaluate, that the facility did not offer a minced and moist diet, and that a soft and bite-sized diet represented an upgraded diet that should not be made without a speech therapy evaluation. The resident’s daughter reported that her father’s swallowing difficulties had worsened after his stroke, that he was admitted for continued therapy, and that she had filed a grievance because he was left unattended while eating despite requiring close supervision. Facility policy required a nursing-to-therapy referral for speech therapy when a resident admitted with mechanical soft or minced and moist diet orders, which was not done in this case.
Kitchen Refrigerated Foods Not Properly Labeled or Discarded
Penalty
Summary
The facility failed to ensure refrigerated food items were labeled with a received date and discarded by the discard date in 2 of 2 reach-in refrigerators reviewed in the kitchen. During observation and interview, five gallons of 2% milk were found in the reach-in refrigerator without a received date label, and the culinary manager stated she would place received dates on them. At the same time, one cottage cheese container had a use-by date of 12/29/25 and another cottage cheese container was not labeled with a received date and had a best-by date of 12/28/25; neither container had been discarded, and the culinary manager stated both should have been discarded. The DON later stated there were no residents in the building with an NPO diet. The facility policy titled "Labeling and Dating" stated opened refrigerated items that have not been cooked can be stored for 7 days and must be labeled with the date placed in storage and the discard date.
Infection Control and TB Screening Documentation Failures
Penalty
Summary
The facility failed to ensure staff wore the required personal protective equipment when entering rooms under droplet/contact precautions for COVID-19. In one double-occupancy room shared by Resident 44 and Resident 48, an isolation cart and signage outside the room indicated that anyone entering was required to wear a gown, N95 respirator, eye protection, and gloves. Despite this, QMA 6 was observed entering the room wearing only a surgical mask, and she stated she did not have a reason for not using the required PPE. Resident 48’s record showed diagnoses including basal cell carcinoma of the skin, dementia with other behavioral disturbance, and schizoaffective disorder, and a nursing note documented COVID precautions due to exposure. Resident 44’s record showed diagnoses including coronary artery disease, hypertension, and anemia, and the resident was documented as COVID positive until 1/6/26. In another double-occupancy room shared by Resident 53 and Resident 56, signage again indicated droplet/contact precautions with required use of a gown, N95 respirator, eye protection, and gloves. CNA 4 was observed entering the room wearing only a surgical mask and gloves, without a gown, N95 mask, or eye protection. CNA 4 stated she was not aware both residents were positive for COVID and thought it was only Resident 53. Resident 53’s record included alcohol dependence with alcohol-induced persisting dementia, 2019-nCoV acute respiratory disease, and major depressive disorder, with a physician order for droplet precautions until 1/6/26. Resident 56’s record included Alzheimer’s dementia, hyperlipidemia, and major depressive disorder, with a physician order indicating droplet precautions until 1/8/26. The facility also failed to document a 2-step TB test in the recommended timeframe for Activity Assistant 7; the first step was completed and read in February 2025, and the second step was documented as completed and read in April 2025. The DON stated the wrong date was documented and that the second step should have been documented as completed in March, but the facility could not provide additional documentation.
Failure to Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed of the risks and benefits of psychotropic medications, available treatment options, and the chosen treatment option for three residents reviewed. For Resident 72, the record showed multiple psychotropic medication changes, including increases in Depakote Sprinkles, changes in sertraline, and the addition of olanzapine. A new order document noted that the resident’s representative was notified of some medication changes, but the record did not include documentation of discussion of alternative measures, risks versus benefits, or the black box warnings for olanzapine, and no informed consent could be found in the electronic health record. Resident 72 had diagnoses including vascular dementia with anxiety, depressive disorder, anxiety disorder, opioid dependence, chronic pain, severe bipolar disorder with psychotic features, Wernicke's encephalopathy, insomnia, and alcohol dependence in remission. Physician and psychiatric notes described the resident as calm, cooperative, and at baseline, with no acute behavioral concerns or plan for medication changes at certain visits, yet the medication regimen was later adjusted to include higher-dose Depakote and olanzapine. During interview, the DON stated the facility used IDT meetings for new medications or changes, but could not identify who spoke with the representative and could not provide documentation of education or consent for the September and October medication changes. For Resident 73, the record showed orders for risperidone for dementia with severe agitation and escitalopram, but no informed consent documenting risks, benefits, black box warnings, or alternative treatment options could be found. For Resident 24, the record showed orders for buspirone, trazodone, and Zoloft for anxiety, depression, and insomnia, and the DON stated consents should be obtained after the physician’s order and before starting the medication, but none were found for the resident’s psychotropic medications. The DON also stated the facility did not have a policy for obtaining informed consent and instead followed an IDT psychotropic medication review guide and a psychotropic management policy that called for review of indications, non-pharmacological interventions, risks, benefits, and consultation with the resident or responsible party.
Psychotropic Medication Changes Lacked Supporting Behavior Documentation
Penalty
Summary
The facility failed to document the behaviors or distress that justified increasing or adding psychotropic medications for one resident with vascular dementia with anxiety, depressive disorder, anxiety disorder, opioid dependence, chronic pain, severe bipolar disorder with psychotic features, Wernicke's encephalopathy, insomnia, and alcohol dependence in remission. The resident was observed multiple times lying in bed with eyes closed, asleep, or speaking very slowly, and was also observed slowly ambulating to the bathroom without assistance. The record showed orders for sertraline and Depakote Sprinkles, with Depakote later increased and olanzapine added, but the chart did not contain documentation of psychotic behaviors, dangerous behaviors, hallucinations, delusions, or distress that would explain the medication changes. The clinical record included a physician note stating there were no problems with behaviors per nursing documentation and no plan for medication changes or additions, yet the note did not reflect the later increase in Depakote. A psychiatric NP note later described the resident as resting soundly in bed and not easily aroused, with staff reporting she was at her neurocognitive baseline and not showing acute mood changes or worsening depression. Nursing notes around that period documented the resident resting in her room, having no changes in mood or behavior, or making repeated requests for water, ice, or soft drinks. An interdisciplinary team behavior note documented repetitive behaviors and listed immediate interventions such as reminding the resident that ice was in her room and providing ice as requested. Later notes stated the resident had no repetitive behaviors during shifts, and an acute care physician note stated there was no plan to adjust medications for dementia, bipolar disorder, depression, or anxiety and did not indicate increased behaviors or psychotic symptoms. During interview, the DON stated the facility’s procedure was to hold an IDT meeting to discuss new medications or medication changes, but the facility could not provide documentation of increased behaviors or non-pharmaceutical interventions attempted.
Failure to Notify Ombudsman of Resident Transfers and Discharges
Penalty
Summary
The facility failed to ensure the Ombudsman was notified of residents' transfers and discharges for 2 of 4 residents reviewed for hospitalization. Resident 73’s clinical record showed diagnoses including hypertension, Alzheimer’s dementia, and major depressive disorder, and that the resident was discharged to a psychiatric facility on 10/29/25. There was no documentation in the clinical record showing the Ombudsman was notified of the transfer/discharge, and Resident 73 was not listed on the facility’s October, November, or December 2025 transfer/discharge notification documents. Resident 21’s clinical record showed diagnoses including dementia, syncope and collapse, and hypertension, and that the resident was discharged from the facility to the hospital on 3/7/25 and returned on 3/10/25, with another later hospital discharge and return also documented. There was no documentation in the clinical record showing the Ombudsman was notified of the transfer/discharge, and Resident 21 was not included on the facility’s transfer/discharge notification lists for September through December 2025. The Executive Director stated the monthly discharge summary list was every resident’s discharge the Ombudsman was notified of, and Social Service 2 stated the report was pulled monthly and populated automatically, but did not know why these residents were not included.
Failure to Complete and Transmit Death-in-Facility MDS Tracking Assessment
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) tracking assessment was transmitted for a resident who expired in the facility. The clinical record for the resident showed diagnoses including dementia, heart failure, and generalized anxiety, and a nursing progress note documented that the resident died with family at the bedside. The MDS tracking assessment for death in the facility was not found in the medical record. During interview, the MDS Coordinator stated that the death-in-facility assessment needed to be completed within seven days and that if it was not completed within that timeframe, it would be late; the resident should have had the MDS completed by the identified date. The DON stated the facility did not have a policy for MDS, and the MDS Coordinator stated the facility used the RAI Manual for MDS guidance.
Oxygen Flow Set Above Ordered Level
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care when Resident 62’s oxygen was not set at the physician-ordered liter flow. Resident 62 had diagnoses including chronic respiratory failure and sleep apnea. The physician’s order, dated 10/22/20, directed that the resident receive 2 liters of oxygen continuously when not wearing a BiPAP machine, and the care plan also directed oxygen at 2 liters as ordered. During observations, Resident 62 was seen receiving oxygen set between 3 and 3.5 liters on 1/6/26 and set at 3 liters on 1/7/26. LPN 11 stated she changed the oxygen setting from 3 liters to 2 liters and that it was supposed to be on 2 liters per the physician’s order. The record review showed multiple oxygen documentation entries in December 2025 indicating 3 liters were administered on several dates, and the ADON and DON both confirmed the resident was supposed to receive 2 liters of oxygen according to the order.
Medication carts contained unlabeled, expired, and improperly stored medications
Penalty
Summary
The facility failed to ensure medications and biologicals were labeled and stored in accordance with accepted professional principles. During observation of the Willow Bend 2/Moving Forward medication cart, surveyors found multiple medication storage and labeling problems, including an inhaler without a pharmacy label or open date, eye drops that were supposed to remain refrigerated until opened but had no open date and still had the sealed cap in place, several opened medications without open dates, loose pills in a drawer, an expired medication still in the cart, and a damaged controlled-medication blister pack secured with clear tape. The cart also contained medication cups with medications left in the narcotic lock box, with identifying information written inconsistently or not at all. The same cart also contained unopened lispro insulin with an open date written on it even though the seal cap was still present and the bottle was labeled to keep it refrigerated until opened. A second bottle of latanoprost for the same resident was also observed, with one bottle appearing unopened and another bottle dated as opened. In interview, the LPN stated the latanoprost had been delivered during the night shift and she was unsure whether it had been opened because the seal cap could be snapped back into place; she then wrote the date on the bottle during the interview. The ADON stated that medication cups should not have been stored in the cart, expired medications should be removed, refrigerated unopened medications should be stored per the bottle instructions, and nurses should date medications when opened. During observation of the Augustes Cottage CB medication cart, surveyors found additional storage problems, including loose pills in a drawer and controlled-medication blister packs for lorazepam and tramadol with clear tape on pockets where the medication was no longer present. The QMA stated he had not placed the tape on the blister packs and that the medications should have been disposed of. The DON stated the facility followed its medication pass procedure and did not have a policy for medication administration. Facility documents stated medications without prescription labels should not be administered, expired medications should not be administered, and medications with shortened expiration dates should have the date opened recorded on the container.
Damaged dining table in memory care unit
Penalty
Summary
The facility failed to ensure furnishings remained in a safe and homelike condition in 1 of 1 dining room observed for environment in the Men's Memory Care Unit. During an observation on 1/5/26 at 11:58 a.m., a dining table placed in front of the nursing station and near the window was observed with approximately one quarter of the laminate coating torn off, exposing a composite board surface. A male resident was seated at the spot where the cover was missing and was running his hand on the loose material, and there was no debris around the resident to indicate he had removed the table laminate. The same table was observed in use and in the same condition on 1/6/26 at 12:11 p.m. LPN 9 stated she was not sure whether the table had been reported to maintenance, and LPN 19 stated she would submit another maintenance request and that the tabletop had been peeled off the prior night. The Maintenance Supervisor examined the table and stated he had not been aware of the concern until that morning and that there could be potential for cuts depending on how someone moved a hand across the table. The DON stated the facility did not have a policy on maintaining furnishings or a homelike environment, and a facility document identified the Maintenance Supervisor as responsible for providing maintenance services to create a safe, sanitary, and homelike environment for residents, staff, and the public.
Resident Rights Violated During Rough Handling by QMA
Penalty
Summary
A deficiency occurred when a Qualified Medication Aide (QMA) failed to treat a resident with respect and dignity during care. The resident, who had diagnoses including dementia with behavioral disturbances, Alzheimer's disease, generalized anxiety disorder, pain, difficulty walking, and cognitive communication deficit, was taken to the shower room by the QMA. After the shower, the QMA transported the resident back to her room by having her sit on the seat of her rollator walker and pushing her. When the resident refused to stand up to be placed in bed, the QMA lifted her under the armpits and placed her on the bed, despite the resident's refusal and care plan interventions that emphasized offering other staff, ensuring safety, and using appropriate communication strategies due to hearing loss. An LPN witnessed the QMA speaking loudly and being rough with the resident, prompting the LPN to intervene and finish assisting the resident to bed. The facility's review determined that the QMA violated the resident's rights by disregarding her safety and not honoring her right to refuse care, although the actions were not deemed abusive. Facility policy states that residents have the right to be treated with consideration, respect, and recognition of their dignity and individuality, including the right to refuse any treatment or service.
Failure to Provide Safe and Respectful ADL Assistance
Penalty
Summary
The facility failed to provide safe and comfortable assistance with activities of daily living (ADLs) for two residents. For one resident with dementia, Alzheimer's disease, and mobility difficulties, a Qualified Medication Aide (QMA) transported her from the shower room to her bed by having her sit on a rollator walker and pushing her, rather than using a gait belt as required by facility policy. The QMA then attempted to transfer the resident to bed by lifting her under the armpits, which was observed by an LPN who intervened due to the rough handling. The QMA admitted to not using a gait belt and acknowledged the resident's refusal to stand, but proceeded with the transfer regardless of proper technique. For another resident with Parkinson's disease, vascular dementia, osteoporosis, and a recent pathological ankle fracture, care plans indicated the need for two-person assistance with bed mobility and transfers due to pain and risk of injury. During incontinence care, a QMA was observed by a CNA to be providing care alone, with the resident crying out in pain and being held in a position that caused distress. The CNA intervened and reported the incident to nursing staff. Both incidents were found to be in violation of facility policy and resident rights, as staff failed to follow established procedures for safe and respectful ADL care.
Failure to Maintain Clean, Sanitary, and Homelike Resident Room Environment
Penalty
Summary
A deficiency was identified in one resident room where the environment was found to be unclean, unsanitary, and not homelike. During observation, the room had a persistent urine odor, approximately seven flies were present, with some crawling on a sleeping resident and in a cup of juice. A sock was found on the bedside table, and the bedside commode contained a small amount of dark yellow urine. In the bathroom, a dried, dark brown substance, identified by staff as likely feces, was smeared on the toilet with flies crawling on it, and a puddle of dark yellow liquid was observed on the floor and trash can liner. Staff interviews revealed that the commode basin was not cleaned after each use as required, and there was uncertainty about when the bathroom was last cleaned. The two residents occupying the room both had diagnoses including dementia and required assistance with toileting due to decreased mobility, weakness, and incontinence, as documented in their care plans. Staff interviews confirmed that standard procedures, such as using liners in the commode and cleaning after each use, were not consistently followed. Housekeeping staff were unclear about cleaning responsibilities, and the facility did not have a specific policy for providing a homelike environment, although it was stated as a mission. The deficiency was cited under 3.1-19(f)(5) and related to a specific complaint investigation.
Failure to Ensure Resident Privacy During Care
Penalty
Summary
The facility failed to ensure a resident's right to privacy during personal care for one of the residents reviewed. During an observation, an LPN entered the room of a resident to administer a gastrostomy tube bolus of Jevity 1.5, a nutritional supplement. The resident's door was left open, and the LPN pulled back the resident's cover and lifted his gown, exposing his abdomen. The privacy curtain was not closed, and three people walked by the room during this time. The resident's clinical record indicated diagnoses including acute respiratory failure with hypoxia, convulsions, congestive heart failure, dysphagia, and atrial fibrillation. Interviews with the Assistant Director of Nursing and the Director of Nursing revealed that the facility did not have a policy on providing privacy for residents, although the facility's Resident Rights policy stated that residents have the right to a dignified existence and self-determination.
Failure to Develop Comprehensive Care Plan for Hand Splint
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed for a resident who was observed wearing a hand splint on multiple occasions. The resident, who had a history of transient ischemic attack, hypertension, anxiety disorder, and major depressive disorder, was seen with a hand splint on her right hand during observations in the dining and activity rooms. However, the electronic medical record did not include a physician's order or a care plan for the hand splint. The Director of Nursing confirmed that there was no care plan for the hand splint prior to a specific date, and the facility did not have any additional care plan policies. The facility's policy indicated that care plan reviews should be interdisciplinary, involving nursing, therapy, and MDS, but this was not adhered to in this case.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to ensure timely pharmaceutical services for a resident, identified as Resident 376, who was at risk for injury related to seizure activity. The resident had a physician's order for Lacosamide, an anticonvulsant medication, dated 1/9/25, which was not available until 1/22/25. As a result, the resident missed 26 doses of the medication, which was critical for managing their seizure risk. The clinical record review revealed that the resident had diagnoses including convulsions, congestive heart failure, emphysema, and encephalopathy. Interviews with facility staff, including a Registered Nurse (RN) and the Director of Nursing (DON), indicated that there were procedures in place to address medication unavailability, such as checking the Pyxis system, contacting the pharmacy, and notifying the physician. However, these procedures were not effectively implemented in this case, as the medication remained unavailable for an extended period. The DON acknowledged that the medication should not have been unavailable for days, and the facility's medication administration policy did not address the issue of missing multiple doses of a scheduled medication.
Failure to Conduct AIMS Assessments for Residents on Antipsychotics
Penalty
Summary
The facility failed to ensure that residents were assessed for side effects of antipsychotic medications using the Abnormal Involuntary Movement Scale (AIMS) as per their policy and procedure. For Resident 37, who had multiple diagnoses including Alzheimer's disease, bipolar disorder, and major depressive disorder, the AIMS assessment was not conducted between January and August, despite the policy requiring it every six months. The resident was on medications such as risperidone, sertraline, and buspirone, which necessitated regular monitoring for involuntary movements. Similarly, for Resident 45, who had conditions like vascular dementia, depressive episodes, and psychotic disorder, an AIMS assessment was not completed upon admission in March, as required by the facility's policy. The resident was prescribed medications including divalproex, risperidone, and sertraline. The Clinical Support Nurse confirmed the absence of the admission AIMS assessment, which should have been conducted with the new order. The facility's policy, revised in July, mandates AIMS assessments every six months and with new orders for residents on antipsychotics.
Deficiency in Accurate Documentation of Resident Care
Penalty
Summary
The facility failed to ensure complete and accurate documentation of care provided to two residents, leading to a deficiency in maintaining medical records according to professional standards. Resident 55, diagnosed with diabetes mellitus, dementia, and hypertension, had a care plan indicating a risk for altered nutritional status and required bedtime snacks as an intervention. However, the January 2025 Medication/Treatment record showed that snacks were not administered on several days due to unavailability, despite a physician's order to provide them. Similarly, Resident 18, with diagnoses including hypertension, chronic kidney disease, and Alzheimer's dementia, also had a physician's order for bedtime snacks. The January 2025 Medication/Treatment record indicated that snacks were not given on specific days due to unavailability. An interview with the Corporate Support Nurse revealed that snacks were supposed to be available, but the nurse responsible for documentation stated they were not, and she improvised by finding something else to give the residents. The facility's skills competency checklist for medication administration did not address the need for accurate documentation on the Medication and Treatment Administration Record.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident B, was assessed for the ability to self-administer medications. During an observation and interview, it was noted that Resident B had a clear plastic cup with approximately eight pills on her table, which were left by a nurse while the resident was bathing or dressing. The nurse instructed Resident B to take the medications with her meal, but the breakfast tray was observed to be untouched. Upon reviewing Resident B's clinical record, it was found that there was no physician's order, care plan, or assessment indicating that the resident was capable of self-administering medications. Interviews with RN 1 and the Director of Nursing confirmed that Resident B did not have the necessary documentation or assessment for self-administration of medications. RN 1 admitted to leaving the medications in the room and acknowledged that she should not have done so. The facility's policy on self-administration of medications, last reviewed in January 2015, requires an interdisciplinary team assessment, a physician's order, and an updated care plan for residents who wish to self-administer medications. These steps were not followed in the case of Resident B.
Deficiency in Cup Cleanliness Due to Hard Water
Penalty
Summary
The facility failed to ensure that cups used for serving drinks to residents were free of film or buildup from hard water. During an observation in the kitchen, clean cups stored in the dishwasher room were found to have a white film that could be scraped off. This issue was observed in 18 out of 29 cups and 9 out of 9 cups with handles. Dietary staff confirmed that these cups were used to serve fluids to residents. The Executive Director acknowledged the presence of hard water and indicated that salt was needed to soften the water, which was not available at the time. Residents were observed using these cups during meals, with several cups noted to have a white film inside. Resident B, Resident C, and Resident D all had cups with visible film, and Resident D specifically mentioned that the facility was using dirty cups. The Executive Director explained that the film was from the sanitizer and that soaking the cups would remove it. The facility's policy on cleaning dishes required items to be checked for cleanliness after washing, but this was not effectively implemented, leading to the deficiency.
Deficient Dementia Care Leads to Resident Altercation
Penalty
Summary
The facility failed to provide effective person-centered dementia care for two residents, leading to an altercation between them. Resident H, who had a history of physically aggressive behaviors, was involved in an incident with Resident J, resulting in Resident J sustaining a fractured left wrist and a laceration above his right eye. The altercation occurred in the men's memory care cottage, and staff did not witness the event, although a CNA heard a noise and found the two residents in a confrontation. Resident H had a complex medical history, including neurocognitive disorder with Lewy bodies, schizophrenia, and other psychiatric conditions. His care plan included various activities and interventions to manage his behaviors, but he frequently exhibited aggressive and intrusive behaviors, such as wandering into other residents' rooms and physically attacking staff and peers. Despite multiple psychiatric evaluations and hospitalizations, Resident H continued to display combative behavior, which was inadequately managed by the facility. Resident J, who had dementia with agitation and other medical conditions, did not initially display aggressive behavior but was involved in the altercation with Resident H. The facility's lack of sufficient activities and staff to manage Resident H's behaviors, particularly after 5:00 p.m., contributed to the incident. Staff interviews revealed that Resident H was difficult to manage due to his combativeness, and there were no structured activities in the evening to engage him, leading to increased risk of altercations.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Indianapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Marquette | 0.5 mi | ★★★★★ | 3 | 0 |
| Brickyard Healthcare - Willow Springs Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Spring Mill Meadows | 0.6 mi | ★★★★★ | 4 | 0 |
| St Augustine Home For The Aged | 0.7 mi | ★★★★★ | 0 | 0 |
| Hooverwood | 1.9 mi | ★★★★★ | 12 | 1 |
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