Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Mason Health Care Center during CMS and state inspections, most recent first.
Surveyors found that staff failed to ensure privacy during incontinence care for three residents with dementia, Alzheimer’s disease, overactive bladder, and other neurologic conditions. Two CNAs provided incontinence care to a resident with intracerebral hemorrhage and altered mental status without pulling the privacy curtain between the resident and a roommate. Two other residents with severe cognitive impairment and documented bladder/bowel incontinence received incontinence care while privacy curtains between them and their roommates were not used and, in some instances, window blinds remained open, leaving a window exposed. A CNA acknowledged that curtains and blinds should have been closed, and facility policy stated residents have a right to be treated with respect and dignity.
Staff did not consistently change gloves between soiled incontinence/peri care and application of clean briefs for three residents with dementia, cognitive impairment, and bowel/bladder incontinence. In multiple observed episodes, CNAs removed soiled briefs, performed peri care with disposable wipes, and then, without changing gloves or performing hand hygiene, applied clean incontinence briefs. One affected resident did not yet have an incontinence care plan in place, while others had documented incontinence and required substantial or total assistance with toileting hygiene.
Unsanitary food storage and kitchen sanitation: Surveyors found unsealed cream cheese, an opened container of expired apple juice, unsealed egg patties with ice build-up, and multiple dry goods not tightly sealed. Follow-up kitchen observations showed a greasy steam table, dirty and wet soup bowls stored as clean, damaged and greasy cookware, and wet steamer pans stored under the prep table. The Dietary Manager, RD, and cook acknowledged the sanitation issues, and facility policy required food items to be covered or in tight containers and steam tables to be cleaned after each use and at least daily.
The facility did not notify the physician or NP of significantly elevated blood glucose levels for two residents with diabetes, despite physician orders and facility policy requiring such notification. Blood glucose readings above the specified threshold were not reported, and there was no documentation in the progress notes to indicate that the provider was informed, as confirmed by staff interviews.
Surveyors found that appropriate care was not consistently provided to residents who were continent or incontinent of bowel and bladder, including improper catheter care and insufficient prevention of UTIs. These failures resulted in a deficiency related to resident care.
A resident with Alzheimer’s disease, depression, bipolar disorder, psychotic disorder, and dementia received an order for Seroquel 25 mg one time for anxiety. The MDS showed the resident could not complete a mini mental assessment and was already receiving an antidepressant and an anticonvulsant. The DON stated the diagnoses were not appropriate for Seroquel, and the facility policy required ongoing review of medication indications and clinical need.
Diabetes Care Plan Did Not Address Refusal of Blood Glucose Monitoring: A resident with type 2 DM, PTSD, pulmonary HTN with HF, restless leg syndrome, and obesity was receiving multiple diabetes medications, including insulin, but refused blood glucose checks for about a year. RN stated she was uncomfortable giving the medications without a BG check, while the resident said she did not feel she needed checks three times daily and had not liked a CGM device. The existing care plan addressed fluctuating blood glucose levels but did not address the resident’s refusal of BG monitoring, and the DON stated the refusal should have been care planned.
A resident who required substantial to maximum assistance with bathing and showering did not receive bathing as care planned. The resident preferred showers and was scheduled for two showers per week, but records showed missed shower opportunities and several bed baths instead of the preferred method. The ED confirmed the resident should have been receiving two showers weekly, and the facility policy stated residents would be provided showers per request or facility schedule protocols.
A resident with bilateral hearing loss and highly impaired hearing had an audiology visit that recommended BTE binaural hearing aids, but the medical record showed no evidence of a referral being made for hearing aid services. The resident’s care plan identified a communication deficit related to hearing loss, and staff noted the referral should have been scheduled.
A facility failed to ensure the narcotic inventory book was completed thoroughly and accurately on the 100 hall med cart. The narcotic card count sheet lacked 8 signatures out of 72 opportunities, and an RN stated that the oncoming and offgoing nurses responsible for the count should have signed the inventory book after the count was completed. The facility policy states that two licensed nurses account for all controlled substances and access keys at the end of each shift.
Medication administration errors exceeded the acceptable rate, with an observed pass showing a missing ordered dose for one resident and the use of an expired opened insulin Lispro vial for another resident with DM. RN staff stated the insulin vial should have been discarded after the facility’s 28- to 30-day timeframe, yet the resident received multiple sliding-scale doses from the expired vial.
Improper Storage and Disposal of Medications: A discontinued controlled med for one resident was found in a medication cart narcotic drawer, and an expired insulin pen for another resident was found in the med storage refrigerator. An RN stated the controlled med had been removed during the narcotic count but was not yet destroyed, and the expired insulin should have been discarded on its expiration date.
An LPN failed to follow infection control practices during a wound treatment for a resident. Treatment supplies, including bandage scissors, were placed directly on the resident's table without a barrier, and after removing gloves and using hand sanitizer, the LPN fanned her hands to dry them before applying new gloves. The LPN stated she should not have fanned her hands and should have used a barrier on the table.
A resident with a gastrostomy tube did not have physician orders or documentation for required water flushes before and after medication administration, nor for insertion site care, despite facility policies and care plan directives. Nursing staff confirmed these orders and care should have been in place, resulting in a deficiency for inadequate feeding tube care.
A resident with complex medical conditions did not receive scheduled pain medication timely due to communication issues with an RN. The resident's pain medication, Norco, was often administered late, exceeding the facility's policy of a one-hour window. Despite the resident and her daughter addressing the issue, the RN failed to ensure timely administration, leading to increased pain levels for the resident.
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, affecting all residents consuming food. Observations revealed improperly stored and expired food items, and staff handling food without gloves. Microwaves in pantries contained dried food debris, violating the facility's food safety policies.
A facility failed to update a resident's activity care plan to reflect their current preferences and needs. The resident, with multiple health conditions, expressed a desire for activities like listening to music and participating in religious activities, but the care plan included irrelevant interventions. Despite an updated activity assessment, the care plan was not revised, leading to a deficiency.
A facility failed to provide appropriate communication devices for a Spanish-speaking resident with cognitive deficits and multiple medical conditions. Despite a care plan indicating the need for translation services, staff were not adequately equipped to communicate with the resident, and a Spanish communication board was not available as required. Observations showed the resident frequently yelling in Spanish, with staff using ineffective ad-hoc methods for communication.
A facility failed to change a resident's respiratory equipment as per physician orders. Observations showed that the oxygen tubing and humidification bottle, dated 8/18/2024, were not changed weekly as required, and the humidification bottle was empty. The resident, with a history of COPD, was receiving oxygen at 2 liters per minute. The facility's policy and physician orders required weekly changes, which were not followed, as confirmed by an LPN.
The facility failed to ensure proper medication storage and handling, with unlocked medication carts, inappropriate items stored with medications, expired medications, and improper labeling. Additionally, a medication room refrigerator had significant ice build-up and was consistently below the appropriate temperature range. Staff interviews confirmed these practices did not align with facility policies.
A facility failed to ensure staff used appropriate PPE when emptying a Foley catheter drainage bag for a resident with a neurogenic bladder and ESBL infection. A QMA was observed performing this task without a face shield or gown, contrary to the facility's Enhanced Barrier Precautions policy, which requires such PPE during high-contact care activities.
Failure to Ensure Privacy During Incontinence Care
Penalty
Summary
The deficiency involves failure to provide privacy during incontinence care for three residents during early morning care. For Resident B, surveyors observed two CNAs providing incontinence care without pulling the privacy curtain between the resident and his roommate. Resident B’s diagnoses included nontraumatic intracerebral hemorrhage, dementia, and altered mental status. At the time of the survey, an admission MDS was in progress and Resident B did not yet have a care plan addressing incontinence care. For Resident C, two CNAs assisted with placement of an incontinence brief while the resident was in bed. One CNA pulled the resident’s lower garment to her ankles and placed the brief underneath her without pulling the privacy curtain between her and her roommate or closing the window blinds. Resident C had Alzheimer’s disease, dementia, and overactive bladder, with an MDS indicating severe cognitive impairment and a need for substantial assistance with toileting hygiene; her care plan documented intermittent incontinence and the need for assistance with incontinence care. For Resident D, two CNAs provided incontinence care with the privacy curtain by the window only partially pulled, leaving an exposed window with open blinds, and the curtain between the resident and her roommate not pulled. Resident D had spastic hemiplegia, cerebral infarction, and overactive bladder, with an MDS indicating severe cognitive impairment and total dependence for toileting hygiene; her care plan documented bladder and bowel incontinence and staff assistance with incontinence care. During interview, one CNA acknowledged that privacy curtains and window blinds should have been closed during incontinence care. The facility’s Resident Rights policy stated that residents have the right to be treated with respect and dignity.
Failure to Change Gloves Between Soiled and Clean Incontinence Care
Penalty
Summary
Staff failed to change gloves between providing soiled incontinence/perineal care and applying clean incontinence briefs for multiple residents. During an early morning observation, two CNAs assisted a resident with dementia and altered mental status who was incontinent of urine in bed. After removing the soiled brief and performing peri care with disposable wipes, one CNA did not change gloves before helping apply a clean brief. This resident’s admission MDS was still in progress and there was no care plan addressing incontinence care at the time of review. In separate observations, another resident with Alzheimer’s disease, dementia, overactive bladder, severe cognitive impairment, and a care plan for intermittent bowel and bladder incontinence received peri care while sitting on the edge of the bed; the assisting CNA did not change gloves before placing a clean brief. A third resident with spastic hemiplegia, cerebral infarction, overactive bladder, severe cognitive impairment, and total incontinence of bowel and bladder was provided incontinent peri care by a CNA who then neither washed hands nor changed gloves before applying a clean brief. The CNA later stated that gloves should have been changed after providing incontinence care and before placing clean briefs. The facility’s incontinence policy stated that incontinent residents would receive appropriate treatment and services, including treatment to prevent infections.
Unsanitary food storage and kitchen sanitation
Penalty
Summary
The facility failed to ensure food was stored, prepared, and served in a sanitary manner in 1 of 1 kitchens reviewed. During observation of the kitchen with the Dietary Manager, surveyors found in the walk-in cooler an unsealed box of cream cheese and an opened container of apple juice with a use-by date of 8/17/2025. In the walk-in freezer, a box of egg patties was not sealed and some patties had ice build-up on them. In the dry storage area, opened packages of spaghetti and macaroni and an opened box of corn starch were not sealed tightly. The Dietary Manager stated the foods should have been sealed appropriately and the juice should have been removed from the cooler. On follow-up observations, the front of the steam table had a greasy substance dripped down it, and 2 dirty and 2 wet soup bowls were put away as clean. Later, small and large skillets were observed with missing Teflon coating on the cooking surfaces, cooking pans had a build-up of black grease on the bottom and around the handles, and steamer pans stored under the food prep table were wet. The Registered Dietician stated they get to the steam table cleaning periodically, and the cook stated she had not had time to clean the steam table. The facility policy required food safety practices throughout the food handling process, including keeping refrigerated foods labeled, dated, covered or in tight containers, and keeping steam tables clean and sanitary after each use and at least once daily.
Failure to Notify Physician of Elevated Blood Glucose Levels
Penalty
Summary
The facility failed to notify the physician or Nurse Practitioner of significantly elevated blood glucose levels for two residents with diabetes, as required by physician orders. For one resident with type 2 diabetes, blood glucose readings exceeded the ordered notification threshold of 400 mg/dl on multiple occasions, specifically with values of 443 mg/dl, 546 mg/dl, and 436 mg/dl, without documentation that the physician or Nurse Practitioner was notified. Interviews with nursing staff and the Director of Nursing confirmed that the protocol was to notify the provider and document the notification in the progress notes, which was not done in these instances. Another resident with multiple diagnoses, including type 2 diabetes and acute kidney failure, had several blood glucose readings ranging from 319 mg/dl to 397 mg/dl over two days. Despite facility policy and staff statements indicating that elevated blood glucose levels should prompt notification of the physician and documentation in the progress notes, there was no evidence in the resident's record that the physician was notified of these abnormal results. The facility's policy required following physician orders and parameters, but this was not adhered to in these cases.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with incontinence, improper catheter care practices, and insufficient measures to prevent UTIs. These lapses were observed during the survey and contributed to the deficiency cited.
Unnecessary Antipsychotic Use Without Supporting Symptoms
Penalty
Summary
The facility failed to ensure there were appropriate medical symptoms to support the use of an antipsychotic for Resident 51. The resident’s record showed diagnoses including Alzheimer’s disease, depression, bipolar disorder, psychotic disorder, and dementia. A quarterly MDS dated 6/9/2025 indicated the resident was unable to complete a mini mental assessment and was receiving an antidepressant and an anticonvulsant medication. A physician’s order dated 6/29/2025 directed Seroquel 25 mg, one tablet one time only, for anxiety. During interview, the DON stated the diagnoses were not appropriate for the use of Seroquel. The facility’s Unnecessary Drugs Policy, provided by the Corporate Nurse, stated that each resident’s drug regimen would be reviewed on an ongoing basis, including indications and clinical need for medication.
Diabetes Care Plan Did Not Address Refusal of Blood Glucose Monitoring
Penalty
Summary
The facility failed to ensure the care plan addressed a diabetic resident’s refusal of blood glucose monitoring. Resident 8 had diagnoses including type 2 diabetes, PTSD, pulmonary hypertension with heart failure, restless leg syndrome, and obesity. The resident’s MDS, completed on 7/17/2025, indicated no cognitive impairments, a diabetes diagnosis, and receipt of insulin injections. Current physician orders included Mounjaro 10 mg weekly, Jardiance 25 mg daily, Actos 15 mg daily, insulin glargine 45 units subcutaneously twice daily, and Humalog 10 units subcutaneously three times daily for diabetes. During interview, RN 5 stated the resident’s refusal of blood sugar checks had been occurring for approximately a year and that she was uncomfortable administering the multiple diabetes medications without having assessed the resident’s blood sugar level. RN 5 also stated the resident had an order to check blood sugars as needed if signs or symptoms of hypo- or hyperglycemia were present. The resident stated she had been on the same medications for a long time and did not feel she needed blood sugar checks three times a day, and she reported trying a continuous glucose monitoring device but not liking how painful it was to attach and detach from her arm. The diabetes care plan, initiated on 4/2/2024, addressed fluctuating blood glucose levels but did not address the resident’s refusal to have blood glucose levels assessed. The DON stated the refusal for blood sugar checks should have been care planned, and the facility did not have a specific policy regarding diabetic management.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide assistance with ADLs related to showering for one resident who required substantial to maximum assistance with bathing and showering. The resident had diagnoses including type 2 diabetes, depression, and need for assistance with personal care. The admission MDS indicated it was very important for the resident to choose between a bed bath, shower, or tub bath, and the care plan stated the resident needed assistance with ADLs, required one person for bathing, preferred showers, and was to receive showers two times per week per the facility shower schedule. During interview, the resident stated the last shower received was approximately eight days earlier. Record review showed the resident received showers on 6/9/2025, 6/16/2025, 6/24/2025, 7/31/2025, 8/7/2025, and 8/14/2025, and bed baths on 7/13/2025, 7/24/2025, 7/28/2025, 8/11/2025, and 8/21/2025. Based on these records, the resident received 11 of 22 care planned bathing opportunities, and 5 of the 11 baths provided were bed baths rather than the resident’s preferred showers. The ED stated the resident should have been receiving two showers per week, and the facility policy stated residents would be provided showers as per request or facility schedule protocols and based upon resident safety.
Failure to Follow Audiologist Recommendation for Hearing Services
Penalty
Summary
The facility failed to ensure that 1 of 3 residents reviewed for hearing and/or vision needs had an audiologist recommendation followed in a timely manner. Resident 3 was observed and interviewed as hard of hearing, and the quarterly MDS dated 8/18/2025 indicated the resident was alert and oriented with hearing that was highly impaired/absence of useful hearing. The care plan, initiated on 5/15/2024, identified a communication deficit related to hearing loss and noted the resident preferred written communication and often spoke loudly because of the hearing loss. Record review showed the resident had been seen by an audiologist in December 2024, and the audiology visit summary dated 12/9/2024 recommended hearing aids, specifically BTE binaural, with impressions taken. The summary also noted medical consults for medical clearance for hearing aids and for left ear Eustachian tube dysfunction, with instruction to continue current means of communication if bilateral tinnitus persisted. However, there was no evidence in the medical record that the resident had been referred to an audiologist for a hearing aid, and the Social Service Director stated the referral should have been scheduled.
Incomplete Narcotic Inventory Documentation
Penalty
Summary
The facility failed to ensure the narcotic inventory book was completed thoroughly and accurately on the 100 hall medication cart. During observation, the narcotic card count sheet for the 100 Hallway medication cart lacked 8 signatures out of 72 opportunities. During interview, RN 5 stated that the oncoming and offgoing medical personnel who performed the narcotic inventory were responsible for signing the narcotic inventory book and that staff should have signed the inventory book after the count was completed. The Executive Director later provided the facility policy titled Controlled Substance Administration and Accountability, which states that two licensed nurses account for all controlled substances and access keys at the end of each shift.
Medication Administration Errors and Expired Insulin Use
Penalty
Summary
The facility failed to ensure medications were administered according to physician's orders and professional standards for 5 of 30 opportunities, resulting in a medication administration error rate of 16.67%. During an observed medication pass, RN 2 administered medications to Resident 73 and stated there were 11 pills in the medication cup. The medications observed included Cymbalta, Finasteride, Floranex, Plavix, Ferrous Sulfate, Metformin, Metoprolol Tartrate, Tylenol, Vascepa, and Vitamin C. A record review showed Resident 73 also had a current order for Docusate 100 mg daily, which was kept on a separate roll of pills in the medication cart. RN 2 later indicated he thought he had given the Docusate, but the observed count in the cup was only 11 pills, meaning the Docusate was not included in the pass. The facility also failed to manage an opened multi-use insulin Lispro vial for Resident 9 according to the stated expiration timeframe. During observation, the vial on the medication cart had an opened date that RN 2 said should have been replaced because opened multi-dose insulin vials were to be discarded after 30 days. Resident 9 had diabetes and a physician's order for Insulin Lispro sliding scale coverage before meals and at bedtime for blood glucose levels greater than 350. The MAR showed the resident received four doses of Lispro insulin from the opened vial after it had expired. RN 6 and QMA 7 stated opened insulin vials were to be discarded after 28 days per facility pharmacy recommendations, and the Executive Director later provided a policy stating opened vials can be kept until used or 28 days after opening.
Improper Storage and Disposal of Discontinued and Expired Medications
Penalty
Summary
Drugs and biologicals were not properly secured and disposed of in the facility’s medication storage areas. During an observation in the 100 hall medication cart, two discontinued Lorazepam 0.5 mg medication cards for Resident 66 were found in the top drawer of the cart’s narcotic drawer. One card contained 10 tablets and the other contained 60 tablets, even though the medication had been discontinued on 8/4/2025. RN 5 stated she had found the discontinued medication during the morning narcotic count and removed the cards from the narcotic drawer, but had been interrupted before taking them to the appropriate disposal area. She stated the medication should have been destroyed on 8/4/2025 and should have remained in the locked narcotic box until it could be properly destroyed. In a separate observation in the medication storage room refrigerator on the 300/400 hall, an unopened insulin lispro pen for Resident 9 was found with an expiration date of 5/20/2024. RN 5 stated the insulin pen should have been discarded on the expiration date. The Executive Director provided policies stating that controlled substances removed from a medication cart must have a documented physician order and that unused drugs must be maintained in a secure area or locked cabinet until transferred to waste disposal service.
Infection Control Lapses During Wound Treatment
Penalty
Summary
The facility failed to ensure staff followed infection control practices during a skin treatment observed for 1 resident. During the treatment, an LPN placed wound treatment supplies, including bandage scissors, directly on the resident's table without using a barrier between the table and the supplies. The LPN removed the resident's sock, elastic bandage, gauze from the right lower leg, and the dressing to the heel, then placed the removed items in the trash can. After removing gloves, the LPN applied hand sanitizer and then used a fanning motion with open hands to dry her hands before putting on new gloves. During interview, the LPN stated she should not have fanned her hands and should have placed a barrier on the table. The facility's Hand Hygiene policy dated 5/29/2024 was provided and indicated that when using an alcohol-based hand rub, hands should be rubbed together covering all surfaces until dry.
Failure to Ensure Proper Feeding Tube Care and Documentation
Penalty
Summary
The facility failed to provide appropriate feeding tube care for one resident who was cognitively intact and had a history of cerebral infarction, dysphagia, severe protein-calorie malnutrition, and adult failure to thrive. The resident had a gastrostomy tube for artificial nutrition and hydration, with a care plan indicating the need for site care and water flushes as ordered. However, a review of physician orders revealed there were no orders for water flushes before and after medication administration, nor for gastrostomy site care. Documentation was also lacking regarding water flushes and insertion site dressing changes. During interviews, nursing staff confirmed that residents should have orders for both medication flushes and insertion site care. Facility policies required staff to follow protocols for flushing feeding tubes before and after feedings and medications, and to perform daily or as-needed gastrostomy site care per physician order and professional standards. Despite these policies, the required orders and documentation were not present for the resident in question, resulting in a deficiency related to feeding tube care.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to provide scheduled pain medication in a timely manner for a resident, identified as Resident B, who was reviewed for pharmaceutical services. Resident B, who was cognitively intact and had complex medical conditions including leukemia, anemia, and anxiety disorder, had a physician's order for Norco to be administered every four hours for pain management. However, the Medication Administration Audit Report revealed multiple instances where the medication was administered significantly later than the scheduled times, often exceeding the facility's policy of administering medication within an hour before or after the scheduled time. Resident B expressed that her pain level increased if she waited more than 40 minutes past the scheduled administration time, and she had to wake up during the night to ensure she received her medication. The issue was compounded by a communication problem involving RN 2, who was responsible for informing other nursing staff to administer the medication during his shifts but failed to do so. Despite Resident B and her daughter addressing the issue with RN 2, he did not take responsibility for ensuring timely medication administration, leading to the deficiency.
Sanitation and Food Handling Deficiencies in Kitchen and Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, as observed during a survey. In the kitchen, black specs were found on a shelf in the walk-in cooler, and several food items, including tater tots and diced pepperoni, were improperly stored without dates or seals. Additionally, expired spices were found on a kitchen shelf. During meal observations, staff members were seen handling food improperly; CNAs passed lunch trays with fingers over the rims of plates and handled a dinner roll with bare hands, contrary to the facility's policy requiring gloves for ready-to-eat foods. Further observations revealed unsanitary conditions in the nutrition pantries, where microwaves contained dried food debris. The facility's policies on food safety, including proper labeling, dating, and handling of food, were not adhered to, as evidenced by the undated and improperly sealed food items and the lack of glove use when handling ready-to-eat foods. These deficiencies had the potential to affect all residents consuming food from the kitchen and pantries.
Failure to Update Resident's Activity Care Plan
Penalty
Summary
The facility failed to ensure that the care plan for a resident was revised and updated in accordance with the resident's current needs and preferences. The resident, who has multiple diagnoses including hemiplegia, dysphagia, and chronic kidney disease, expressed specific preferences for activities such as listening to music, being around pets, and participating in religious activities. However, the care plan, which was last updated in July 2023, did not reflect these preferences accurately. Instead, it included interventions that were not aligned with the resident's stated interests, such as providing magazines and crosswords, which the resident indicated were not very important. The deficiency was identified during a record review and interview process. The facility's policy requires care plans to be reviewed and revised as necessary when a resident experiences a status change. Despite an activity assessment update in June 2024, which noted the resident's participation in sensory club and acceptance of pet visits, the care plan was not updated to reflect these changes. The Activities Director was responsible for updating the care plan but failed to do so, leading to a discrepancy between the resident's current needs and the documented care plan.
Failure to Provide Communication Devices for Spanish-Speaking Resident
Penalty
Summary
The facility failed to provide appropriate communication devices for a Spanish-speaking resident, identified as Resident 29, who was reviewed for communication needs. Resident 29 had a medical history that included hemiplegia, hemiparesis, anxiety disorder, dysphagia, and major depressive disorder. The resident's care plan indicated that her primary language was Spanish and that she required a translator at times. Despite these documented needs, the facility did not ensure the availability of a communication board or other effective communication tools for Resident 29. Observations revealed that Resident 29 was frequently yelling out in Spanish, and staff members, including a housekeeper and a Qualified Medication Aide (QMA), were not adequately equipped to communicate with her. The staff relied on ad-hoc methods such as using Google Translate or asking Spanish-speaking staff members to assist, which were not consistently effective. Interviews with staff members, including the Executive Director and Registered Nurses (RNs), revealed a lack of awareness and availability of the Spanish communication board, which was supposed to be accessible at the nursing station. The Executive Director mentioned that an in-service training on the Spanish communication board had been conducted, but housekeeping staff were not in attendance, and the communication board was not found at the designated location. The facility's policy on communicating with persons with Limited English Proficiency (LEP) outlined the need for meaningful communication and the use of language assistance services, but these measures were not effectively implemented for Resident 29.
Failure to Change Respiratory Equipment as Ordered
Penalty
Summary
The facility failed to ensure that respiratory equipment was changed according to physician orders for a resident using oxygen. Observations on multiple dates revealed that the oxygen tubing and humidification bottle for a resident were not changed weekly as required. Specifically, the oxygen tubing and humidification bottle were dated 8/18/2024 and remained unchanged and empty during observations on 8/26/2024, 8/28/2024, and 8/29/2024. The resident's physician orders, dated 5/28/2024, specified that the oxygen tubing and supplies should be changed weekly, every night shift on Sunday. The resident in question had a history of paraplegia, malnutrition, depression, and asthma, and was receiving oxygen at 2 liters per minute via nasal cannula for chronic obstructive pulmonary disease (COPD). The care plan indicated that the resident should receive oxygen as ordered and that the oxygen tubing should be changed weekly. However, the Treatment Administration Record (TAR) showed that the oxygen tubing and water bottle had not been changed since 8/18/2024. An interview with an LPN confirmed that the tubing had not been changed and the humidification bottle should not have been empty. The facility's policy required changing the oxygen tubing and mask/cannula weekly and the humidifier bottle when empty or weekly, which was not adhered to in this case.
Medication Storage and Handling Deficiencies
Penalty
Summary
The facility failed to ensure proper medication storage and handling across four medication storage areas. Observations revealed that a medication cart on the 400 hall was left unlocked when not in use, as a QMA walked away from it, and an LPN passed by it twice without securing it. Additionally, the 300 hall medication cart contained inappropriate items, such as a bottle of shampoo and an expired container of skin cream. The 100 hall medication cart had an opened and undated bottle of Miralax, indicating a lack of proper labeling and dating of medications. Furthermore, the medication room on the 100 hall had a refrigerator with a significant ice build-up in the freezer section, and the temperature log indicated that the refrigerator's temperature was consistently below the appropriate range on several dates. The facility's policies on medication storage and drug disposition were not adhered to, as evidenced by the presence of expired and improperly stored medications. Interviews with staff confirmed these deficiencies, acknowledging that the observed practices did not align with the facility's policies.
Failure to Use Appropriate PPE During Catheter Care
Penalty
Summary
The facility failed to ensure that staff used appropriate personal protective equipment (PPE) when emptying a Foley catheter drainage bag for a resident. During an observation, a Qualified Medication Aide (QMA) was seen emptying the urine drainage bag of a resident without wearing a face shield or gown, which are required under the facility's Enhanced Barrier Precautions policy. The resident in question had a Foley catheter due to a neurogenic bladder and was on enhanced barrier precautions due to an extended-spectrum beta-lactamase (ESBL) infection in the urine. The resident's medical history included paraplegia, malnutrition, depression, and neuromuscular dysfunction of the bladder. The facility's policy, provided by the Director of Nursing, indicated that enhanced barrier precautions require the use of gowns and gloves during high-contact care activities, such as device care involving urinary catheters. The QMA was unaware of the need for a gown and face shield, indicating a lapse in adherence to the infection control policy.
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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.
Illustrative
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Illustrative
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Nursing homes near Warsaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Paddock Springs | 1.6 mi | ★★★★★ | 4 | 0 |
| Warsaw Meadows | 1.8 mi | ★★★★★ | 16 | 0 |
| Grace Village Health Care Facility | 2.1 mi | ★★★★★ | 0 | 0 |
| Miller's Merry Manor | 2.6 mi | ★★★★★ | 0 | 0 |
| Waters Of Syracuse Skilled Nursing Facility, The | 12.4 mi | ★★★★★ | 22 | 0 |
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