Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Signature Healthcare Of Bremen during CMS and state inspections, most recent first.
A nurse performed CPR on a resident who was unresponsive and later died, but chest compressions were given while the resident remained partly on a mattress instead of on a hard surface. Surveyors also found that multiple RNs, LPNs, the DON, and the ADON had CPR certifications from an online provider without completing the required hands-on skills component, and the ED stated staff were not required to have hands-on training.
Failure to update a resident’s communication care plan after MDS findings showed severe visual impairment and severe cognitive deficit. The resident had a diagnosis of unqualified visual loss in both eyes, was observed stating he was blind, and could not make eye contact. The care plan still listed communication interventions such as a communication book/board, writing pad, signs, and gestures, even though staff stated the resident could not see pictures or use a communication board.
A resident receiving tube feeding was observed lying in bed with the HOB below 30 degrees while the feeding was infusing. An LPN noted the bed was not at a 30-degree angle, and an OT measured the bed frame at 12 degrees. The resident had diagnoses including persistent vegetative state, tracheostomy and gastronomy status, moderate protein-calorie malnutrition, diffuse traumatic brain injury, and quadriplegia. The resident’s order and care plan both directed that the HOB be elevated to at least 30 degrees during tube feeding.
A resident with dementia and a documented tomato allergy was served ketchup on a hotdog, despite care plan and physician orders prohibiting tomato products. The CNA provided the food after the resident requested it, only noticing the allergy after the resident had eaten several bites. This failure to follow the care plan was documented in progress notes and led to a family grievance.
A resident with a Stage 2 pressure ulcer did not receive daily wound care as ordered by the physician, with staff documenting completion of dressing changes that were not actually performed. The issue was identified when the resident's family noticed the dressing had not been changed for two days, leading to confirmation that required wound care was missed and not in accordance with facility policy.
An LPN failed to follow infection control procedures during a medication pass for two residents. The LPN broke tablets with bare hands, coughed into her hand, and administered an insulin injection without sanitizing hands or wearing gloves. The DON confirmed that gloves should have been worn, as per facility policy.
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, affecting meal safety for residents. Observations revealed unsealed and expired food, dirty equipment, and improper storage practices. The Dietary Manager and Corporate Dietician acknowledged these issues, which were not in compliance with the facility's food handling and ware washing policies.
A facility failed to ensure an advance directive was completed upon admission for a resident with significantly impaired cognition. Although a Physician's Order indicated a Do Not Resuscitate (DNR) status, there was no documentation of a completed DNR form signed by the resident or their representative. The Administrator acknowledged the oversight, and the facility's policy required determining advance directive status during admission.
A facility failed to notify the Ombudsman of hospital transfers for a resident with severe cognitive impairment and an indwelling urinary catheter. The resident was transferred to a neuropsychological hospital and later returned, but was not listed in the facility's transfer and discharge records. The DON confirmed the Ombudsman should have been notified, as per the facility's policy.
A facility failed to accurately complete the MDS assessment for a resident with multiple falls. The resident, with conditions such as COPD and diabetes, reported several falls, but only two were documented in the clinical record. These falls were not included in the Quarterly MDS assessment. The MDS Nurse admitted the oversight, and the facility lacked a specific policy for MDS completion, relying on the RAI Manual.
The facility failed to create comprehensive care plans for three residents, leading to unaddressed skin issues and behavioral problems. A resident with cancerous skin areas lacked a care plan for her condition and behavior of picking at her face. Another resident had bruises from medical procedures without a care plan for skin assessment or aspirin use. A third resident with cognitive impairment and a history of aggression lacked a behavioral care plan to address physical altercations.
Two residents in an LTC facility did not receive scheduled showers as required for their ADL care. One resident with dementia and diabetes was observed with greasy hair, and documentation showed infrequent showers without recorded refusals. Another resident with hemiplegia and aphasia had long fingernails, indicating neglect in personal care, with significant gaps in shower documentation. Staff interviews revealed inconsistencies in documentation practices.
A facility failed to assess a resident for new and existing skin issues after returning from a hospital stay. The resident, with multiple health conditions, was observed with numerous bruises on their arms and hands, but the clinical record lacked proper documentation. Despite policy requirements for weekly skin assessments and documentation of new impairments, no skin event form was completed, and assessments were not conducted on shower days.
A resident with severe cognitive impairment and multiple psychiatric diagnoses was involved in repeated physical altercations with other residents. Despite being on psychiatric medications and having physician orders for behavior monitoring, the facility failed to implement a behavioral care plan with preventative interventions. The facility also lacked a behavior management policy, contributing to the recurrence of these incidents.
The facility failed to provide adequate showering assistance to eight residents who required help with ADLs. Observations and record reviews revealed that these residents received fewer showers than the facility's standard of two per week. Interviews with staff highlighted inconsistencies in documentation and understanding of the electronic medical record system, contributing to the deficiency.
A resident in a reclining chair requested assistance for toileting multiple times but was not promptly assisted by staff, resulting in an incontinence episode. Despite visible distress and repeated requests, the staff prioritized feeding over toileting needs. The resident's care plan indicated a risk for urinary incontinence, but interventions were not followed, and the facility's policy on resident rights was not upheld.
The facility failed to notify the physician of significant changes in the conditions of two residents. One resident with atrial fibrillation experienced elevated heart rates without physician notification, while another resident with Lennox-Gastaut syndrome missed multiple doses of anti-seizure medication, leading to seizures, without the physician being informed. The facility did not adhere to its policy requiring notification of significant changes in resident status.
A facility failed to develop a care plan for a resident with a seizure disorder, despite the resident's complex medical history and frequent seizure activity. The resident, diagnosed with Lennox-Gastaut syndrome and other conditions, experienced numerous seizures, as documented in nursing progress notes. Despite being prescribed multiple medications, there was no care plan in place to address the resident's seizures, and the facility did not provide a policy regarding care plans before the survey exit.
The facility failed to administer physician-ordered medications to two residents, resulting in missed doses of Hydrocodone and Lyrica. The administrator confirmed the residents should have received their medications as per orders, but no policy for following physician orders was provided.
The facility failed to ensure medications were available and administered as ordered for three residents. A resident with Alzheimer's and acute kidney failure missed multiple doses of Mupirocin and Clonazepam due to unavailability. Another resident with chronic headaches had discrepancies in Lyrica administration, including missed and extra doses. A third resident with dementia did not receive Valsartan as prescribed. The facility lacked a policy for handling unavailable medications, and the Administrator acknowledged the need for proper medication management.
A resident with multiple diagnoses, including Alzheimer's and depression, was administered Clonazepam without a stop date, leading to continuous use throughout October. The facility's policy limits PRN orders for psychotropic drugs to 14 days, but this was not followed. The resident also received Ativan on several occasions, and the Administrator confirmed the use of both medications due to behavioral issues.
A resident with severe cognitive disabilities and epilepsy experienced significant medication errors, including missed doses and incorrect administration of antiseizure medications over several months. Facility staff failed to communicate effectively with the pharmacy and physician, leading to ongoing medication administration issues.
A resident with a history of Parkinson's disease, dementia, neurogenic bladder, and diabetes was observed multiple times with their urinary catheter equipment improperly positioned on the floor, despite physician orders and care plans indicating the need for proper catheter management. Interviews confirmed that the catheter tubing and drainage bag should not be on the floor, highlighting a failure in maintaining sanitary conditions.
The facility failed to notify the physician about the removal of a PICC line and discharge of a resident, as well as a low blood glucose level in another resident. The first resident had a PICC line removed without physician notification and was discharged without informing the physician. The second resident experienced a low blood sugar reading, but there was no documentation of physician notification, despite the care plan requiring monitoring for hypo/hyperglycemia.
A facility failed to provide a transfer/discharge form for a resident during two hospital transfers. The resident, with multiple diagnoses including diabetes and fractures, was first transferred after being found unresponsive with low blood sugar. Later, the resident was transferred again due to abdominal swelling and bruising, requiring surgery for a hematoma. In both cases, the required documentation was not provided, contrary to facility policy.
A resident with multiple medical conditions was transferred to the hospital for emergency treatment and surgery, but the facility failed to provide a bed hold form as required by their policy. The Director of Nursing confirmed that such documentation should have been included, and the facility's policy mandates notification of the bed-hold policy during hospital transfers.
The facility failed to manage a diabetic resident's care, resulting in a critical hypoglycemic event without proper physician orders for emergency transfer or blood sugar monitoring. Additionally, another resident was discharged without notifying the physician or documenting the removal of a PICC line, contrary to facility policy.
A facility failed to provide timely dressing changes for a PICC line for a resident with multiple health issues, including osteomyelitis and MRSA infection. The resident was admitted with a PICC line, and physician orders required weekly dressing changes. However, the first documented change occurred over a week after admission. The DON confirmed the lack of documentation for dressing changes during this period, despite the facility's policy outlining the procedure.
A resident with multiple medical conditions, including a right hip fracture, was not transferred according to physician orders, which required a mechanical lift. A CNA attempted to transfer the resident without the lift, resulting in the resident being lowered to the floor. The CNA was unaware of the updated transfer requirements due to not reviewing the electronic tablet with care instructions.
Improper CPR Technique and Incomplete CPR Training
Penalty
Summary
The facility failed to ensure a staff nurse performed CPR correctly for a resident who later died. The resident had diagnoses including acute on chronic diastolic heart failure, type 2 diabetes mellitus, COPD, and conversion disorder with seizures/convulsions. The resident’s MDS indicated severe cognitive impairment and independence with bed mobility, and the care plan showed the resident had an advance directive for full code status. When the resident complained of not being able to get her breath, the nurse left the room to find another nurse, then returned to find the resident unresponsive without blood pressure or an apical pulse and began CPR. Body camera footage reviewed by surveyors showed the nurse performing chest compressions while the resident remained on a pressure redistribution mattress, with the upper body on the mattress and the lower body off the side of the bed and feet on the floor. The nurse was observed standing over the resident while providing CPR, and the footage confirmed there was not a hard surface underneath the resident during compressions. The nurse later stated the resident should have been moved to a solid surface before CPR was provided, and another LPN also stated the resident had not been on a solid surface and should have been moved. The facility also failed to ensure that multiple nursing staff members who obtained CPR certification through an online provider completed the hands-on component required by the course. Surveyors reviewed CPR certifications for several RNs, LPNs, the DON, and the ADON and found the online curriculum stated hands-on training was not provided and directed users to virtual or in-person instructors for the skills component. The Executive Director stated nursing staff were not required to have hands-on training as part of the facility’s CPR certification process.
Failure to Update Communication Care Plan for Resident with Severe Visual Impairment
Penalty
Summary
The facility failed to update a resident’s care plan related to communication after the resident’s condition reflected severe visual impairment. Resident 20 had a care plan problem dated 2/11/2026 and revised on 4/8/2026 that identified difficulty with communication and included interventions such as a communication book/board, writing pad, signs, and gestures. However, during observation on 5/8/2026, the resident was in the common area talking with a staff member, stated he was blind and bored, and was unable to make eye contact, instead looking off into the distance. Record review showed Resident 20 had a diagnosis of unqualified visual loss in both eyes, and a quarterly MDS dated 4/2/2026 indicated severe cognitive deficit and severe visual impairment. During interview, the Clinical Reimbursement Specialist stated she completed the most recent MDS and updated the care plans, but it was unclear why the communication interventions had not been revised to reflect the resident’s severely impaired vision. A QMA stated the resident could see shadows of objects and people nearby but was unable to see pictures or use a communication board.
Tube Feeding While Head of Bed Was Below Ordered Elevation
Penalty
Summary
The facility failed to ensure the head of the bed was elevated to at least 30 degrees for a resident receiving tube feeding. During an observation, the resident was lying in bed with the head of the bed below 30 degrees while the tube feeding was infusing, and the resident’s head was close to the body elevation. When an LPN observed the bed shortly afterward, she stated the head of the bed was a little low and not at a 30-degree angle, and indicated the CNAs must have just finished changing the resident. An OT then measured the bed angle with a goniometer and found the bed frame was at 12 degrees. Record review showed the resident had diagnoses including persistent vegetative state, tracheostomy and gastronomy status, moderate protein-calorie malnutrition, diffuse traumatic brain injury, and quadriplegia. The resident’s MDS indicated he was rarely or never understood, received tube feeding, and was dependent with bed mobility. A physician’s order directed that the head of the bed be elevated at 30 degrees every shift, and the care plan included keeping the head of the bed elevated at least 30 degrees while tube feeding was infusing.
Failure to Follow Care Plan for Food Allergy
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including dementia, feeding difficulties, and a documented allergy to tomatoes, was served food containing tomato despite clear care plan instructions and physician orders indicating the allergy. The resident's care plan specifically stated that tomato should not be served at meals, and the dietary order reinforced this restriction. However, the resident was given ketchup on a hotdog, which was delivered from the kitchen on the resident's tray. The incident was documented in nursing progress notes and led to a grievance filed by the resident's family. A CNA reported offering ketchup and mustard to the resident, who accepted, and only realized the tomato allergy after the resident had consumed several bites. The facility's policy required implementation of a comprehensive, person-centered care plan, but in this instance, the care plan related to the resident's food allergy was not followed.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
A resident with multiple complex medical conditions, including chronic obstructive pulmonary disease, vascular dementia, and muscle wasting, developed a Stage 2 pressure ulcer on the right heel. Physician orders were in place to cleanse the wound, apply calcium alginate, and cover it with ABD and rolled gauze daily. However, documentation and interviews revealed that the dressing was not changed as ordered on two consecutive days. The treatment administration record showed that staff had signed off on the dressing changes, but the dressing remained unchanged and was still dated from two days prior. This discrepancy was brought to staff attention by the resident's family, who noticed the outdated dressing. Further investigation confirmed that the responsible LPN had not performed the dressing changes on the specified dates and had mistakenly documented completion in the electronic charting system. Facility policy required that residents with impaired skin integrity receive necessary treatment and services to promote healing, and that neglect, defined as failure to provide necessary services to avoid physical harm, be prevented. The facility was unable to provide a specific policy regarding pressure wound care upon request.
Infection Control Breach During Medication Pass
Penalty
Summary
The facility failed to adhere to infection control procedures during a medication pass for two residents. An LPN was observed breaking potassium chloride tablets with bare hands, despite having sanitized her hands prior to medication preparation. Additionally, the LPN coughed into her bare hand while at the medication cart. Furthermore, the LPN prepared and administered an insulin injection to another resident without sanitizing her hands or wearing gloves. The Director of Nursing confirmed that gloves should have been worn during these procedures, as per the facility's medication administration policy.
Sanitation Deficiencies in Kitchen and Nutrition Pantries
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen and nutrition pantries, potentially affecting 59 of 61 residents who received meals from the kitchen. During an initial tour, surveyors observed several issues in the kitchen, including an opened and unsealed bag of chicken pieces in the walk-in freezer, food debris on the floor, and expired or improperly labeled food items in the walk-in cooler. Additionally, the dry storage area contained an opened bag of graham cracker crumbs that were not sealed tightly. The Dietary Manager acknowledged these issues, indicating that expired foods should have been removed, opened foods sealed tightly, and liquids dated when opened. Further observations revealed additional deficiencies, such as skillets with missing Teflon and rust-colored areas, steam table pans with dried food substances, and improperly sealed food items. The Corporate Dietician confirmed these items should not have been used or stored in their current condition. In the nutrition pantries, issues included a dirty microwave, a broken refrigerator seal, and a lack of a thermometer. The Director of Nursing acknowledged these problems, indicating that the microwave should have been cleaned, the refrigerator seal fixed, and staff items should not have been in the resident's refrigerators. The facility's policies on food handling and ware washing were not adhered to, contributing to these deficiencies.
Failure to Complete Advance Directive Upon Admission
Penalty
Summary
The facility failed to ensure that an advance directive was completed upon admission for a resident with significantly impaired cognition. The resident was admitted to the facility, and a review of their records revealed a Physician's Order indicating a Do Not Resuscitate (DNR) status. However, there was no documentation of a completed DNR form signed by the resident or their representative. During an interview, the Administrator acknowledged that the resident should have had a signed DNR form upon admission. The facility's policy on advance directives, which was provided by the Administrator, stated that the facility would attempt to determine whether a resident has an advance directive during the admission process and, if not, whether the resident wishes to formulate one.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of hospital transfers for a resident, identified as Resident 52, who was reviewed for hospitalizations. Resident 52 had diagnoses including Alzheimer's disease, delusional disorder, neuromuscular dysfunction of the bladder, and obstructive and reflux uropathy. The resident had severe cognitive impairment and an indwelling urinary catheter as indicated in a Quarterly Minimum Data Set (MDS) assessment. On September 7, 2024, Resident 52 was transferred to a neuropsychological hospital, and on September 23, 2024, the resident returned to the facility. Another transfer occurred, and the resident returned from the hospital on October 2, 2025, with a replaced urinary catheter. A review of the facility's transfer and discharge list for September and October revealed that Resident 52 was not listed as a transfer from the facility, indicating a failure to notify the Ombudsman. During an interview, the Director of Nursing confirmed that the Ombudsman should have been notified of the transfers. The facility's current policy, titled 'Transfer/Discharge Notice,' mandates that a copy of the notice of transfer or discharge must be sent to the representative of the Office of the State Long-Term Care Ombudsman, which was not adhered to in this case.
Inaccurate MDS Assessment for Resident with Falls
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessment for a resident reviewed for accidents. The resident, who had diagnoses including chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic bronchitis, and generalized anxiety disorder, reported having fallen about five times in recent months without major injuries. A review of the resident's clinical records revealed two falls in January, which were not documented in the Quarterly MDS assessment dated February 10, 2025. The MDS Nurse, who participated in follow-up Interdisciplinary Team Meetings after falls, acknowledged that the falls should have been recorded in the MDS assessment. The Executive Director indicated that the facility did not have a specific policy for completing MDS assessments, instead following the Resident Assessment Instrument (RAI) Manual.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to deficiencies in addressing their specific needs. Resident 5 had a history of picking at cancerous areas on her face, yet her care plan lacked any mention of these behaviors or the skin condition. Despite having a physician's order for topical treatment, there was no care plan to manage her skin issues or her behavior of picking at her face. The administrator acknowledged the absence of a care plan for these issues. Resident 38 was observed with numerous bruises on his arms and hands upon readmission from a hospital stay, attributed to IVs and blood draws. However, the facility did not complete a skin event assessment or develop a care plan to address the bruising or the use of aspirin, which could exacerbate the condition. Resident 52, who had severe cognitive impairment and a history of physical altercations with other residents, also lacked a behavioral care plan to address these issues. Despite multiple incidents of aggression, the facility only had a plan to monitor her behavior of pointing fingers at others, failing to address her physical altercations.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that two residents received their scheduled showers, as required for their activities of daily living (ADL) care. Resident 57, who has diagnoses including dementia and diabetes mellitus type 2, was observed multiple times with greasy and disheveled hair, indicating a lack of proper hygiene care. Despite having a physician's order for showers on specific days, documentation showed that Resident 57 received showers infrequently, with no records of refusals or reasons for missed showers. Interviews with staff revealed inconsistencies in documentation practices, with no refusals noted in the Medication Administration Record. Similarly, Resident 48, who requires substantial assistance for showers due to conditions such as hemiplegia and aphasia, was observed with long fingernails, suggesting neglect in personal care. The resident's care plan indicated a need for assistance with ADLs, yet documentation showed significant gaps in showering, with no recorded refusals in the Nursing Progress Notes. Staff interviews confirmed that shower documentation was only completed electronically, which may have contributed to the oversight in care.
Failure to Conduct Proper Skin Assessments for Returning Resident
Penalty
Summary
The facility failed to ensure a resident who returned from a hospital stay was properly assessed for new and existing skin issues. Resident 38, who had diagnoses including congestive heart failure, diabetes, renal disease, and hypertension, was observed with numerous purple areas on both arms and hands. Despite a Nursing Progress Note indicating the presence of bruises related to IVs and blood draws upon the resident's return on 2/3/2025, the clinical record lacked a skin event form and documentation of these bruised areas. A Weekly Skin Assessment completed on 2/8/2025 noted existing impaired skin but did not specify the location or description of the impairment. Interviews with the Director of Nursing and the Administrator revealed that skin assessments should be conducted weekly, and no skin event form was completed for Resident 38 upon their return from the hospital. The resident reported that skin assessments were not conducted on their shower days, and they identified areas of skin impairment from both the hospital stay and an incident involving a wheelchair. The facility's policy on Skin Integrity, dated 1/31/2025, requires initial skin checks upon admission and ongoing observation by licensed nursing staff, with documentation initiated for new impairments. However, no further wound or skin assessments were provided before the survey exit.
Failure to Implement Effective Behavior Monitoring
Penalty
Summary
The facility failed to implement effective behavior monitoring to prevent resident-to-resident altercations from recurring. Resident 52, who has diagnoses including Alzheimer's disease, dementia with agitation, major depressive disorder, post-traumatic stress disorder, and delusional disorder, was involved in multiple incidents of physical altercations with other residents. Despite being on antipsychotic, antianxiety, and antidepressant medications, Resident 52 exhibited behaviors such as pointing fingers at other residents, taking off clothing, and exit-seeking. These behaviors were noted in physician orders and psychiatric consults, yet the facility did not have a behavioral care plan in place with preventative interventions to address these physical altercations. The report details several incidents involving Resident 52, including poking another resident, being unkind, and making physical contact with others. Despite these incidents, the facility did not have a policy for behavior management available when requested. The Executive Director indicated that behaviors were discussed regularly with various staff members, and interventions were supposed to be care planned, but this was not effectively implemented. The lack of a behavioral care plan and preventative interventions contributed to the recurrence of altercations involving Resident 52.
Failure to Provide Adequate Showering Assistance
Penalty
Summary
The facility failed to ensure that showers were provided for eight residents who required assistance with activities of daily living (ADLs). These residents, identified as H, J, L, C, N, P, M, and Q, were observed and documented to have received fewer showers than the facility's standard of two showers per week. The deficiency was identified through a combination of record reviews, interviews, and observations conducted by surveyors. Resident H, diagnosed with dementia and anxiety, was documented to have received only two showers in October 2024, despite being dependent on staff for personal care. Similarly, Resident J, who has Parkinson's disease and dementia, received only one shower in the same month. Resident L, with Alzheimer's disease, was also found to have received fewer showers than required, with documentation showing only five showers over two months. Observations of Resident C revealed greasy hair, and records indicated inconsistent showering, with only a few documented showers in October 2024. Other residents, such as N, P, M, and Q, also experienced similar deficiencies in showering assistance. Resident N's records lacked documentation of showers or refusals, while Resident P's records showed only one documented refusal and no showers. Resident M received only two showers in October 2024, and Resident Q had only one documented shower. Interviews with staff, including CNAs and the Director of Nursing, revealed inconsistencies in shower documentation and a lack of understanding of the electronic medical record system, contributing to the deficiency in providing adequate care.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to provide timely assistance for toileting to Resident C, a continent resident, resulting in an incontinence episode. On the observed date, Resident C was in a small dining room and requested assistance from CNA 10 to go to the bathroom. Despite her repeated requests and visible distress, including moaning and banging her hand on the armrest, CNA 10 did not assist her immediately. Instead, CNA 10 left the dining room and later returned with the resident's lunch tray, prioritizing feeding over addressing the resident's toileting needs. After the meal, Resident C was moved to the nurse's desk, where she continued to request help for toileting, but was again not assisted promptly. Resident C was eventually taken to her room, where it was discovered that her pants were wet, indicating an incontinence episode. Despite the resident's requests and the visible signs of distress, the staff, including LPN 9, did not offer a bed pan or take her to the bathroom in a timely manner. The care plan for Resident C indicated she was at risk for complications associated with urinary incontinence, yet the interventions outlined were not followed. The facility's policy on resident rights emphasized treating residents with respect, kindness, and dignity, which was not upheld in this instance.
Failure to Notify Physician of Significant Changes in Resident Conditions
Penalty
Summary
The facility failed to notify the physician of significant changes in the condition of two residents, leading to deficiencies in care. Resident N, who has a history of atrial fibrillation, experienced elevated heart rates ranging from 176 to 211 beats per minute over a period of time. Despite the care plan's directive to report such changes, there was no documentation indicating that the physician was notified of these elevated heart rates. Interviews with nursing staff confirmed that changes in vital signs should prompt notification to the physician, but this protocol was not followed in Resident N's case. Resident E, diagnosed with Lennox-Gastaut syndrome and other severe cognitive disabilities, experienced multiple missed doses of the anti-seizure medication Fycompa over several months. The missed doses coincided with numerous documented seizure activities, yet there was no evidence that the physician was informed of the missed medication or the seizure occurrences. Nursing staff admitted to not notifying the physician about the missed doses or the seizure activity, which is contrary to the facility's policy on notifying changes in a resident's condition. The facility's policy requires that significant changes in a resident's physical, mental, or psychosocial status be communicated to the resident, their representative, and the physician. However, in both cases, the facility did not adhere to this policy, resulting in a failure to provide timely medical intervention for the residents. The lack of documentation and communication with the physician represents a significant oversight in the care provided to these residents.
Failure to Develop Seizure Care Plan for Resident
Penalty
Summary
The facility failed to develop a care plan for a resident with a seizure disorder, despite the resident's complex medical history and frequent seizure activity. The resident, diagnosed with Lennox-Gastaut syndrome, severe intellectual disabilities, autistic disorder, and schizophreniform disorder, was admitted to the facility and had an active diagnosis of seizure disorder. The resident was prescribed multiple medications to manage seizures, including Clobazam, Fycompa, Lamotrigine, Rufinamide, and Clonazepam. Despite these prescriptions, the resident experienced numerous seizures, as documented in nursing progress notes, with episodes occurring on multiple occasions and varying in duration and severity. Observations and interviews revealed that the resident continued to have seizures, including an incident witnessed by a surveyor. Despite the frequent seizure activity and the need for consistent medication administration, there was no current care plan in place to address the resident's seizures. The Executive Director acknowledged that the resident should have uninterrupted administration of seizure medications. However, the facility did not provide a policy regarding care plans before the survey exit, indicating a lack of formalized planning for the resident's seizure management.
Failure to Administer Physician-Ordered Medications
Penalty
Summary
The facility failed to administer physician-ordered medications to two residents, resulting in a deficiency. Resident J, diagnosed with Parkinson's disease, dementia, neurogenic bladder, diabetes, and joint pain, did not receive four scheduled doses of Hydrocodone on a specific date and the midnight dose the following day. The facility's administrator confirmed that the resident should have received the medication as per the physician's orders. Similarly, Resident L, who has Alzheimer's disease, hypertension, depression, dementia, and chronic cluster headaches, missed several doses of Lyrica, a controlled pain medication, on multiple occasions. The facility's administrator acknowledged that the resident should have received these medications. The facility's policy on controlled medication administration was reviewed, but no policy for following physician orders was provided. This deficiency was related to a specific complaint.
Medication Availability and Administration Deficiencies
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for three residents. Resident M, diagnosed with multiple conditions including Alzheimer's disease and acute kidney failure, did not receive Mupirocin ointment and Clonazepam as ordered on several occasions due to the medications being unavailable. The October Medication Administration Record (MAR) indicated multiple missed doses for both medications over a span of days. During an interview, a Qualified Medication Aide (QMA) confirmed that medications should always be double-checked with the MAR prior to administration. Resident L, with diagnoses including Alzheimer's disease and chronic cluster headaches, had discrepancies in the administration of Lyrica, a controlled medication. The Controlled Drug Record showed missed doses and extra doses administered on different dates. The MAR indicated that Lyrica was not available on certain days, and the Administrator acknowledged that the resident should not have received extra doses. Resident C, diagnosed with dementia and chronic kidney disease, did not receive Valsartan as ordered due to the medication being unavailable on multiple occasions. The Administrator noted that medications should have been obtained from the Pyxis or through a STAT delivery from the pharmacy, and there was no existing policy for handling unavailable medications.
Excessive Duration of Antianxiety Medication Administration
Penalty
Summary
The facility failed to ensure that an antianxiety drug was not administered for an excessive duration for a resident, identified as Resident M. The medical record review revealed that Resident M had multiple diagnoses, including Alzheimer's disease, acute kidney failure, and depression, among others. Physician's orders indicated that Resident M was prescribed Ativan, an antianxiety medication, to be taken as needed, and Clonazepam, another antianxiety medication, to be taken twice daily. However, the Clonazepam prescription did not have a stop date, and the resident received the medication continuously throughout October. The facility's current Care Plan for Resident M, reviewed in mid-October, noted the risk of drug-related side effects due to psychotropic medication. Despite this, the October Medication Administration Record showed that Resident M received both Clonazepam and Ativan on multiple occasions. During an interview, the Administrator acknowledged that Resident M was on both medications due to behavioral issues. The facility's policy on psychotropic medications, which was provided by the Administrator, stated that PRN orders for such drugs are limited to 14 days and should include documentation of the rationale and duration in the resident's medical record. This policy was not adhered to in Resident M's case, leading to the deficiency.
Significant Medication Errors in Antiseizure Medication Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically related to the administration of antiseizure medications. The resident, who had severe cognitive disabilities and multiple diagnoses including Lennox-Gastaut syndrome and epilepsy, experienced numerous medication errors over several months. These errors included missed doses, overdosing, and underdosing of medications such as Clobazam, Fycompa, and Clonazepam. The narcotic signature sheets for August, September, and October 2024 revealed multiple instances where the resident either missed doses or received incorrect dosages of these medications. Interviews with facility staff and pharmacy personnel indicated a lack of communication and follow-up regarding the medication errors. The pharmacy was contacted multiple times about the missing medications, but there were delays in delivery, and the facility staff failed to notify the physician about the missed doses. Additionally, there was confusion among the nursing staff regarding the correct administration schedule for Clobazam. The facility was unable to provide a policy on medication errors when requested during the survey, highlighting a gap in their procedures for managing medication administration errors.
Improper Maintenance of Urinary Catheter Equipment
Penalty
Summary
The facility failed to maintain urinary catheter equipment in a sanitary manner for Resident J, who was observed multiple times with the catheter tubing and urine collection bag lying on the floor. This was first noted during an observation on October 30, 2024, at 11:41 A.M., when Resident J's catheter equipment was found on the floor under his wheelchair. Subsequent observations on October 31 and November 1, 2024, confirmed that the urine collection bag continued to be improperly positioned on the floor, including when Resident J was in the dining room. Interviews with CNA 11 corroborated that the catheter tubing and drainage bag should not be on the floor, indicating a lapse in adherence to proper catheter management protocols. Resident J's medical record revealed a history of Parkinson's disease, dementia, neurogenic bladder, and diabetes, with a documented use of an indwelling catheter. A physician's order from August 21, 2024, specified the use of a Foley/Supra-pubic catheter with a privacy bag, and another order from August 29, 2024, required the catheter bag to be secured with a Tube Tie adhesive holder every shift. Despite these orders, the facility did not provide a policy for catheter use when requested on October 31, 2024. Resident J's care plan, revised on October 10, 2024, indicated a risk for complications related to the catheter, including a urinary tract infection, but failed to ensure proper catheter care and positioning, leading to the observed deficiencies.
Failure to Notify Physician of Critical Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician regarding the removal of a PICC line and the discharge of Resident B. Resident B, who had multiple diagnoses including diabetes and an infection of the left lower stump, had a PICC line inserted for intravenous antibiotics. On one occasion, the PICC line was found to be out of place, and nursing staff removed it without notifying the physician. Additionally, the resident was discharged from the facility without the physician being informed, as documented in the nursing progress notes. For Resident C, the facility did not notify the physician of a low blood glucose level. Resident C, diagnosed with diabetes mellitus and multiple fractures, had a recorded low blood sugar reading, but there was no documentation of physician notification. The resident's care plan included monitoring for signs of hypo/hyperglycemia, but there were no physician orders for treating hypoglycemia or parameters for notifying the physician about abnormal blood sugar levels. The facility's policy required notifying the physician of significant changes in a resident's condition, but this was not adhered to in these cases.
Failure to Provide Transfer/Discharge Form for Resident Transfers
Penalty
Summary
The facility failed to provide a transfer/discharge form for a resident, identified as Resident C, during two separate hospital transfers. Resident C, who had diagnoses including diabetes mellitus type 2 and fractures of the neck, lumbar and thoracic vertebra, and right humerus, was first transferred to a local hospital after being found unresponsive with symptoms such as cold, clammy skin, non-reactive pupils, labored breathing, and weak hand grips. The resident's blood sugar was recorded at 49 mg/dL. The resident returned from the hospital the same day. On a subsequent occasion, Resident C was transferred to the emergency department due to a swollen and firm left abdomen, bruising on the right arm, and increased pain and swelling. The resident was admitted to the hospital and later transferred to another hospital for surgery due to a large hematoma. In both instances, there was no documentation that a transfer/discharge form was provided, as confirmed by the Director of Nursing. The facility's policy requires that appropriate notice be provided to the resident and/or their representative, which was not adhered to in these cases.
Failure to Provide Bed Hold Form During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed hold form for a resident who was transferred to the hospital, which is a requirement under their policy. The resident, who had diagnoses including diabetes mellitus type 2 and fractures of the neck, lumbar and thoracic vertebra, and right humerus, was transferred to the emergency department due to a swollen and bruised left abdomen and increased pain and swelling in the right arm. The resident was subsequently admitted to the hospital and then transferred to another hospital for surgery due to a large hematoma. Despite these transfers, there was no documentation that a bed hold form was sent to the hospital or provided to the resident's Power of Attorney. The Director of Nursing confirmed that transfer documentation should include a bed hold form, and the facility's policy mandates notifying the resident or their representative of the bed-hold policy at admission and during any hospital transfer or therapeutic leave.
Deficiencies in Diabetes Management and Discharge Procedures
Penalty
Summary
The facility failed to properly manage the care of a resident with diabetes, leading to a critical incident where the resident was found unresponsive with hypoglycemia. The resident, who had a history of diabetes, was discovered by a CNA in a state of unresponsiveness, with symptoms including cold and clammy skin, non-reactive pupils, labored breathing, and weak hand grips. The resident's blood sugar was critically low at 49 mg/dL, and despite administering sugar, it only increased to 56 mg/dL. The facility did not have a physician's order to send the resident to the emergency room, nor were there adequate orders for managing hypoglycemia or parameters for notifying the physician of abnormal blood sugar levels. Additionally, blood sugar monitoring was not conducted routinely or as needed, particularly before administering bedtime insulin. In another instance, the facility failed to notify the physician of a resident's discharge and the removal of a PICC line. The resident, who had multiple diagnoses including diabetes and an infection requiring IV antibiotics, was discharged without proper documentation of physician notification. The resident was informed about the importance of completing her IV antibiotic treatment, but she chose to leave the facility. The facility's policy required physician orders to be followed and the physician to be notified of any concerns or changes, but this was not adhered to in the case of the resident's discharge and PICC line removal.
Failure to Provide Timely PICC Line Dressing Changes
Penalty
Summary
The facility failed to provide timely dressing changes for a PICC line for Resident D, as required by physician orders. Resident D, who had a history of osteomyelitis, alcohol abuse with withdrawal, psychoactive substance abuse, malnutrition, MRSA infection, and patient non-compliance, was admitted to the facility with a PICC line in place. The physician orders specified that the PICC line dressing should be changed weekly. However, the clinical record showed that the first documented dressing change occurred on 5/17/2024, despite the resident being admitted on 5/8/2024. The Director of Nursing confirmed during an interview that there was no documentation of a PICC line dressing change between the resident's admission and 5/17/2024. The facility's policy on vascular access devices and infusion therapy procedures, which was provided by the DON, outlined the steps for dressing changes, including performing hand hygiene, assessing the site, cleaning an area larger than the dressing to be applied, and applying a transparent dressing. This deficiency was identified during a complaint investigation.
Failure to Follow Transfer Orders for Resident
Penalty
Summary
The facility failed to ensure that a resident was transferred according to the physician's orders, leading to a deficiency. Resident C, who had multiple medical conditions including heart failure, end-stage renal disease, and a right hip fracture, was ordered to be non-weight bearing and required a mechanical lift for transfers. However, on one occasion, a CNA attempted to transfer the resident from the bed to a wheelchair without using the mechanical lift, resulting in the resident being lowered to the floor. The CNA was unaware of the updated transfer requirements as she had not reviewed the electronic tablet that contained the resident's care instructions. The incident occurred despite the facility's policy that physician orders should be followed and discussed with staff. The CNA involved had not worked after the new order was received and was not informed of the change in the resident's transfer procedure. The facility's policies on physician orders and fall prevention were not effectively implemented, as evidenced by the CNA's lack of awareness and the absence of a proper transfer method, which contributed to the resident being lowered to the floor during the transfer.
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What surveyors actually found near you
We read the 504 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Bremen
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Wakarusa Skilled Nursing Facility, The | 8.8 mi | ★★★★★ | 2 | 0 |
| Pilgrim Manor | 11.1 mi | ★★★★★ | 21 | 0 |
| Miller's Merry Manor | 12.1 mi | ★★★★★ | 0 | 0 |
| Southfield Village | 12.4 mi | ★★★★★ | 23 | 0 |
| Brickyard Healthcare - Twelfth Street Care Center | 14.4 mi | ★★★★★ | 29 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.