Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at South Shore Health & Rehabilitation Center during CMS and state inspections, most recent first.
Unsafe and uncomfortable temperatures were observed on the 500 Unit, where the hallway and multiple resident rooms were very warm and humid. A resident reported feeling hot in the room, and several residents stated their rooms were warm or quite warm. The Maintenance Director noted that Corporate Maintenance had been notified about the HVAC changeover, and room temperatures measured by the Maintenance Director were in the low 80s.
A resident with multiple chronic conditions, including kidney failure, heart failure, epilepsy, COPD, and diabetes, was transferred to the hospital for low hemoglobin without a documented nursing assessment or current vital signs on the SBAR at the time of transfer. Nursing notes recorded that an order was received to send the resident out for abnormal hemoglobin and that the resident was sent out, but the chart lacked documentation of the actual transfer time. Vital signs were taken earlier in the day, including post-dialysis, and another set was later documented as taken in the afternoon even though, according to the DON, the resident had already left the facility by that time. The DON acknowledged that the SBAR was incomplete and that the later vital signs were entered after the resident’s departure.
Sanitary Kitchen and Dishwashing Failure: The facility failed to maintain a sanitary kitchen when the low-temp chemical dishwasher was not sanitizing properly. The DM found no ppm of sanitizing solution in the dishwasher water, and a Dietary Aide reported using bleach in a bucket of water in the sink to sanitize dishes, which the DM said was not the correct method. The issue had the potential to affect all 70 residents who received meals prepared in the kitchen.
Improper Preparation of Pureed Food: A dietary staff member was observed preparing pureed turkey pot pie for residents who required pureed meals, but he added extra broth beyond the recipe while making 10 servings. The recipe on the counter specified 3 oz protein and 1 1/4 cup chicken broth for 10 servings, yet the staff member stated he added more broth to extend the recipe in case residents wanted seconds.
Environmental Cleanliness and Repair Deficiencies: Surveyors observed marred walls and doors, missing cove base, dirty and discolored floor and ceiling tiles, and missing privacy curtain hooks in multiple rooms across 2 of 4 units. The DON acknowledged the concerns during the tour and said she would relay them to the Maintenance Director.
The facility did not notify physicians in a timely manner when two residents failed to receive ordered medications, including an IV antibiotic for a wound infection and an antiviral for COVID-19. In both cases, the residents' records lacked documentation of physician notification, and facility policy requiring such notification was not followed.
Three residents did not receive medications and laboratory tests as ordered, including blood pressure medications not held or given per parameters, PRN medications not administered when indicated, and required labs and potassium not completed or given. The DON confirmed that orders were not followed and clarifications were not obtained.
Two residents did not receive prescribed medications for infections and COVID-19 as ordered, including missed doses of IV antibiotics and Paxlovid, with no documentation or explanation for the omissions. Facility staff were unable to account for the missed administrations, and there was a lack of follow-up or communication regarding the errors.
A resident with severe cognitive impairment, hemiplegia following a stroke, traumatic subdural hemorrhage, and gastrostomy status was left undressed and exposed during bathing. The resident was also observed wearing a hospital gown during the day on multiple occasions, and the record lacked a care plan for that practice. The DON and Corporate Nurse stated aides should have kept the resident covered during care.
Failure to obtain informed psychotropic medication consent. A resident with renal disease, GAD, major depression, and severe cognitive deficits was ordered alprazolam, quetiapine, and sertraline. A psychotropic consent form was signed by the Social Service Director but not by the resident or representative, and there was no documentation that the resident or representative was informed of the risks and benefits. The DON acknowledged the missing signature.
Failure to assess self-administration of medications: A resident with COPD and HTN was observed keeping an Albuterol inhaler at the bedside while stating he used it PRN and sometimes did his own nebulizer treatments. The resident was cognitively intact, but the chart had no current self-administration assessment and no order authorizing self-administration of the inhaler or nebulizer medication; an LPN said the resident gave himself the inhaler, and the DON was unsure how often the assessment should be completed.
Improper CNA Handling of Tube Feeding: CNAs stopped and restarted a resident’s tube feeding during bathing while the resident was lying flat, then restarted the pump after the head of the bed was elevated. The resident had a gastrostomy tube, severe cognitive impairment, and was dependent for ADLs and transfers. The DON stated CNAs should not stop or start tube feedings and should get a nurse to do it.
Failure to provide ongoing activities and sensory stimulation for dependent residents. Three residents with severe cognitive impairment and significant functional dependence were repeatedly observed in bed or in their rooms without TV, music, or staff interaction. Care plans called for one-on-one visits, music, reading/talking, and sensory or cognitive stimulation, but the activity records showed missed one-to-one visits and the AD stated the residents should receive regular stimulation.
Failure to provide restorative ROM services for two residents with limited mobility. One resident with hemiplegia, dementia, and a contracted knee was observed in bed without movement of the affected arm or leg, and the record lacked documentation of the ordered splint program and passive ROM. Another resident with fractures, Alzheimer’s disease, and repeated falls was observed in a wheelchair with no movement of one arm and a splint in place, but the record lacked documentation of ordered active ROM and a walking program. An LPN said the restorative program had not run for months because of staffing shortages, and the DON said it would resume once enough staff were hired and trained.
A resident with severe cognitive impairment and enteral nutrition orders was observed without tube feeding infusing when it should have been running, and staff reported the prior nurse had taken it down early and not restarted it. Another resident with dementia and dysphagia was observed with tube feeding infusing while the HOB was below the ordered elevation, and a CNA flattened the bed during care while the feeding continued. A third resident with gastrostomy status was also observed without tube feeding infusing despite an active order, and the DON confirmed it should have been running as ordered.
Incorrect Oxygen Flow Rates: The facility failed to ensure oxygen was set at the ordered flow rate for two residents. One resident with pleural effusion, HF, and anxiety was observed repeatedly on nasal cannula with the concentrator set at 8 liters despite an order for 4 liters continuously. Another resident with COPD and HTN was observed with oxygen in use while the concentrator was set at 2 to 3 liters despite an order for 2 liters PRN to keep O2 saturation above 92%; an LPN stated the concentrator was always set at 3 liters.
Pharmacy recommendation not completed for a resident with hemiplegia, DM, and A-fib. The resident had moderate cognitive impairment and was dependent for toileting and transfers. A pharmacy review recommended CBC, CMP, A1c, Vitamin D, and lipid testing, and the physician signed off on it, but the A1c, Vitamin D, and lipid tests were not completed. The DON said she normally reviews pharmacy recommendations and forwards them to the MD or NP, but did not know why this one was not completed.
Failure to use EBP PPE during high-contact care: Staff provided bathing and incontinence care to two residents with gastrostomy tubes and severe cognitive impairment without wearing the required gown and/or gloves. The residents had physician orders and care plans directing gown and glove use for high-contact activities such as bathing, hygiene, and changing briefs, and the DON stated staff should wear gown and gloves with any direct contact for residents on EBP.
An LPN entered a shared room to provide incontinence care without knocking or announcing herself, contrary to facility policy requiring staff to request permission before entry. A resident in the room was cognitively impaired, dependent for all ADLs, and had multiple complex medical conditions. The LPN admitted to forgetting to knock when questioned.
A resident with significant mobility and cognitive impairments, identified as high risk for falls, did not have required fall precautions in place, including a missing bed bolster and improperly placed fall mats. The resident suffered a fall and injury in the shower room due to a broken shower bed, with staff confirming the equipment malfunction and lack of proper monitoring.
A resident with severe cognitive impairment and multiple medical conditions did not receive scheduled pain medication on time, as documented in the MAR and reported by the resident's family. Pain medication was administered several hours late on multiple occasions, contrary to physician orders.
The facility failed to maintain sanitary conditions during food preparation and service. A CNA used bare hands to serve a resident's meal, contrary to guidelines. Additionally, a kitchen inspection revealed unsanitary conditions, including greasy equipment and dirty fans. The Dietary Manager acknowledged the need for cleaning.
The facility failed to administer medications according to physician's orders for two residents, did not assess and monitor skin conditions for two others, and failed to provide transportation for medical appointments for three residents. These deficiencies involved improper medication administration, lack of timely skin assessments, and missed medical appointments due to transportation issues.
A facility failed to honor a resident's preference for television volume, impacting their ability to engage in activities. The resident, with a history of stroke and other conditions, was found unable to hear the television due to it being placed on a tall wardrobe with the volume off and a loud vent nearby. Despite expressing the importance of keeping up with the news and enjoying television, the facility did not ensure the resident could hear the television, failing to support their self-determination and choice.
The facility failed to notify responsible parties of significant changes for two residents. A resident's POA was not informed of a large bruise until three days after it was observed, following a fall. Another resident's guardian was not notified of medication changes despite increased agitation and hallucinations. The facility did not adhere to its policy requiring immediate notification of significant changes.
A resident with multiple medical conditions experienced a decline in ambulation ability due to the facility's failure to implement a Functional Maintenance Program (FMP) after discharge from physical therapy. Despite recommendations for a restorative nursing program, there was no documentation of necessary exercises being provided, and staff interviews revealed communication gaps and lack of access to therapy notes.
A resident, who was dependent on staff for personal hygiene due to mobility impairments, was observed with unwanted facial hair on multiple occasions. Despite the resident's expressed preference for facial hair removal, the facility did not provide timely assistance, failing to adhere to the resident's care plan which required extensive assistance with personal hygiene.
A facility failed to complete meal consumption logs for a resident with significant weight loss and medical conditions including lung cancer, dysphagia, and vascular dementia. The resident, who required assistance with eating and a mechanically altered diet, experienced notable weight loss over several months. Missing documentation for multiple meals was identified, and the DON confirmed that logs should have been completed for each meal.
A resident with respiratory issues did not receive oxygen at the prescribed flow rate and missed a pulmonologist appointment due to transportation issues. Observations showed inconsistent oxygen flow rates, contrary to the physician's order for 3 liters per minute. The resident's appointment for CPAP evaluation was missed due to the facility's transportation coordinator resigning without notice.
A resident with a history of stroke, hypertension, and opioid abuse reported pain but was not offered pain relief due to discontinued medication and lack of documented interventions. Despite care plans requiring pain monitoring and comfort measures, these were not implemented. Staff interviews confirmed the absence of pharmacological or non-pharmacological interventions.
The facility failed to provide annual dental services for two residents, despite their requests and signed consents. One resident had decayed teeth and another was missing top teeth, yet neither had seen a dentist in over a year. Both residents were cognitively intact and had multiple health conditions, but the facility's dental action plan was not effectively implemented.
The facility failed to maintain a clean and safe environment, with observations revealing dirt, debris, and poor maintenance in resident rooms and bathrooms. Issues included dirty floors, cobwebs, trash, and unlabeled personal care items. The Administrator acknowledged these findings and confirmed the lack of a deep cleaning policy.
The facility failed to maintain an effective pest control program, as evidenced by the presence of dead bugs, water bugs, and mice droppings in resident rooms and bathrooms. The Administrator was unsure who was responsible for checking the traps, despite the facility's pest control policy indicating that a qualified pest control service would be contracted and a report system maintained for issues arising between scheduled visits.
A resident's legal guardian refused the administration of Remeron, an antidepressant, but the medication continued to be given from 3/8/24 to 4/28/24 due to a miscommunication between the DON and the Psychiatric NP. This violated the resident's right to direct their own medical treatment.
A resident with dementia and osteoarthritis did not receive routine pain medication as ordered due to the facility's failure to re-order the medication in a timely manner. The resident missed doses of acetaminophen-codeine from 3/6/24 at 12 a.m. until 3/9/24 at 12 a.m., and the Director of Nursing confirmed the lapse was due to a delay in re-ordering the medication.
The facility failed to ensure residents were free from unnecessary medications. A resident had multiple undated Lidocaine patches applied contrary to physician's orders, and another resident was administered Midodrine HCI despite blood pressure readings being outside the prescribed parameters.
The facility failed to ensure the posted Nurse Staffing Information was up-to-date and current. The responsible staff member was on vacation, and no one else had access to update the information. Past postings were found in a box for papers to be shredded, and the Scheduler was unaware of the need to retain them. A review revealed missing postings and a lack of actual hours worked documented. The Regional Nurse Consultant confirmed the omission of actual hours worked.
The facility failed to notify residents and their Responsible Parties in writing of room changes and new roommate assignments. Two residents were moved without proper documentation or notification, contrary to the facility's policy requiring advance notice and documentation of such changes.
The facility failed to complete meal consumption logs for a resident with significant weight loss and multiple health issues. The resident's weights fluctuated, and meal logs were incomplete on several dates. The DON confirmed that logs should be completed after every meal.
Unsafe and uncomfortable temperatures on the 500 Unit
Penalty
Summary
The facility failed to maintain comfortable and safe temperature levels on the 500 Unit, where 22 residents resided. During an initial tour of the unit, the hallway and resident rooms were observed to be very warm and humid, and Resident G stated that it was warm. The Maintenance Director later stated that Corporate Maintenance had been notified on 5/15/26 and that the Heating/Cooling Company was scheduled to come to the facility on 5/19/26 to change from the boiler to the chiller, explaining that the outside temperatures were cool at night and the changeover had not been completed. During an interview, Resident F told the Maintenance Director that it was hot in his room, and the Maintenance Director said he would obtain a thermometer to monitor room temperatures. A wall thermometer outside one room showed the hallway temperature at 82 degrees. On a later observation, the Maintenance Director measured multiple rooms on the 500 Unit and recorded temperatures of 82.2, 82.2, 81.6, 81.5, 81.6, 81.2, and 81.6 degrees. Residents in those rooms stated that the rooms were warm, and Resident K said it was quite warm in the room. Resident G also stated that it had been warm in her room for the past three days.
Failure to Assess Change in Condition and Accurately Document Vitals Before Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident experiencing a change in condition prior to transfer and to accurately document vital signs at the time of transfer. The resident had multiple significant diagnoses, including kidney failure, heart failure, epilepsy, COPD, and diabetes, and was documented as severely impaired for daily decision making and dependent in all ADLs and transfers. An SBAR completed for the resident’s transfer due to a low hemoglobin contained no vital signs or assessment data other than a prior weight from two days earlier. Nursing notes documented that an order was received to send the resident to the hospital for evaluation of an abnormal hemoglobin level of 6.5 and later that the resident had been sent out for low hemoglobin, but there was no documentation of an assessment at the time of transfer. Vital signs were recorded in the chart at 8:17 a.m. and 3:17 p.m. on the day of transfer, and an additional set of vitals was taken at 11:00 a.m. after dialysis, before the order to send the resident out was received. The record lacked documentation of the actual time the resident left the facility, and the DON reported that they could only infer the departure time from the census, which showed the resident removed at 12:17 p.m. The DON also confirmed that the vital signs documented as taken at 3:17 p.m. were entered hours after the resident had already left the facility and that the SBAR should have included a complete assessment and vitals at the time of transfer. The resident was later documented as admitted to the hospital with a hemoglobin of 6.2 and having received a blood transfusion.
Sanitary Kitchen and Dishwashing Failure
Penalty
Summary
The facility failed to maintain a sanitary kitchen because the low temperature chemical dishwasher was not sanitizing properly. During the initial kitchen tour, the Dietary Manager stated the chemical dishwasher was not working properly and that service was scheduled for Friday. He tested the dishwasher water with a strip, and it did not register any parts per million of sanitizing solution. A Dietary Aide stated she had put bleach in a bucket of water in the sink to sanitize the dishes, and the Dietary Manager said that was not the correct way to sanitize dishes. On the following day, the Dietary Manager stated he had educated kitchen staff to use sanitizing solution in the sink until the dishwasher was fixed. The report states this had the potential to affect all 70 residents who received meals prepared in the kitchen.
Improper Preparation of Pureed Food
Penalty
Summary
The facility failed to ensure pureed food was prepared correctly for residents who received pureed meals from the kitchen. During observation on 9/18/25 at 11:30 a.m., the dietary staff member was seen preparing pureed turkey pot pie for lunch and stated that eight residents received pureed food, with ten servings being prepared to allow for extra portions. He placed four large serving spoons of turkey pot pie into a blender, added hot water mixed with chicken stock, and then added approximately a quart of chicken broth. The recipe for pureed turkey pot pie on the counter specified 10 servings with 3 oz protein and 1 1/4 cup chicken broth, but the staff member added additional broth beyond the recipe, stating he did so to extend the recipe in case residents wanted seconds. During interview, the Dietary Manager stated he would re-educate the staff member on how to make pureed food.
Environmental Cleanliness and Repair Deficiencies
Penalty
Summary
The facility failed to ensure the residents' environment was clean and in good repair in 2 of 4 units throughout the facility. During an environmental tour with the DON and Corporate Nurse Consultant, surveyors observed multiple areas of damage and poor condition, including a room entry door with chipped paint and a marred base, missing cove base next to one bed, and privacy curtains with missing hooks for two residents. In another unit, walls beside and at the foot of a bed were scratched and marred in a room occupied by one resident. Additional observations included a scratched and marred wall in a room occupied by two residents, a discolored and bulging ceiling tile above a heat register, scuffed and marred floor tile, and a bathroom floor tile with an accumulation of dirt along the baseboard in a room shared by two residents and four residents using the bathroom. During the interview, the DON stated she would relay the concerns to the Maintenance Director.
Failure to Notify Physician of Missed Medication Administration
Penalty
Summary
The facility failed to ensure timely physician notification when residents did not receive prescribed medications as ordered. For one resident with a history of left below the knee amputation, diabetes, hypertension, pressure ulcers, and heart failure, an IV antibiotic (Flagyl) was ordered for a wound infection but was not available and never administered. There was no documentation that the physician was notified of the missed doses, and interviews confirmed that the physician was not informed until several days later. The resident's record also lacked evidence of appropriate documentation regarding the missed medication and physician notification. In another case, a resident with Alzheimer's, diabetes, and COVID-19 was prescribed Paxlovid for COVID-19 treatment, but only received 3 out of 10 scheduled doses due to the medication not arriving. The record did not show that the physician was notified about the missed doses, and facility leadership confirmed that the nurse should have notified the physician and documented this in the record. The facility's policy required physician notification when there was a need to alter treatment, but this was not followed in these instances.
Failure to Administer Medications and Labs per Physician Orders
Penalty
Summary
The facility failed to administer blood pressure medications and laboratory tests according to physician orders and established parameters for three residents. For one resident with end stage renal disease, hypotension, and hypertension, the care plan required medications to be given per physician order, including Midodrine HCl to be held if systolic blood pressure was less than or greater than 110 or heart rate was less than 60. However, the medication was administered on multiple occasions when the resident's blood pressure readings were outside the specified parameters, and the DON acknowledged the need for order clarification. Another resident with Alzheimer's disease, hypertensive heart disease, and hypotension had orders for Lisinopril to be held if blood pressure was less than 100/60, and for PRN Midodrine if systolic blood pressure was less than 90. The resident received Lisinopril on several occasions when blood pressure was below the hold threshold, and did not receive PRN Midodrine when blood pressure was low enough to warrant it. Additionally, blood pressure monitoring was not performed at the frequency specified in the order. The DON confirmed that the medication administration did not follow the orders and that clarification should have been obtained. A third resident with hemiplegia, diabetes, and atrial fibrillation had handwritten orders for repeat laboratory tests and potassium administration, but these were not entered into the electronic record. There was no evidence that the repeat lab was completed or that potassium was given as ordered. The DON confirmed that these actions were not carried out as required.
Failure to Administer Prescribed Medications for Infection and COVID-19
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically related to the administration of prescribed antibiotics and antiviral medications. For one resident with multiple diagnoses including a recent below-the-knee amputation, diabetes, and pressure ulcers, a physician ordered intravenous Flagyl for a wound infection. The medication was not available and was never administered, with no documentation of physician notification or follow-up. The resident's condition deteriorated, and the wound doctor was not informed of the missed doses until after the resident was hospitalized and subsequently expired. The facility's staff, including the DON and corporate nurse, were unable to explain why the medication was not given as ordered. Another resident with Alzheimer's disease, diabetes, and COVID-19 was prescribed Paxlovid for a confirmed COVID-19 infection. Although the medication was delivered as a single unit from the pharmacy, the resident received only 3 out of 10 scheduled doses, with no documentation explaining the missed doses. The DON and corporate nurse confirmed that the medication should have been available and could not account for the failure to administer it as prescribed. The records lacked evidence of appropriate follow-up or communication regarding the missed medication doses.
Resident Left Exposed During Bathing and Kept in Hospital Gown Without Care Plan
Penalty
Summary
The facility failed to maintain Resident 64’s dignity by leaving the resident undressed and exposed during bathing and by allowing the resident to wear a hospital gown during the day without a documented care plan for that practice. During observation on 9/16/25 at 10:29 a.m., CNA 2 and CNA 3 were seen bathing the resident, and the resident was left undressed and exposed throughout the bath. Resident 64’s record showed diagnoses including traumatic subdural hemorrhage, hemiplegia following a stroke, and gastrostomy status. The 7/14/25 Quarterly MDS indicated severe cognitive impairment and dependence for ADLs and transfers. The resident was observed wearing a hospital gown during the day on multiple occasions, including 9/16/25, 9/17/25, 9/18/25, and 9/19/25, and the record lacked a care plan for wearing a hospital gown during the day. During interview, the DON and Corporate Nurse 1 stated the aides should have kept the resident covered during the bath, only uncovering what was being washed.
Failure to Obtain Informed Psychotropic Medication Consent
Penalty
Summary
The facility failed to ensure a resident was fully informed of the risks and benefits of psychotropic medication before the medication was started. Resident 11 was admitted with renal disease, generalized anxiety disorder, and major depression, and the admission MDS indicated severe cognitive deficits with dependence for bed mobility, transfers, and toileting. Physician orders included alprazolam 0.5 mg three times daily for anxiety and quetiapine fumarate 25 mg, two tablets twice daily for psychotic disorder with delusions, and a nursing progress note later documented sertraline 50 mg daily ordered by the psychiatric NP. A psychotropic consent assessment was completed for alprazolam, quetiapine, and sertraline and signed by the Social Service Director, but it was not signed by the resident or the resident's representative, and there was no documentation that the resident or representative had been informed about the medications' risks and benefits. The DON stated she was aware the consent had not been signed by the resident representative.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for self-administration of medications for 1 of 1 resident reviewed for self-administration of medication. Resident 24 had diagnoses including COPD and hypertension, and the 8/31/25 MDS indicated the resident was cognitively intact for daily decision making. A care plan dated 6/7/24 and identified as current stated the resident chose to administer his inhaler and included interventions for education on inhaler use, proper storage, a lock box in the room, and routine self-administration evaluation. During observations on 9/15/25, 9/16/25, and 9/17/25, an Albuterol inhaler was seen at the resident’s bedside or bedside table, and the resident stated he used the inhaler PRN and at times did his own nebulizer treatments. The resident shared the room with two other residents. Physician orders dated 8/24/25 included Albuterol Sulfate inhaler PRN and Ipratropium-Albuterol nebulizer treatments, but there was no order allowing self-administration of either medication. The only self-administration assessment available was dated 6/7/24 for a Breztri inhaler, and there was no current self-administration assessment available. An LPN stated the resident administered his inhaler by himself, and the DON stated she was not sure how often the self-administration assessment was to be completed.
Improper CNA Handling of Tube Feeding
Penalty
Summary
The facility failed to ensure professional standards of quality were maintained when CNAs stopped and started a resident’s tube feeding during care. During an observation, two CNAs were bathing Resident 64, who had a gastrostomy tube connected to a feeding pump. The pump was paused while the resident was lying flat, and when the pump began beeping, one CNA pushed buttons on the pump. After the bath was completed and the head of the bed was elevated, the same CNA restarted the tube feeding pump. During the observation, both CNAs stated they had stopped the tube feeding before laying the resident flat and restarted it after the head of the bed was elevated. The resident’s record showed diagnoses including traumatic subdural hemorrhage, hemiplegia following a stroke, and gastrostomy status. The resident was severely cognitively impaired and dependent for ADLs and transfers, and had an order for Jevity 1.2 tube feeding at 50 mL/hr for 20 hours daily. The DON stated the CNAs should not stop or start the tube feedings and should get a nurse to do it.
Failure to Provide Ongoing Activities and Sensory Stimulation
Penalty
Summary
The facility failed to provide ongoing activities and sensory stimulation for dependent residents 14, 35, and 44. Resident 14, who had diagnoses including Alzheimer's dementia, severe protein calorie malnutrition, and adult failure to thrive, was repeatedly observed in bed or in her chair without a radio or television on in the room. Her MDS indicated severe cognitive impairment and dependence for bed mobility, toileting, and transfers, and her activity care plan stated that she enjoyed television and may require sensory and cognitive stimulation. The Activity Director stated the resident received one-on-one visits about three times per week for about 15 minutes and that the radio or television should be on, usually by nursing staff. Resident 35, who had cerebral palsy, epilepsy, and visual loss, was also repeatedly observed in bed without a radio or television on, and at one point her roommate was yelling loudly next to her while no television or radio was on. Her MDS showed severe cognitive impairment and dependence for bed mobility, toileting, and transfers. Her care plan stated she could not express her care needs and required assistance with daily needs, with interventions to provide one-on-one activities, talk/read to her, and provide music. Resident 44, who had hemiplegia following a stroke, seizures, and dementia, was observed lying in bed awake without television, music, or staff interaction on multiple occasions. Her MDS indicated severe cognitive impairment and dependence in ADLs and transfers, her activities review noted she enjoyed self-directed leisure, sensory stimulation, and music, and her current care plan included a one-on-one sensory stimulation goal. A review of the one-to-one visits report showed she did not receive three visits during the week reviewed, and the Activities Director stated she should receive one-on-one visits three times a week.
Failure to Provide Restorative ROM Services
Penalty
Summary
The facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase or prevent further decrease in ROM for 2 of 4 residents reviewed for mobility. One resident with diagnoses including hemiplegia following a stroke affecting the left side, seizures, and dementia was observed lying in bed without moving the left arm or leg, and the left knee appeared contracted. The resident’s record showed severe cognitive impairment, dependence in ADLs and transfers, and a restorative care plan that included a splint program to prevent further contracture of the left knee and passive ROM exercises. However, the record lacked documentation that ROM exercises or the brace program had been implemented since the last restorative note, which stated the goals were not met and the restorative program would continue. A second resident with diagnoses including fractures of the left tibia and left clavicle, Alzheimer’s disease, and repeated falls was observed sitting in a wheelchair with no movement of the right arm and a carrot splint in the right hand. The resident’s record showed severe cognitive impairment and substantial assistance needs with ADLs, and the restorative care plan called for active ROM exercises 5 days a week and participation in a walking program. The record lacked documentation that active ROM exercises or the walking program had been implemented since the last restorative note, which also indicated the programs were recommended to continue. An LPN stated there had not been a restorative program for a couple of months because staffing was insufficient, and the DON stated the restorative care program would resume when enough staff were hired and trained.
Tube Feeding Not Infusing as Ordered and Head of Bed Not Maintained During Feeding
Penalty
Summary
The facility failed to ensure tube feedings were infusing at the ordered times for residents with enteral nutrition orders. Resident 14, who had diagnoses including Alzheimer's dementia, severe protein calorie malnutrition, and adult failure to thrive, was observed without tube feeding hanging or infusing on multiple occasions. The resident's record showed severe cognitive impairment and dependence for bed mobility, toileting, and transfers, and the physician ordered Jevity 1.2 to run continuously at 50 mL per hour for 18 hours daily, with the MAR directing it to be turned on at 6:00 p.m. and off at 1:00 p.m. RN 2 stated the feeding should have been on until 1:00 p.m., but the previous nurse had taken it off early and it had not been restarted. The facility also failed to maintain the head of bed elevation during tube feeding for another resident and failed to keep tube feeding infusing for a third resident. Resident 9, who had dementia, Alzheimer's, and dysphagia, was observed with tube feeding infusing while the head of bed was less than 30 degrees, and CNA 1 later flattened the bed to provide care while the feeding continued to infuse; CNA 1 stated she sometimes stopped the pump before laying the resident flat and sometimes did not. The resident's order required the head of bed to be elevated 30 to 45 degrees at all times with tube feeding. Resident 64, who had traumatic subdural hemorrhage, hemiplegia following a stroke, and gastrostomy status, was observed on two occasions with no tube feeding hanging or infusing despite an order for Jevity 1.2 at 50 mL per hour for 20 hours daily. RN 2 stated the feeding should have been infusing, and the DON indicated it should have been infusing as ordered.
Incorrect Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure oxygen was set at the correct flow rate for 2 of 3 residents reviewed for respiratory care. Resident 12 was observed multiple times in bed with oxygen via nasal cannula in use, and the oxygen concentrator was set at 8 liters each time. The resident’s record showed diagnoses including pleural effusion, heart failure, and anxiety, and the 5-day MDS indicated the resident was cognitively intact and received oxygen while in the facility. The care plan directed oxygen therapy related to congestive heart failure, history of pneumonia, pulmonary embolism, pulmonary edema, and respiratory failure, and a physician’s order dated 9/12/25 directed oxygen at 4 liters continuously every shift. Resident 24 was also observed with oxygen via nasal cannula in use, but the oxygen concentrator was not consistently set at the ordered flow rate and was observed at 2 liters on one occasion and 3 liters on others. The resident’s record showed diagnoses including COPD and hypertension. The 8/31/25 MDS indicated the resident was cognitively intact and was not receiving oxygen, while the care plan identified oxygen therapy as needed related to COPD and a history of pneumonia. Physician’s orders dated 8/27/25 directed 2 liters of oxygen per nasal cannula PRN to keep oxygen saturation above 92% every shift, and the September 2025 MAR showed oxygen signed out as being in use each shift except for one evening. An LPN stated the resident’s oxygen concentrator was always set at 3 liters, and the DON was informed of the incorrect flow rate.
Pharmacy Recommendation Not Completed
Penalty
Summary
The facility failed to ensure a pharmacy recommendation was completed as ordered for one resident reviewed for unnecessary medications. The resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, diabetes mellitus, and atrial fibrillation, and the quarterly MDS indicated moderate cognitive impairment with dependence for toileting and transfers. A pharmacy review identified a recommendation for the physician to consider scheduling a CBC, CMP, A1c, Vitamin D level, and lipid testing at the next convenient lab, and the physician agreed and signed the recommendation. A CBC and CMP were completed, but the A1c, Vitamin D, and lipid tests had not been completed. The DON stated she normally reviews pharmacy recommendations and gives them to the physician or NP, but she did not know why this recommendation had not been completed.
Failure to Use EBP PPE During High-Contact Resident Care
Penalty
Summary
The facility failed to ensure infection control practices were in place and implemented related to enhanced barrier precautions (EBP) for two residents during direct care observations. During a random observation, a CNA provided a partial bath and incontinence care for a resident with a gastrostomy tube without wearing a gown, even though the resident had severe cognitive impairment, was dependent in ADLs and transfers, and had a physician's order requiring staff to don gown and gloves for all high-contact resident care activities. The resident's care plan also directed EBP during bathing, dressing, hygiene, changing linens, and changing briefs. In a separate observation, two CNAs bathed another resident with a gastrostomy tube without wearing gowns, and later a CNA was observed adjusting the resident's brief without wearing a gown or gloves. That resident also had severe cognitive impairment, was dependent in ADLs and transfers, and had a physician's order requiring EBP with gown and glove use for high-contact activities including bathing, dressing, hygiene, changing linens, and changing briefs. The DON stated staff should wear a gown and gloves with any direct contact with a resident on EBP, and the facility policy identified high-contact care activities such as bathing, hygiene, and changing briefs as requiring targeted gown and glove use.
Failure to Maintain Resident Dignity During Room Entry
Penalty
Summary
A deficiency was identified when an LPN failed to knock or announce herself before entering a resident's room during incontinence care, despite facility policy requiring staff to knock and request permission prior to entry. The incident occurred in a shared room with two residents present. The resident involved had multiple diagnoses, including Parkinson's disease, dementia, a stage 4 sacral pressure ulcer, heart disease, bladder dysfunction, hypertension, gastrostomy status, and a psychotic disorder. The resident was noted to be cognitively impaired and dependent on staff for all activities of daily living and transfers. The LPN acknowledged forgetting to knock when interviewed at the time of the incident.
Failure to Maintain Equipment and Implement Fall Precautions Leads to Resident Injury
Penalty
Summary
A resident with multiple diagnoses, including heart disease, hypertension, congestive heart failure, psychotic disorder, depression, and anemia, was identified as being at risk for falls due to impaired mobility and cognitive impairment. The care plan required the use of a fall mat, a bed bolster, and monitoring of these interventions every shift. However, observations revealed that the bed bolster was missing, and fall mats were placed on the floor rather than next to the bed. Documentation showed that the bed bolster was not listed on the Treatment Administration Record (TAR) for August, and there was no evidence of monitoring from the beginning of the month through the date of observation. The resident experienced a witnessed fall in the shower room, resulting in a forehead injury and subsequent transfer to the hospital. The post-fall evaluation identified that the shower bed was broken, which contributed to the fall. Staff interviews confirmed that the shower bed moved unexpectedly during care, leading to the resident's fall. The facility's policy required identification and mitigation of hazards, but the broken equipment and lack of proper fall precautions were not addressed, resulting in the incident.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's pain medication was administered as ordered and in a timely manner. A resident with diagnoses including dementia, Alzheimer's, hypertension, depression, anxiety, COPD, and adult failure to thrive was assessed as severely cognitively impaired and required scheduled pain medication for lower back pain. Physician's orders specified Acetaminophen-Codeine 300-30 mg to be given by mouth three times daily. However, the Medication Administration Record showed that the medication was administered late on multiple occasions, with doses given several hours after the scheduled times on two consecutive days. The resident's daughter reported that the pain medication was not received on time, and a nurse consultant confirmed that the medication should have been administered as scheduled.
Sanitation Deficiencies in Food Preparation and Service
Penalty
Summary
The facility failed to maintain sanitary conditions during food preparation and service, as observed in two separate incidents. In the first incident, a CNA was observed serving a resident a hot dog on plain white bread and used her bare hands to break the hot dog and bread in half before handing it to the resident. The CNA acknowledged that she was aware of the requirement to use utensils instead of bare hands for such tasks. The Dietary Manager confirmed that staff were instructed to use utensils for cutting residents' food. In the second incident, a kitchen sanitation tour revealed multiple unsanitary conditions. The deep fryer had a heavy accumulation of grease and burned food, while the convection oven had a large amount of burned food on the bottom and greasy, dirty doors. The steam table wells were rusted with peeling metal pieces, and the shelf under the table was dirty with food crumbs and grease. Additionally, two standing fans were dirty and dusty, blowing towards the steam table and dish machine. The Dietary Manager acknowledged the need for cleaning these areas.
Medication Administration and Monitoring Failures in LTC Facility
Penalty
Summary
The facility failed to administer medications according to physician's orders for two residents. Resident H, who has hypertension, type 2 diabetes, and vascular dementia, was prescribed Metoprolol Succinate with specific parameters for administration based on blood pressure and pulse. However, the facility did not document the resident's pulse from late June to late July, potentially leading to improper medication administration. Similarly, Resident J, who has end-stage renal disease and hypotension, was not administered Midodrine HCl as needed when blood pressure parameters were met, and Irbesartan was not held when blood pressure was below the required threshold. The facility also failed to assess and monitor skin conditions for two residents. Resident C, who has multiple health issues including respiratory failure and dementia, developed a large bruise after a fall, which was not assessed or documented in a timely manner. The bruise was only noted days later, and there was a lack of communication among staff regarding its presence. Resident G, who has fibromyalgia and lupus, was observed with a facial rash that was not documented in skin assessments, and there was no physician order for the ointment being used. Additionally, the facility did not provide transportation for medical appointments for three residents. Resident D missed a urology appointment, Resident E missed a nephrology appointment, and Resident F missed a pulmonary appointment due to the facility's inability to provide transportation. This was attributed to issues with the payer source for Medicaid residents and the resignation of the facility driver, leading to outsourcing transportation needs and resulting in missed appointments.
Failure to Honor Resident's Television Preferences
Penalty
Summary
The facility failed to honor a resident's preferences regarding television volume, impacting the resident's ability to engage in activities. During multiple observations, the resident was found in his room with the television on top of a tall wardrobe closet, but the volume was turned off, and a loud air return vent was nearby. The resident expressed during an interview that he could not hear the television. The resident's medical record indicated a history of stroke, type 2 diabetes mellitus, epilepsy, vascular dementia, anemia, major depressive disorder, and high blood pressure. The resident was not cognitively intact for daily decision-making but had expressed that it was somewhat important to keep up with the news and enjoy activities like watching television. Activity assessments confirmed the resident's enjoyment of television, yet the facility did not ensure the resident could hear the television, thus failing to support the resident's self-determination and choice.
Failure to Notify Responsible Parties of Significant Changes
Penalty
Summary
The facility failed to notify the responsible parties of two residents about significant changes in their conditions. For Resident C, the facility did not inform the Power of Attorney (POA) about a large bruise that appeared on the resident's chest until three days after it was first observed. The bruise was likely related to a fall that occurred on 7/14/24, but there was no documentation of any injury immediately following the fall. The bruise was first noticed by a CNA on the day of the fall, but the information was not properly communicated to the nursing staff or documented until 7/17/24. Interviews with staff revealed a lack of communication and documentation regarding the bruise, leading to a delay in notifying the resident's POA. For Resident B, the facility did not document notifying the resident's brother, who is the guardian, about changes in the resident's medication regimen. The resident, who has a history of Alzheimer's disease, schizophrenia, and other conditions, was experiencing increased agitation and hallucinations. A nurse practitioner adjusted the resident's medications, discontinuing some and starting others, but there was no record of the guardian being informed of these changes. The facility's policy requires immediate notification of significant changes in a resident's physical status to the resident's representative, which was not followed in this case.
Failure to Implement Functional Maintenance Program Post-Discharge
Penalty
Summary
The facility failed to implement a Functional Maintenance Program (FMP) for a resident after discharge from physical therapy, leading to a decline in the resident's ability to ambulate. The resident, who had a history of respiratory failure, joint stiffness, COPD, Parkinson's disease, chronic bronchitis, and dementia, was previously able to walk 50 feet with standby assistance using a walker at the time of discharge from physical therapy. The discharge recommendation included 24-hour nursing care and a restorative nursing program (RNP) to maintain the resident's current level of performance and prevent decline. However, there was no documentation of passive range of motion or ambulation exercises being provided from the time of discharge until several months later. Interviews with facility staff revealed a lack of communication and access to necessary information regarding the resident's need for a restorative program. The Restorative Nurse indicated that the RNP did not resume until a month after discharge, and the Unit Manager and Director of Nursing confirmed that they were not informed of the therapy department's recommendations. Additionally, nursing staff did not have access to therapy progress notes, which contributed to the oversight in providing the necessary care to maintain the resident's functional abilities.
Failure to Assist Resident with Personal Hygiene Needs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was dependent on staff for personal hygiene. The resident, who was cognitively intact but had impairments in both upper and lower extremities and used a wheelchair, was observed multiple times with long black facial hair above her top lip. Despite the resident expressing a desire to not have facial hair, the facility did not address this need in a timely manner. The resident's care plan indicated a need for extensive assistance with personal hygiene, yet the staff did not maintain the resident's facial hair as preferred by the resident.
Failure to Document Meal Consumption for Resident with Weight Loss
Penalty
Summary
The facility failed to ensure that meal consumption logs were completed for a resident with a history of significant weight loss. Resident 68, who has diagnoses including lung cancer, dysphagia, and vascular dementia with behavior disturbance, was observed eating lunch with his fingers. The resident's medical records indicated a severe impairment in daily decision-making and a need for assistance with eating, as well as a mechanically altered diet due to swallowing difficulties. The resident experienced a 9.4% weight loss in one month and a 14.5% weight loss over six months. The food consumption logs for Resident 68 showed missing documentation for several meals over a month-long period. Specifically, there was no dinner intake recorded on one date, and no breakfast or lunch intake documented on three other dates, with a complete lack of documentation for any meal on another date. During an interview, the Director of Nursing confirmed that the food consumption logs should have been completed for each meal, indicating a lapse in the facility's monitoring of the resident's nutritional intake.
Failure in Respiratory Care and Transportation Coordination
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident, identified as Resident C, by not ensuring the oxygen was set at the correct flow rate and failing to transport the resident to a scheduled pulmonologist appointment. Observations revealed inconsistencies in the oxygen flow rate administered to the resident, with the rate set at 0.75 liters per minute during some observations and 2 liters per minute during others, despite a physician's order for continuous oxygen at 3 liters per minute. This discrepancy indicates a failure to adhere to the prescribed treatment plan for the resident, who has a medical history including respiratory failure, COPD, Parkinson's disease, chronic bronchitis, heart disease, atrial fibrillation, and dementia. Additionally, the resident missed a crucial cardio/pulmonologist appointment due to transportation issues, as the facility's transportation coordinator resigned without notice, leaving some residents without transportation to their appointments. The appointment was initially scheduled to evaluate the resident for a CPAP machine, which is essential for managing her respiratory condition. The resident's power of attorney was informed of the missed appointment and the need to reschedule, highlighting a lapse in the facility's coordination of care and transportation services.
Failure to Provide Appropriate Pain Management
Penalty
Summary
The facility failed to provide safe and appropriate pain management for a resident, identified as Resident 45, who required such services. The resident, who had a history of stroke, hypertension, anxiety, hemiplegia, benign prostatic hyperplasia, and opioid abuse, reported experiencing pain in his stomach and penis. Despite expressing his pain to the nursing staff, he was not offered Tylenol or any other pain relief. The resident's care plan included monitoring for pain and offering comfort measures, but these interventions were not documented or implemented. A physician's order required monitoring pain levels every shift and trying non-pharmacological interventions before medicating, but these were not followed. The resident's ibuprofen prescription was discontinued due to findings of drug-seeking behavior, as indicated by a nurse's progress note. The Medication Administration Record (MAR) showed that pain assessments were signed off as completed, but they lacked documentation of pain levels or interventions. Interviews with staff revealed that the resident's pain medication had been discontinued, and there were no pharmacological or non-pharmacological interventions documented or in place. The Director of Nursing confirmed the discontinuation of ibuprofen and the absence of new orders from the resident's urologist and pain clinic.
Failure to Provide Annual Dental Services
Penalty
Summary
The facility failed to ensure that each resident received dental services at least annually, as evidenced by the cases of Residents K and D. Resident K, who was cognitively intact and had multiple health conditions including heart failure and diabetes, was observed with decayed teeth and had requested to see a dentist. Despite signing a dental consent in April 2024 and having an oral assessment indicating dental issues, Resident K had not been seen by a dentist in the past year. The facility had a dental action plan dated February 2024, but it was not effectively implemented to ensure timely dental care for Resident K. Similarly, Resident D, who was also cognitively intact and had a history of heart failure, stroke, and other health issues, expressed a desire to see a dentist for missing top teeth. Despite having a care plan addressing oral and dental problems and signing a dental consent in April 2024, Resident D had not been seen by a dentist since admission in February 2022. The facility's failure to provide timely dental services for these residents highlights a deficiency in meeting the required standard of care.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to ensure the residents' environment was clean and in good repair. Observations revealed dirt and debris in the corners and along the baseboards of resident rooms and bathrooms. Specific issues included stained and dirty floors, cobwebs, trash on the floor, and dirty privacy curtains. Additionally, there were instances of dried liquid feeding on pump poles and floors, and personal care items stored in bathrooms were unlabeled and uncovered. These conditions were noted in multiple rooms across different halls, indicating a widespread issue with cleanliness and maintenance in the facility. In the 200 Hall, rooms were found with dirt and debris along baseboards, cobwebs, and dried liquid feeding on equipment. Bathrooms shared between rooms had unlabeled and uncovered personal care items stored on the floor. Similar conditions were observed in the 300 Hall, where privacy curtains were dirty, and there was dirt and debris under beds and behind closets. Bathrooms had holes in the floor, missing tiles, and dim lighting, contributing to an overall unclean and poorly maintained environment. The 400 and 500 Halls also exhibited significant cleanliness and maintenance issues. Rooms had stained and dirty privacy curtains, dirt and debris on floors, and cobwebs. In one instance, a resident used a water pitcher liner for urine elimination due to the absence of a proper urinal. The Administrator acknowledged these findings during an environmental tour and confirmed the lack of a policy for deep cleaning rooms. The facility's policy for routine cleaning was not effectively implemented, leading to the observed deficiencies.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of dead bugs, water bugs, and mice droppings in resident rooms and bathrooms. Specifically, dead bugs and mice droppings were found in room 310, mouse droppings were observed in room 408, mouse droppings and a dead bug were found in room 402, and multiple bugs were seen in a glue trap in room 213. The Administrator was unsure who was responsible for checking the traps, despite the facility's pest control policy indicating that a qualified pest control service would be contracted and a report system maintained for issues arising between scheduled visits. This deficiency was noted during observations and interviews conducted on 4/29/24 and 4/30/24.
Failure to Discontinue Medication Despite Guardian's Refusal
Penalty
Summary
The facility failed to respect the right of a resident's legal guardian to direct medical treatment. Resident B, diagnosed with dementia and osteoarthritis, had two Permanent Co-Guardians appointed. A Physician's Order dated 3/8/24 prescribed Remeron, an antidepressant, to be administered nightly due to significant weight loss, comments about wanting to die, and decreased appetite. The Co-Guardian was informed of the new medication order and expressed refusal of the treatment. Despite this, the Remeron was not discontinued, and the medication continued to be administered from 3/8/24 to 4/28/24. The Psychiatric Nurse Practitioner (NP) noted the family's refusal of the treatment on 3/12/24 and again on 3/14/24, but no order to discontinue the medication was written. The Director of Nursing (DON) assumed the nurse had already discontinued the medication, but the NP usually entered their own orders into the computer. This miscommunication led to the continued administration of Remeron against the Co-Guardian's wishes, violating the resident's right to direct their own medical treatment.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure a resident with pain received routine pain medication as ordered by the physician. Resident B, who had diagnoses including dementia and osteoarthritis, was supposed to receive acetaminophen-codeine (acetaminophen #3) every eight hours. However, the medication was not re-ordered from the pharmacy in a timely manner, resulting in the resident missing doses from 3/6/24 at 12 a.m. until 3/9/24 at 12 a.m. The Medication Administration Record (MAR) and Controlled Drug Records indicated that the medication was not available for administration during this period, and there was no documentation that the resident's family had administered the medication during this time. Interviews with the Director of Nursing (DON) confirmed that the medication had not been re-ordered until 3/7/24, and the pharmacy required a prescription to refill the controlled substance. The prescription was received on 3/8/24, and the medication was delivered early morning on 3/9/24. The DON acknowledged that the medication should have been re-ordered when it was getting low to prevent the lapse in administration. This deficiency was related to complaints IN00429414 and IN00429590.
Failure to Ensure Residents Were Free from Unnecessary Medications
Penalty
Summary
The facility failed to ensure residents were free from unnecessary medications. In the case of Resident B, multiple undated Lidocaine patches were observed on various parts of her body, contrary to the physician's order which specified only one patch should be applied to the lower back daily. The resident's care plan indicated that her Guardian was responsible for placing the patches, and staff were to check for and remove any extra patches upon her return from visits outside the facility. However, this protocol was not followed, leading to the application of multiple patches simultaneously. The resident's pain management plan included acetaminophen-codeine and repositioning, but the presence of multiple patches indicated a failure to adhere to the prescribed regimen. For Resident F, the facility administered Midodrine HCI despite the resident's blood pressure being outside the prescribed parameters. The physician's order specified that the medication should be held if the systolic blood pressure was greater than 120 and diastolic blood pressure was greater than 80. However, the medication was administered on several occasions when the resident's blood pressure readings exceeded these limits. The Director of Nursing confirmed that the medication was given outside of the physician's ordered parameters, indicating a failure to follow the prescribed medication regimen for Resident F.
Failure to Update and Maintain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure the posted Nurse Staffing Information was up-to-date and current. During an observation, it was found that the Nurse Staffing Information was dated 4/19/24, despite the observation occurring on 4/28/24. The Administrator indicated that the staff member responsible for updating the information was on vacation, and no one else had access to the locked frame. Additionally, the Director of Nursing (DON) found past postings in a box for papers to be shredded, and the Scheduler was unaware that the postings needed to be retained. A review of nursing schedules and posting information revealed missing postings for specific dates and a lack of actual hours worked documented on the postings. The Regional Nurse Consultant confirmed that the actual hours worked were not included on the postings. This deficiency was related to complaints IN00429414 and IN00429590.
Failure to Notify Residents and Responsible Parties of Room Changes
Penalty
Summary
The facility failed to notify residents and/or their Responsible Parties in writing of intrafacility transfers and new roommate assignments for two residents. Resident B, who had diagnoses including dementia, Alzheimer's disease, and anxiety, received a new roommate without documentation in the clinical record. When the new roommate tested positive for COVID-19, Resident B was moved to a different room without an intrafacility transfer form or proper documentation. The Infection Preventionist confirmed that the resident's Responsible Party was informed verbally, but this was not documented in the clinical record. The Director of Nursing also confirmed the lack of documentation and the absence of an intrafacility transfer form for the room change on 12/8/23. Resident H, who had diagnoses including stroke, heart disease, and major depressive disorder, tested positive for COVID-19 and was moved to a private room. The resident was later moved to another room and then back to the original room after isolation, but there was no documentation of these transfers or notification to the resident's Responsible Party. The Director of Nursing confirmed that the Responsible Party was not informed of the second transfer or the return to the original room, and no intrafacility transfer forms were completed for these moves. The facility's policy required advance notice and documentation of room changes, which was not followed in these cases.
Failure to Complete Meal Consumption Logs for Resident with Significant Weight Loss
Penalty
Summary
The facility failed to ensure meal consumption logs were completed for a resident with a history of significant weight loss. Resident C, who had multiple diagnoses including a right humerus fracture, heart disease, high blood pressure, heart failure, a pressure ulcer of the sacrum, a cardiac pacemaker, vision loss in both eyes, and a history of falls, experienced fluctuating weights from 88 pounds to 101 pounds over a period of time. The meal consumption logs for Resident C were incomplete on multiple dates for breakfast, lunch, and dinner. During an interview, the Director of Nursing confirmed that meal consumption logs were supposed to be completed after every meal.
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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 Gary
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Tolleston Park | 2.2 mi | ★★★★★ | 31 | 0 |
| Waters Of Hobart Skilled Nursing Facility, The | 4.9 mi | ★★★★★ | 0 | 0 |
| Casa Of Hobart | 5.5 mi | ★★★★★ | 27 | 0 |
| Harbor Health & Rehab | 6.2 mi | ★★★★★ | 38 | 0 |
| Rehabilitation Center At Hartsfield Village | 8.5 mi | ★★★★★ | 11 | 0 |
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