Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southwood Healthcare Center during CMS and state inspections, most recent first.
A resident with chronic kidney disease, obstructive uropathy, suprapubic catheter, and back drains was scheduled for bladder removal and urinary diversion surgery, requiring hospital admission 48 hours in advance for a neurology consult. The surgeon’s office reported notifying the DON and the resident’s representative of the revised admission date, and the hospital later called to say the bed was ready. However, no appointment was entered in the facility’s scheduling log, transport was not arranged for the correct day, and an LPN, unaware of the required date, informed the hospital that transport was set for the following day. The resident was ultimately sent to the hospital a day late, at which point the surgery was cancelled because the pre-surgical neurology consultation could not be completed as planned, leaving the resident upset and disappointed.
A resident with dementia, oropharyngeal dysphagia, and protein-calorie malnutrition, who required supervision with eating and had an order for a dysphagia-advanced diet, was served whole Brussels sprouts instead of chopped vegetables as specified on the diet ticket. During a lunch meal, a CNA observed the resident rapidly shoving food into her mouth without chewing and pocketing food, then noted bluish lips and performed the Heimlich maneuver, expelling a whole Brussels sprout before an LPN took over care. The facility’s risk management nurse confirmed that the vegetables had not been prepared in the chopped form required by the resident’s ordered modified diet.
The facility failed to keep paper towels at handwashing areas sanitary when commercial towel rolls were left next to sinks with wet marks and staff touched them with wet hands because dispensers were empty or broken. The facility also failed to ensure safe, sanitary meal service when CNAs handled ready-to-eat food with bare hands and did not sanitize hands between residents while assisting with meals and passing trays.
Missing Psychotropic Consent Documentation: The facility failed to obtain or maintain informed consent documentation for psychotropic medications when antipsychotic, antidepressant, and antianxiety drugs were started or increased for multiple residents. Records showed missing consent for Seroquel and risperidone changes, and for another resident, missing or incomplete consent for Effexor, Paxil, Buspirone, and Lorazepam, including absent black box warning information on some forms.
Call lights were not kept within reach for three residents. One resident with severe cognitive impairment and a history of falls had the call light placed at the foot of the bed or stuck between the bed and wall. Another resident with moderate cognitive impairment and transfer assistance needs had the call light clipped behind the head of the bed and stated he could not find it. A third resident with hemiplegia and a fall history had the call light left out of reach in bed and in a chair, and staff stated call lights should have been within reach before leaving the room.
Inaccurate code status orders were found for a resident with multiple myeloma, dementia, and diabetes whose MDS indicated cognitive impairment. The resident's POST form showed DNR, but the care plan listed CPR code status and a physician order also directed CPR, creating a mismatch with the POST form before a later order reflected DNR.
A resident’s PASRR was not re-evaluated after bipolar II disorder was added to the resident’s profile. The record showed an earlier Level I outcome with no Level II required, but there was no documentation that the PASRR was updated when the new psych dx was added. Risk Mgmt later issued an updated Level I screen that included the bipolar dx and referred the resident for an on-site Level II eval, stating the re-evaluation should have occurred when the diagnosis was added.
Incomplete Elopement Risk Care Planning: A resident with COPD and bipolar disorder had a Wander Guard order and care plan identifying elopement risk, but the record lacked documentation of exit-seeking behavior. Later wandering/elopement assessments and MDS entries stated wandering was not exhibited, while an LPN said the bracelet was used because the resident had dementia and had tried to go outside when first admitted, despite no supporting dementia diagnosis in the record. The guardian was unsure why the Wander Guard was still being used.
Failure to Provide Needed Grooming and Daily Care: A resident who was cognitively intact and required extensive to maximum assistance with ADLs was observed with excessive facial hair, dried pureed food on her shirt, oxygen tubing lying in the food, and greasy, disheveled hair. The record lacked documentation of refusal of care, while an LPN said the resident refused shaving, a CNA said she allowed care, and the resident stated she did not refuse assistance.
A resident with Alzheimer's disease, COPD, epilepsy, and nicotine dependence was observed smoking independently while keeping cigarettes and a lighter unsecured in her purse. She had a history of falls in the smoking area, and a later smoking assessment stated she was no longer safe to smoke independently, but this change was not documented as communicated to staff or the resident. Staff interviews showed inconsistent understanding of smoking supervision and storage requirements, and the resident smoker list still identified her as an independent smoker.
Nebulizer equipment was not properly cleaned and stored after use for two residents. One resident with diabetes, HTN, anxiety, and osteomyelitis had nebulizer tubing, mask, and chamber left on the bedside nightstand or on a plastic bag with clear liquid still in the chamber, and the care plan lacked a nebulizer intervention. Another resident with COPD and acute respiratory failure had unbagged nebulizer tubing and mouthpiece left on a chair next to the bed, with clear liquid and bubbles still in the chamber after a recent treatment. An LPN said the equipment should be rinsed and placed in a plastic bag, and the RDCO said the facility lacked a storage policy but equipment should be stored in a dated bag.
Failure to provide routine dental services: A cognitively intact resident reported wanting to see a dentist for missing and fallen-out teeth, but the chart lacked documentation that dental care was offered, provided, or refused. Risk management could not find evidence that dental services had been offered since admission, despite the care plan noting oral/dental risk and the facility policy addressing routine dental services.
A resident with a history of TIA and seizure disorder experienced an acute neurological change after being found on the bathroom floor unresponsive with right-sided facial droop and inability to raise the right arm. Staff called 911 and the resident was transferred by ambulance to a local ED and later to an ICU where life-sustaining interventions, including a ventilator, were initiated. Although the resident’s sister was listed as the emergency contact, the clinical record showed no documentation that she was notified of the fall, significant change in condition, or hospital transfer, and the transfer form indicated she was not aware of the transfer. The family member reported multiple unsuccessful attempts to reach the resident that day and only learned of the events during a late evening call, despite facility policy requiring prompt notification of the resident representative for significant changes in condition and transfers to the hospital.
A resident with multiple chronic conditions and a history of falls was not monitored or provided care during an entire night shift. Staff did not enter the resident's room or visualize her, relying on the assumption that she would request help if needed. The resident was found deceased on the floor between her bed and wheelchair the next morning, with records and staff interviews confirming that required checks and care were not performed.
A facility failed to provide adequate night shift staffing, with only one nurse, one QMA, and one CNA covering multiple units and nearly 100 residents. A resident with multiple chronic conditions was not checked on throughout the night and was found deceased in the morning, with staff admitting they did not perform required two-hourly checks. Documentation showed missed care, and both staff and residents reported ongoing issues with insufficient staffing and delayed care.
The facility did not ensure thorough investigations or maintain complete records for abuse allegations involving three residents with cognitive impairments. In two separate incidents, required documentation such as resident and staff interviews, as well as proper entries in the residents' medical records, was missing or incomplete, contrary to facility policy.
A resident with paraplegia and diabetes had inaccurate wound documentation upon admission, with wound measurements not matching those from an outside wound center and staff uncertainty about proper measurement protocols. Another resident with diabetes had multiple instances of insulin administration documented at times inconsistent with physician orders, with staff citing delayed documentation and time management issues. Facility policies required accurate and timely documentation, but these were not followed in both cases.
Insulin and other diabetes medications were not consistently administered or documented according to physician orders for four residents with diabetes. Doses were frequently given outside the prescribed time frames, sometimes hours late or not documented at all. Residents reported inconsistent administration times, and staff cited high workload as a reason for delays. Medical records showed repeated late or missing entries for both scheduled and sliding scale insulin, despite facility policy requiring timely administration and documentation.
A resident with a stage four pressure ulcer required enhanced barrier precautions during wound care. During a dressing change, an LPN followed proper protocol, but a CNA assisting did not perform hand hygiene upon entering the room, donned gloves without a gown, and removed a dressing without changing gloves or performing hand hygiene afterward. Facility policy required the use of gowns and gloves and hand hygiene for such procedures, but these were not followed by the CNA.
The facility failed to provide adequate nurse staffing, resulting in missed insulin doses for residents with diabetes. A resident on the 400 unit and another on the 2A unit reported not receiving their insulin as prescribed. The review of staffing schedules and MARs revealed multiple instances of insufficient nurse coverage, leading to missed doses of Lispro, Glargine, Fiasp, Exenatide, and Basaglar insulin. The facility's practice of having one nurse oversee multiple QMAs across different units contributed to the deficiencies.
The facility failed to administer insulin medications as ordered for three residents, leading to significant medication errors. Residents with diabetes did not receive several doses of their prescribed insulin, and there was a lack of documentation in the Medication Administration Record (MAR). Interviews revealed that staff were overwhelmed, leading to missed doses and improper documentation. The Regional Director of Clinical Operations acknowledged the issue and mentioned ongoing re-education of the nursing staff.
The facility failed to ensure proper hand hygiene and dishwashing temperatures. Staff used commercial paper towel rolls, leading to contamination, and dish machine temperatures were below required levels due to lime buildup and faulty gauges. The facility had a supply issue with paper towels, and the dish machine company was contacted for repairs.
A facility failed to document and communicate a resident's code status, leading to difficulty in accessing this critical information. The resident, with severe cognitive deficits and heart disease, did not have their DNR status readily available in the EMR or physician's orders. Staff interviews revealed that the code status should have been easily accessible, but it was not documented as expected, contrary to the facility's policy on advanced directives.
A facility failed to notify the Ombudsman of a resident's hospital discharge, as required. The resident, with conditions including hemiplegia, COPD, and CHF, was transferred to the hospital due to a change in condition. The Social Services Director, new to her position, did not send the required notification for the discharge, which was confirmed by the Regional Director of Clinical Operations and the Ombudsman.
The facility failed to complete MDS assessments in a timely manner for two residents discharged without anticipated return. The assessments were delayed and only identified by the corporate office, highlighting a lack of timely audits at the facility level.
A facility failed to implement timely treatment for a resident with a stage 4 pressure ulcer. The resident was admitted with the ulcer, but the prescribed wound vacuum treatment was delayed by two days, and there was a lack of documentation for five days. The care plan did not reflect the necessary treatment, and staff interviews revealed that the admitting nurse did not obtain immediate wound care orders. The facility's policy for obtaining physician orders and documenting treatment was not followed, resulting in the deficiency.
The facility failed to maintain sufficient weekend staffing during a fiscal quarter, as revealed by staffing data and staff interviews. A CNA and an LPN reported challenges in completing assignments due to low staffing levels, with CNAs handling up to two halls and even fewer staff on weekends. The facility's staffing schedules lacked necessary details, and the Nurse Staff Scheduler acknowledged ongoing staffing issues, particularly with CNAs. The facility did not have a staffing policy in place.
The facility failed to ensure staff competency in medication administration, leading to deficiencies for two residents. An LPN improperly used and cleaned a glucometer and left medication carts unlocked, while a QMA administered medications in coffee, including crushing a do-not-crush medication. The incidents highlighted lapses in adherence to facility policies on staff education and competency testing.
A facility failed to ensure the correct diagnosis for prescribing an antipsychotic to a resident and did not attempt a Gradual Dose Reduction (GDR) for another resident. The first resident was prescribed Invega for schizophrenia without a documented diagnosis, while the second resident's records lacked evidence of behaviors justifying continued psychotropic use or GDR attempts. Staff interviews revealed inadequate documentation and failed GDR attempts due to family intervention.
A facility failed to properly label an insulin pen for a resident with type 2 diabetes. An undated and opened Novolog insulin pen was found in a medication cart, and the LPN was unaware of how long it had been opened. Another LPN confirmed that insulin pens should have an open date and are good for 28 days once opened. The facility's policy required an open date sticker for medications with a specified usable duration after opening.
The facility failed to follow infection control protocols during medication administration and in the laundry room. An LPN did not use bleach wipes to clean a glucometer or place a barrier under it, and disposed of a lancet improperly. In the laundry room, clean items were stored in the soiled area, violating the facility's policy.
A facility failed to supervise and implement effective interventions for a dementia resident with intrusive wandering behaviors, leading to an altercation with another resident. Despite being on one-on-one observation, the resident entered another's room and was hit, resulting in a reddened area on her temple. The care plans lacked specific, person-centered interventions, and documentation of intervention efficacy was insufficient, contributing to the incident.
A facility failed to maintain a system for narcotic reconciliation, resulting in drug diversion incidents involving a resident's Norco and tramadol medications. Despite suspending staff and conducting investigations, the facility could not determine the whereabouts of the missing medication cards. Discrepancies in narcotic counts and inadequate documentation practices were identified, highlighting a breach in regulatory compliance.
A resident with multiple medical conditions was transported to a urology appointment in an undignified manner, wrapped in a sheet covered in feces, wearing only an adult diaper, with a leaking colostomy bag and a falling catheter. Staff were aware of the resident's care needs but failed to ensure he was properly cleaned and clothed before the appointment.
The facility failed to ensure accurate documentation of IV medication administration for a resident with multiple diagnoses, including metabolic encephalopathy and acute kidney failure. The MAR lacked documentation for several doses of cefazolin sodium, heparin sodium lock flush, and sodium chloride flush. Interviews revealed that staff did not understand the blanks in the MAR, and the facility's medication administration policy was not followed.
Failure to Arrange Timely Hospital Transport Resulting in Cancelled Surgery
Penalty
Summary
The deficiency involves the facility’s failure to arrange timely transportation for a resident to an acute care hospital for a scheduled pre-surgical admission, which resulted in cancellation of the resident’s surgery. The resident, who had chronic kidney disease, obstructive and reflux uropathy, artificial urinary openings, a suprapubic catheter, drains to his back, and major depressive disorder, had been scheduled for bladder removal and urinary diversion surgery. The plan required admission to the hospital two days prior to surgery for a neurology consultation. The surgery scheduler reported that the admission date had been moved to 3/29/26 to allow for this consultation and stated she had informed both the resident representative and the DON of the new admission date and the need for the resident to arrive 48 hours before surgery. The DON acknowledged that the hospital wanted the resident admitted the day before surgery and that the hospital would call when a bed was ready, but she stated she believed the admission and neurology consultation would occur on 3/30/26, the day before the 3/31/26 surgery. She reported telling hospital central scheduling that the facility required a specific time and 24–48 hours’ notice to arrange stretcher transport, and that the hospital could not provide a specific time. The DON stated she did not recall being told that the admission date had been changed to 3/29/26 and did not realize the resident needed to be at the hospital that day. The facility’s scheduling log contained no entry for any appointment on 3/29/26, and LPN 4 reported being unaware that the resident was supposed to go out on that date. On the afternoon of 3/29/26, the hospital called the facility and informed LPN 4 that the resident’s bed was ready and provided a room number. LPN 4 spoke with the resident, who said he was going on Monday, and she then informed the hospital that transportation had not been arranged for that day and that transport was set up for 3/30/26 instead. The surgery scheduler later called the facility again that night and was told transport would pick the resident up on 3/30/26 at 9:00 a.m. The resident was ultimately transported to the hospital on 3/30/26, placed in a hospital bed, changed into a gown, and had his wounds checked and redressed, but hospital staff then informed him that his surgery had been cancelled because he had not arrived on 3/29/26 for the neurology consultation. The resident expressed that he was very upset and disappointed, believed the DON knew he was supposed to go on 3/29/26, and blamed the DON for the cancellation and the need to reschedule his procedure. The facility’s undated Resident Transportation policy stated that the facility would assist residents in making transportation arrangements to and from needed services. Despite this policy, there was no documented appointment or transport arrangement for the required 3/29/26 hospital admission, and communication between the DON, LPN 4, the hospital, the surgery scheduler, the resident, and the resident representative was inconsistent regarding the correct admission date. The DON later stated she had since learned that the transport company could arrange quick transport for an extra fee, but at the time she believed she could not arrange transportation without a specific time. The lack of a documented appointment on the scheduling log, the failure to arrange transportation for the correct admission date, and the miscommunication about the required arrival date for neurology consultation led directly to the resident not being admitted on 3/29/26 and the subsequent cancellation of his surgery.
Failure to Provide Diet Texture Consistent With Dysphagia Order
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a form consistent with a physician-ordered modified diet for a resident with dysphagia and severe cognitive impairment. The resident had diagnoses including dementia, oropharyngeal phase dysphagia, and protein-calorie malnutrition, and required supervision and/or touching assistance for eating. A physician’s order specified a regular diet with dysphagia advanced texture and regular consistency. The facility’s menu and diet ticket for a lunch meal listed roasted Brussels sprouts that were to be served chopped for this dysphagia advanced diet. On the day of the incident, a CNA observed the resident during lunch rapidly shoving food into her mouth, not chewing, and pocketing food in her cheeks, which was unusual for the resident who typically fed herself slowly. The CNA moved the plate out of reach to slow the resident’s intake and address the food already in her mouth, then noted the resident’s lips turning bluish and believed she was choking. The CNA performed the Heimlich maneuver while the resident was seated, resulting in expulsion of a whole Brussels sprout, after which an LPN assumed care. The Corporate Risk Management Nurse later confirmed the resident had been served whole Brussels sprouts instead of chopped Brussels sprouts as required by the ordered dysphagia advanced diet and the facility’s texture policy.
Unsanitary hand hygiene supplies and unsafe meal assistance
Penalty
Summary
The facility failed to maintain paper towels at handwashing areas in a sanitary manner. During a kitchen observation, a commercial-sized roll of paper towels was sitting on a table next to the handwash sink with visible wet marks on the side and top of the roll, and the Culinary Director stated the dispenser was out of towels and housekeeping had not refilled it. During a later observation on the Memory Care Unit, staff were performing handwashing before serving meal trays, and another commercial-sized roll of paper towels was observed sitting on the counter next to the handwash sink with wet marks after staff touched the roll with wet hands. The Resident Services Director stated the towel dispenser was broken, and the Housekeeping Director later stated the brown and white towels for the dispensers were on recall. The facility also failed to ensure food was distributed in a safe and sanitary manner and failed to ensure staff assisted residents with meals in a safe and sanitary manner during lunch service in the activity room. A CNA uncovered a peanut butter and jelly sandwich, picked up half of it with bare hands, and placed it in a resident's hand, then moved the sandwich with bare hands from one hand to the other when the resident had difficulty eating. Another CNA picked up half of a peanut butter sandwich with bare hands and fed it to a resident. Additional observations showed a CNA passing food trays and setting up meals without sanitizing hands between residents, a CNA assisting one resident and returning to another without sanitizing hands, and a CNA alternating between two residents without sanitizing hands. Staff interviews indicated that bare-hand contact with food should not occur and that the facility did not have a policy for assisting residents with meals.
Missing Psychotropic Consent Documentation
Penalty
Summary
The facility failed to ensure informed consent documentation was obtained for psychotropic medications, including antipsychotics, when medications were initiated or doses were increased for 3 residents reviewed. The record review and interviews showed missing consent documentation for medication starts and dose changes, and in some cases the existing consent forms did not include the required black box warning information. The Regional Director of Clinical Operations stated the facility could not locate the needed consent documentation for the medication increases and/or initiations and that the consent forms needed to be updated to include the proper black box warning verbiage. Resident 11 had diagnoses including severe manic episode without psychotic symptoms and unspecified psychosis, and a significant change MDS indicated severe cognitive deficit and routine antipsychotic use. The record showed Seroquel orders for 200 mg at bedtime for mania, an additional 200 mg dose for one morning administration, and later an increase to a total bedtime dose of 250 mg with 50 mg plus 200 mg. A signed consent was present for Seroquel, but it lacked the required black box warning information, and the record lacked documentation of consent for the additional dose and the dose increase. Resident 59 had diagnoses including unspecified dementia, major depressive disorder, and psychotic disorder with hallucinations, and the MDS indicated the resident was rarely understood and received antipsychotic medication during the look-back period. The record showed risperidone 0.25 mg twice daily for hallucinations, later increased to 0.5 mg twice daily for delusional disorder, but the electronic record lacked documentation of psychotropic informed consent for the increased dose. Resident 62 had diagnoses including CHF, dementia, anxiety, and depression, and the record showed orders for Effexor, Paxil, Buspirone, and Lorazepam with multiple dose changes. The record lacked psychotropic consent documentation for the Effexor and Paxil orders and dose increases, and the Buspirone consent did not include black box warning information for the resident and responsible party; additional Buspirone dose increases also lacked evidence of psychotropic consent.
Call Lights Not Kept Within Residents’ Reach
Penalty
Summary
The facility failed to ensure call lights were kept within reach for 3 residents reviewed for call light access. During observations, Resident 19 had a touch pad call light placed at the foot of the bed and later stuck between the bed and the wall, both times out of reach. Resident 19’s record showed severe cognitive impairment, partial/moderate assistance needed for transfers, and a history of multiple falls. The care plan identified the resident as at risk for falls and noted multiple falls, with interventions that included placing the call light within reach and reminding the resident to ask for assistance. Resident 55 was observed with the call light clipped to something hanging on the wall behind the head of the bed, out of reach, and the resident stated he used the call light for staff assistance but did not know where it was. On later observations, the call light remained in the same out-of-reach location while the resident was in bed. Resident 55’s record showed moderate cognitive impairment, an ADL self-care performance deficit requiring assistance from one staff member with transfers, and a fall risk care plan that included educating the resident to work the call light. A CNA stated the call light should have been placed where the resident could reach it. Resident 10 was observed with the touch pad call light at the foot of the bed and later clipped behind the resident’s head or placed on top of a glove box above the bed, all out of reach. The resident stated he did not know where the call light was located, and when shown its location, he was unable to reach it. Resident 10’s record showed hemiplegia affecting the right dominant side, a fall risk, a history of falls, and dependence on staff assistance for transfers. An LPN stated all residents should have had their call lights within reach before staff left the room, and the facility policy stated call light or bell access would be within reach as one method for residents to communicate needs to staff.
Inaccurate Code Status Orders
Penalty
Summary
The facility failed to ensure accurate advance directives were ordered for one resident when the POST form did not match the physician order and care plan. Resident 15 was admitted with diagnoses including multiple myeloma, dementia, and diabetes, and the admission MDS indicated the resident was cognitively impaired. The record showed a POST form dated [DATE] indicating DNR status, while the care plan dated [DATE] indicated a CPR code status and included interventions stating the code status would be established at admission, re-admission, and reviewed quarterly and as needed. The record also contained a physician order dated [DATE] to administer CPR, which did not match the POST form. A later physician order dated [DATE] indicated DNR. During interview, the RDCO stated the facility had identified the discrepancy between the POST form and physician order and had corrected the order on [DATE]. The facility policy provided by the RDCO stated staff should verify advance directives or the resident's CPR wishes upon admission and, if admission orders differ or do not address code status, document the resident's wishes and contact the physician to obtain the order.
PASRR Not Updated After New Bipolar Diagnosis
Penalty
Summary
The facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was updated when a psychiatric diagnosis was added to a resident’s profile for one resident reviewed for PASRR. Resident 55’s record showed admission to the facility and an annual MDS dated 11/12/25 indicating the resident was not considered by the state to have a Level II PASRR for serious mental illness. A Notice of PASRR Level I Screen Outcome dated 4/10/24 stated that no Level II was required because the resident did not have a serious mental illness. The resident’s profile showed that a diagnosis of bipolar II disorder was added on 8/28/24, but the record lacked documentation that PASRR was re-assessed for the possible need for a Level II after that diagnosis was added. On 1/27/26, Risk Management provided an updated Notice of PASRR Level I Screen Outcome dated 1/23/26, which included the bipolar II disorder diagnosis and indicated the resident was referred for an on-site Level II evaluation. Risk Management stated the PASRR should have been re-evaluated when the resident received the new bipolar diagnosis in August 2024, but it was missed.
Incomplete Elopement Risk Care Planning
Penalty
Summary
The facility failed to develop, review, and revise a complete care plan within 7 days of the comprehensive assessment for a resident identified as an elopement risk. The resident was admitted with diagnoses including COPD and bipolar disorder, and a physician order dated 10/3/24 directed staff to place a Wander Guard bracelet on the right ankle and check its placement every shift. A care plan dated 10/3/24 identified the resident as an elopement risk and included Wander Guard placement to the right ankle, but the care plan record lacked any indication or documentation that the resident exhibited exit-seeking behavior. Assessments titled Wandering and Elopement risk dated 6/30/25, 10/6/25, and 1/8/26 indicated the resident was not an elopement risk. Multiple quarterly and annual MDS assessments also indicated wandering and exit-seeking behaviors were not exhibited, with the resident described as cognitively intact on some assessments and having limited cognition on others. An LPN stated the resident had a Wander Guard because he had dementia and had tried to go outside when first admitted, but the medical record lacked a supporting diagnosis of dementia. The resident's guardian stated she was unsure why the Wander Guard was still in place and was not aware whether the resident continued to wander.
Failure to Provide Needed Grooming and Daily Care
Penalty
Summary
The facility failed to ensure Resident 12 received the necessary assistance with grooming and daily care needs. During an initial observation, the resident was found lying in bed with excessive facial hair, dried pureed food on her shirt, oxygen tubing lying in the dried food, and greasy, disheveled hair. The resident’s medical record showed diagnoses including diabetes, hypertension, anxiety, and osteomyelitis of the left foot, and the annual MDS indicated she was cognitively intact and required extensive to maximum assistance with daily care needs. The record did not contain supporting documentation for a respiratory diagnosis and did not include a care plan indicating the resident refused care. Later observations again showed the resident lying in bed with excessive facial hair. During interviews, an LPN stated the resident refused to allow staff to shave her, while a CNA stated the resident allowed her to shave and assist with care needs. The resident also stated she allowed staff to shave her and did not refuse assistance with care needs.
Unsafe Smoking Supervision and Storage
Penalty
Summary
The facility failed to ensure safe smoking protocols were followed for one resident who smoked independently. The resident indicated she smoked one or two cigarettes at a time outside, was allowed to keep her own cigarettes and lighter in her room, and kept them in her purse because the facility had not provided anything to lock them in. She also reported a history of seizures. During continuous observation, the resident exited her room in a wheelchair, traveled down the hallways to the smoking exit door, went outside, removed cigarettes and a lighter from her purse, lit a cigarette, and smoked. The cigarettes and lighter were kept freely in her purse and were not secured in a locked bag. No staff offered or provided assistance or supervision during the observation. On another observation, the resident was seen in the hallway without her oxygen tank, and she stated she did not always use oxygen and only needed it sometimes in her room. Record review showed diagnoses including Alzheimer's disease, COPD, epilepsy, and cigarette nicotine dependence. A physician's order directed oxygen at 2 liters continuously for COPD. Prior assessments documented falls related to the smoking area, including falling while returning from the smoking area, being found on her knees outside the smoking door, and falling outside the smoking area door. A later smoking assessment stated the resident was not currently an independent smoker, had difficulty getting in and out of the smoking area, had poor safety awareness, and had had falls in the smoking area, but the assessment lacked documentation that this change was communicated to staff or the resident. The care plan still indicated she smoked independently and followed smoking protocols, and the resident smoker list still identified her as an independent smoker with a lockbox for smoking materials. Staff interviews reflected differing understanding of whether residents could keep their own cigarettes and whether smoking assessments showing a change were communicated.
Nebulizer Equipment Left Uncleaned and Improperly Stored
Penalty
Summary
The facility failed to ensure nebulizer equipment was properly cleaned and stored after use for 2 residents who received respiratory treatments. For one resident, the nebulizer tubing, mask, and medication chamber were repeatedly observed lying on the bedside nightstand or on a plastic storage bag, with clear liquid remaining in the medication chamber. The resident’s record showed diagnoses including diabetes, hypertension, anxiety, and osteomyelitis of the left foot, and a physician order dated 12/18/25 directed ipratropium-albuterol nebulizer treatments three times daily. The care plan noted oxygen therapy and medication administration, but it lacked documentation of an intervention for respiratory nebulizer treatments. For the second resident, the unbagged nebulizer mouthpiece and tubing were repeatedly observed on the seat of a chair next to the bed, and the medication chamber contained clear liquid and small bubbles. The resident’s record showed diagnoses including COPD and acute respiratory failure with hypoxia. The care plan addressed COPD and shortness of breath while lying flat and included administering medication per provider orders, monitoring vitals, and observing for signs and symptoms of COPD. A physician order dated 6/22/25 directed albuterol sulfate inhalation nebulization solution every 6 hours as needed for wheezing, and the January 2026 MAR showed the resident received a nebulizer treatment on January 20, 2026 at 7:52 p.m. During interviews, an LPN stated that after a nebulizer treatment, the equipment was to be rinsed and then placed in a plastic bag for storage when not in use. The Regional Director of Clinical Operations stated the facility did not have a policy regarding storage of nebulizer equipment while not in use but that it should be stored in a dated bag. The RDCO also provided an undated nebulizer treatment policy stating to rinse the nebulizer with sterile water and allow it to dry, or discard it after therapy if applicable.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to ensure routine dental services were provided for one resident who was reviewed for dental services. During an interview, the resident stated she wanted to see a dentist, did not think dental services had been offered since admission, and reported missing teeth and teeth that had fallen out that she wanted checked. The resident was cognitively intact per a significant change MDS assessment dated 12/19/25, and her care plan identified a potential for oral/dental problems due to carious teeth with an intervention for dental consult as needed. Record review showed the resident's electronic record lacked documentation that she had been offered, provided, or refused dental care. Risk Management staff stated they could not find documentation that dental services had been offered since admission, and noted that dental services should have been offered to all residents at admission. The Regional Director of Clinical Operations provided the facility's Dental Services policy, which stated the facility would assist residents in obtaining routine dental services.
Failure to Notify Resident Representative of Significant Change and Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s emergency contact of a significant change in condition, transfer to the hospital, and subsequent initiation of life-sustaining interventions. The resident had diagnoses including a personal history of transient cerebral ischemic attack (TIA) and seizure disorder. On the date of the incident, documentation showed the resident was observed by a CNA at approximately 5:00 a.m. and was up and talking at that time. Around 5:35 a.m., the resident’s roommate activated the call light and reported the resident was on the bathroom floor. The resident was found unresponsive with right-sided facial drooping and inability to raise the right arm, 911 was called, and the resident was transferred by ambulance to a local hospital emergency room. A Transfer to Hospital form listed the resident’s sister as the emergency contact and indicated she was not aware of the transfer, and the clinical record contained no documentation that the emergency contact was notified of the fall, acute change in condition, or hospital transfer. The resident’s family member, identified as the emergency contact, reported that she and the resident communicated often and that the family had planned to visit for the resident’s upcoming birthday. She stated she made three calls to the resident that day, each transferred to the nurse’s station without being answered, and on a fourth call around 9:00 p.m. a staff member informed her that the resident had been sent to a local hospital that morning and later transferred to a hospital in Indianapolis, where the resident was in the ICU on a ventilator receiving life-sustaining interventions. The family member stated that, in her opinion, the resident had suffered while alone in the hospital and that, had the facility contacted her as required, she might have been able to be present during his last lucid moments. The resident subsequently died without regaining consciousness. The facility’s own Notification of Change in Condition policy required prompt notification of the resident’s representative for significant changes in condition, life-threatening conditions, and transfers to the hospital, but this notification did not occur as required for this resident.
Failure to Monitor and Provide Nighttime Care Resulting in Resident Neglect
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not providing adequate monitoring and care during the night shift. A resident with multiple medical conditions, including COPD, congestive heart failure, diabetes, and atherosclerotic heart disease, required supervision or assistance with activities of daily living (ADLs) and was at risk for falls. Care plans indicated the need for staff to check for incontinence, provide assistance with transfers, and ensure the call light was within reach, but there was no documentation that the resident was independent with ADLs or refused care. On the night in question, staff did not enter the resident's room or visualize her for the entire 8-hour night shift, relying instead on the assumption that the resident would come out or use the call light if assistance was needed. Staff statements and interviews revealed that the nurse and CNA assigned to the resident's unit did not physically check on the resident during the night, with the CNA last seeing her between 9:00 p.m. and 10:00 p.m. and the nurse not seeing her at all. The QMA assigned to the unit opened the resident's door but did not fully enter or confirm the resident's presence, only assuming she was in bed. Documentation in the resident's records, including progress notes and care logs, lacked entries indicating care or monitoring was provided after late evening, and there was no evidence the resident refused care or requested privacy that would have precluded staff checks. Staffing levels were reported as typical for the facility but were described by multiple staff as insufficient to allow for regular two-hour checks, especially during night shifts. The resident was found deceased on the floor between her bed and wheelchair by the oncoming shift nurse the next morning, with rigor mortis present, indicating she had been dead for several hours. The coroner and police were notified, and the preliminary autopsy indicated death from natural cardiac causes with no suspicious trauma. Staff interviews confirmed that routine two-hour checks were expected but not performed, and the resident's care plan did not document any preference to avoid such checks. The facility's policies required regular monitoring for safety and care needs, but these were not followed, resulting in the resident not being observed or assisted throughout the night.
Failure to Provide Sufficient Night Shift Staffing Resulting in Resident Death
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs and ensure the supervision of residents, resulting in a deficiency related to inadequate staffing. On the night in question, only one nurse was on duty for the entire building, with one QMA assigned to three units and one CNA assigned to two units. This staffing pattern was not unusual for the facility, despite a census of approximately 93 to 97 residents. Staff interviews revealed that residents were not checked on every two hours as expected, and some staff did not physically enter certain residents' rooms, relying instead on residents to seek help if needed. Documentation and care records for one resident showed a lack of entries for toileting and other care after a certain time, indicating that required checks and assistance were not provided throughout the night. A resident with multiple chronic conditions, including COPD, congestive heart failure, diabetes, and heart disease, was found deceased on the floor between the bed and wheelchair during morning rounds. The resident had previously indicated a desire for CPR in the event of cardiac arrest, but was found with irreversible signs of death, and CPR was not initiated. Staff statements confirmed that the resident was not checked on during the night shift, and the last known interaction was the previous evening. The CNA assigned to the resident's unit had worked a double shift and did not perform the expected two-hourly checks, citing difficulty managing the workload. Other staff corroborated that night shift staffing was consistently low, making it challenging to provide timely care and supervision. The facility's own assessment and staffing model indicated a need for more licensed nurses and nurse aides per unit than were actually scheduled, and the assessment lacked documentation of how policies and procedures were evaluated or updated. Multiple staff and residents reported that the number of staff on night shift was insufficient to meet care needs, with delays in response to call lights and medication requests. Staffing schedules showed frequent instances of only one nurse on duty, with no documentation of efforts to secure replacements when staff called in. The deficiency was identified as immediate jeopardy due to the failure to provide adequate care and supervision, resulting in a resident not being checked on all night and subsequently being found deceased.
Failure to Conduct and Document Thorough Abuse Investigations
Penalty
Summary
The facility failed to conduct thorough investigations and maintain complete records for abuse allegations involving three residents. In one incident, two residents with cognitive impairments were involved in an altercation in the dining room, where one resident pushed another's wheelchair. Although staff separated the residents and initiated an investigation, the incident file lacked documentation of resident interviews and did not include statements from other residents to determine if there were additional concerns. Furthermore, the electronic health records for both residents did not contain any documentation of the incident. In another case, a resident with severe dementia reportedly sustained a skin tear to the right forearm after contact with a CNA. The CNA was suspended pending investigation, but the facility's documentation was incomplete. There was no skin assessment performed on the date of the incident, and subsequent skin check forms and nurse progress notes did not document the injury. The investigation file included an undated statement from the CNA and a resident interview, but lacked individual, signed, and dated statements from all staff present at the time of the incident. Additionally, the facility could not locate a statement from the nurse on duty during the incident. The facility's policy required obtaining statements from all involved parties and documenting facts and findings in each resident's medical record. However, in both incidents, the required documentation was missing or incomplete, including resident and staff statements, and proper recording of the incidents in the residents' health records. These deficiencies were confirmed through record review and interviews with the Executive Director and Regional Director of Clinical Operations.
Deficient Documentation of Wound Care and Insulin Administration
Penalty
Summary
The facility failed to accurately document wound descriptions upon admission and did not ensure medication administration was documented according to physician orders for two residents. For one resident with paraplegia and type 2 diabetes, the medical record review revealed inconsistencies in wound measurement documentation. The wound was measured in centimeters, but the recorded size did not match the measurements from an outside wound center, which showed significant changes in wound size before and after the resident's stay. Interviews with staff indicated uncertainty about proper wound staging and measurement protocols, despite facility policy requiring measurements in centimeters. For another resident with type 2 diabetes and moderate cognitive deficit, the facility did not document insulin administration according to physician orders. The medication administration record (MAR) showed multiple instances where insulin doses were recorded as given at times significantly different from the prescribed schedule. Staff interviews revealed that nurses sometimes delayed documentation, making it appear as though medications were administered late, and that time management challenges contributed to the issue, especially when nurses had to cover for medication aides who could not administer insulin. Facility policies required timely and accurate documentation of both wound care and medication administration, including adherence to the five rights of medication administration and real-time charting. However, the observed practices did not align with these policies, as evidenced by the discrepancies in wound documentation and the inconsistent timing of insulin administration entries in the MAR.
Failure to Administer and Document Insulin According to Physician Orders
Penalty
Summary
The facility failed to ensure that insulin and other diabetes medications were administered and documented according to physician orders for four residents. Multiple observations, record reviews, and interviews revealed that insulin doses were frequently given outside of the prescribed time frames, with some doses being administered several hours late or not documented at all. Residents reported inconsistent administration times, with some indicating they received insulin before meals as ordered, while others were unsure of the timing or reported significant delays. Staff interviews confirmed that medications were sometimes administered late due to workload and that documentation was not always completed at the time of administration. Medical record reviews for the affected residents showed repeated instances where insulin was administered well outside the one-hour window before or after the scheduled time, as required by facility policy. For example, insulin doses scheduled for early morning or before meals were often given in the late morning, afternoon, or even evening. In some cases, there was a complete lack of documentation for certain insulin administrations, including STAT orders for hyperglycemia. The medication administration records (MARs) reflected numerous late entries and missing documentation for both scheduled and sliding scale insulin doses. The residents involved had diagnoses of type 2 diabetes mellitus, some with complications such as diabetic neuropathy or chronic kidney disease, and were assessed as requiring regular insulin injections. Care plans for these residents included interventions to administer diabetes medications as ordered, but these interventions were not consistently followed. Staff interviews indicated that high workload and the need to cover multiple halls contributed to the delays. The facility's medication administration policy required medications to be given within a specific time frame and for documentation to be current, but these standards were not met for the residents reviewed.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure proper implementation of enhanced barrier precautions during a dressing change for a resident with pressure ulcers. During a continuous observation, an LPN performed hand hygiene, donned gloves and a gown, and completed a dressing change to the resident's sacrum. Near the end of the procedure, a CNA entered the room to assist but did not perform hand hygiene upon entry, donned gloves without a gown, and removed the dressing from the resident's left heel. The CNA continued to hold the resident's leg and did not perform hand hygiene or change gloves after removing the dressing. The LPN later confirmed that the CNA should have performed hand hygiene before donning gloves, worn a gown, and not removed the dressing from the resident's heel. The resident involved had a diagnosis of a stage four pressure ulcer of the sacral region and required enhanced barrier precautions for wound care, as indicated by physician orders. Facility policy required the use of gowns and gloves, as well as hand hygiene, during high-contact care activities such as wound care for residents with wounds. The Nurse Consultant confirmed that the facility's current policies required these precautions but stated there was no specific policy for dressing changes.
Inadequate Staffing Leads to Missed Insulin Administration
Penalty
Summary
The facility failed to ensure adequate nurse staffing across multiple units, leading to missed administration of critical insulin medications for residents. Resident K, who resides on the 400 unit and has a diagnosis of type 2 diabetes mellitus, reported not receiving her insulin doses as prescribed. The review of the nursing staff schedule and medication administration records (MAR) for December 2024 revealed multiple instances where no nurse or Qualified Medication Aide (QMA) was scheduled, resulting in missed doses of Lispro and Glargine insulin on several days. The Regional Director of Clinical Operations (RDCO) suggested that the nurses might have administered the medications but failed to document them. Similarly, Resident F, residing on the 2A unit, also reported missing insulin doses, particularly during the evening shifts. The review of the staffing sheets and MAR indicated that on several occasions, there was a lack of documentation for the administration of Fiasp, Exenatide, and Basaglar insulin, as well as accu checks. The staffing schedule often lacked clarity on which nurse was responsible for covering the QMA, leading to confusion and potential oversight in medication administration. Interviews with staff members highlighted the challenges faced due to the confusing schedule and the need for nurses to cover multiple units simultaneously. The facility's staffing issues were further compounded by the practice of having one nurse oversee multiple QMAs across different units, which overwhelmed the staff and led to inadequate coverage. On several occasions, the schedule lacked evidence of nurse coverage for specific halls, leaving residents without proper care. The RDCO acknowledged the documentation issues and the need for re-education of the nursing staff, but the facility did not have a formal policy for staffing, contributing to the ongoing deficiencies.
Insulin Administration Deficiencies
Penalty
Summary
The facility failed to ensure that insulin medications were administered as ordered for three residents, leading to significant medication errors. Resident F, who was diagnosed with systemic lupus erythematosus and diabetes mellitus, did not receive several doses of her prescribed insulin medications, including Fiasp, Exenatide, and Basaglar, as documented in the December 2024 Medication Administration Record (MAR). Additionally, there were missing records of blood glucose monitoring (accu checks) for Resident F. During an interview, Resident F confirmed that she missed doses of her insulin, particularly during the evening shift. The Regional Director of Clinical Operations (RDCO) acknowledged the documentation issues and mentioned ongoing re-education of the nursing staff. Resident K, diagnosed with type 2 diabetes mellitus with hyperglycemia, also experienced missed doses of insulin medications, including Glargine and Lispro, as indicated by the December 2024 MAR. There was no documentation of the resident's refusal to take the medication. The RDCO believed that the nurses administered the insulin but failed to document it properly. This lack of documentation and administration was consistent across multiple dates. Resident H, who had multiple diagnoses including COPD, type 2 diabetes, and congestive heart failure, also had missing documentation for the administration of Lantus and Lispro insulin. The MAR for December 2024 showed that several doses were not recorded as administered. Resident H did not recall missing any insulin doses but mentioned refusing insulin when her blood sugar was too low. The facility's policy on injectable medication administration required documentation of the administration site and any reactions, which was not consistently followed. Interviews with staff revealed challenges in overseeing multiple halls and ensuring proper administration and documentation of insulin medications.
Deficiencies in Hand Hygiene and Dishwashing Temperatures
Penalty
Summary
The facility failed to ensure proper hand hygiene during dining and kitchen observations. Staff members, including a Central Supply Aide, a CNA, and an LPN, were observed washing their hands and then using a commercial size roll of paper towels to dry their hands. This practice led to contamination of the paper towel roll with water, as staff touched the roll with wet hands. Additionally, staff used the same paper towel to turn off the faucet and then proceeded to serve food to residents, further compromising hand hygiene standards. The facility also failed to maintain adequate dishwashing temperatures during kitchen observations. The dish machine's wash and rinse temperatures were observed to be below the required levels, with the wash temperature at 148 degrees Fahrenheit and the rinse temperature at 155 degrees Fahrenheit, both of which are below the manufacturer's recommended temperatures. The issue was attributed to significant lime buildup and faulty temperature gauges, which were later inspected and replaced. Interviews with staff revealed that the facility had a supply issue with paper towels, leading to the use of commercial rolls instead of the appropriate sheets for dispensers. The Director of Nursing and the Regional Director of Clinical Operations were unaware of the use of commercial rolls and acknowledged that it was not suitable for proper hand hygiene. The Dietary Manager confirmed the dish machine's temperature issues and had contacted the dish machine company for repairs.
Failure to Document and Communicate Resident's Code Status
Penalty
Summary
The facility failed to ensure that the code status of a resident was documented and readily available to staff. Resident 152, who had severe cognitive deficits and a history of heart disease, did not have an established code status documented in their electronic medical record (EMR) or in the physician's orders. During a review of the resident's records, it was found that the code status was not easily accessible, and the Licensed Practical Nurse (LPN) had difficulty locating it. Eventually, the LPN found the resident's POST (Physician Orders for Scope of Treatment) document in the hard chart, indicating a Do Not Resuscitate (DNR) status. Interviews with facility staff, including the Regional Director of Clinical Operations (RDCO) and the Director of Nursing (DON), revealed that the expectation was for the code status to be a physician's order and appear on the first page of the EMR. The POST form should have been scanned into the EMR and easily accessible to staff. However, the resident's code status was not documented as expected, leading to confusion and difficulty in accessing this critical information. The facility's policy on advanced directives emphasized the importance of documenting and communicating the resident's choices regarding life-sustaining treatment, which was not adhered to in this case.
Failure to Notify Ombudsman of Resident's Hospital Discharge
Penalty
Summary
The facility failed to notify the Ombudsman of a resident's discharge to the hospital, which was required as part of the discharge process. This deficiency was identified during a review of the records for a resident who was hospitalized. The resident, who had diagnoses including hemiplegia and hemiparesis following a stroke, COPD, and CHF, experienced a change in condition with new or worsening abdominal pain and shortness of breath. The resident was transferred to the hospital for evaluation and treatment on the physician's order. However, the facility's records did not include documentation that the Ombudsman was notified of this discharge. Interviews with facility staff revealed that the Social Services Director, who had recently assumed her position, had not sent the required notification for October 2024. The Regional Director of Clinical Operations confirmed that the notification had not been completed. The Ombudsman also confirmed not receiving the discharge notification for October 2024. The facility's Bed Hold Policy required that a copy of the Acute Transfer Letter be sent to the Ombudsman, but this procedure was not followed in this instance.
Delayed MDS Assessments for Discharged Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) resident assessments were completed in a timely manner for two residents whose records were reviewed. Resident 42 was discharged with no anticipated return, yet her discharge MDS assessment was not completed until several months later, on 12/9/24, after being identified by the corporate office. Employee 19, responsible for audits, was unaware of the oversight until notified by the corporate office, which maintained an audit log, unlike the facility. Similarly, Resident 2 was discharged with no anticipated return, but her discharge MDS assessment was not completed until 12/2/24 and accepted on 12/3/24, again identified by the corporate office. Employee 19 was not familiar with the specifics of Resident 2's case but acknowledged the corporate office's role in discovering the delay. The Regional Director of Clinical Operations provided documentation from the CMS RAI Manual, which mandates that discharge assessments be completed within 14 days of discharge and submitted within 14 days of completion.
Failure to Implement Timely Pressure Ulcer Treatment
Penalty
Summary
The facility failed to obtain and implement treatment orders upon admission for a stage 4 pressure ulcer for Resident K. The resident was admitted with a stage 4 pressure ulcer on the sacrum, but the facility did not start the prescribed wound vacuum treatment until two days after the order was obtained. The medical record lacked documentation of wound treatment for five days, and the care plan did not reflect the presence of a stage 4 pressure wound or the necessary medical treatment. The wound vacuum was discontinued due to contamination issues, and there was a lack of documentation indicating that the treatment was completed as ordered. Interviews with staff revealed that the admitting nurse did not contact the physician or nurse practitioner to receive orders for wound care at the time of admission. The wound vacuum order was obtained on 10/28/24, but the treatment was not started until 10/30/24, following the schedule of Monday, Wednesday, and Friday. The facility's policy required obtaining a physician's order and documenting treatment in the Treatment Administration Record, but these steps were not followed, leading to the deficiency.
Insufficient Weekend Staffing in Facility
Penalty
Summary
The facility failed to ensure sufficient weekend staffing during the third fiscal year quarter from April 1, 2024, to June 30, 2024. This deficiency was identified through a review of staffing data and interviews with facility staff. On December 2, 2024, the staffing data report revealed low weekend staffing during this period. Interviews with a Certified Nursing Assistant (CNA) and a Licensed Practical Nurse (LPN) on December 4, 2024, highlighted that staff were unable to complete their daily assignments due to insufficient staffing levels. The CNA mentioned being frequently asked to work overtime, which she declined to avoid burnout, while the LPN noted that each CNA was responsible for up to two halls during day and evening shifts, with even fewer staff available on weekends. Further investigation on December 9, 2024, revealed that the facility's staffing schedules for April, May, and June 2024 lacked information on census, required number of staff, and assigned number of staff. The Nurse Staff Scheduler acknowledged the issue of low weekend staffing and mentioned efforts to hire more staff, particularly for the night shift. However, the facility did not have a policy related to staffing, as confirmed by the Regional Director of Clinical Operations. The deficiency was primarily attributed to a shortage of CNAs on weekends.
Deficiencies in Medication Administration and Infection Control
Penalty
Summary
The facility failed to ensure that staff was competent in medication administration for two residents, leading to deficiencies in care. For Resident 51, an LPN used a glucometer machine without proper cleaning and placed it on a bedside table without a barrier. The nurse also left medication carts unlocked and a computer screen open with resident information visible. The LPN was unsure about the correct procedure for cleaning the glucometer and admitted that residents shared the machines. Another staff member confirmed that bleach wipes should be used for cleaning and that a barrier should be used when placing the glucometer on surfaces. Additionally, the lancet was improperly disposed of in the trash instead of a sharps container. For Resident M, a QMA administered medications in coffee, which was not an approved method. The QMA was unaware that crushing Depakote ER, a medication on the do-not-crush list, was inappropriate. The QMA had been administering medications in coffee since starting at the facility, following advice from another staff member whose identity she could not recall. The resident's medical records indicated cognitive impairment and a history of dementia and major depressive disorder. The QMA had been working in the facility for a short period and was not fully aware of the proper medication administration procedures. The facility's policy on staff education and competency testing emphasized safety and required competency testing through various methods. However, the incidents with Residents 51 and M highlighted lapses in adherence to these policies, resulting in improper medication administration and infection control practices. The Regional Director of Clinical Operations acknowledged the errors and indicated that the staff involved would receive further education on proper procedures.
Deficiencies in Antipsychotic Medication Management
Penalty
Summary
The facility failed to ensure the correct supporting diagnosis was used to prescribe an antipsychotic medication for one resident. The resident's records indicated a prescription for Invega, an antipsychotic medication, for schizophrenia, despite lacking a documented diagnosis of schizophrenia. The Regional Director of Clinical Operations acknowledged the error, noting that the incorrect diagnosis was perpetuated by successive nursing staff following an initial incorrect entry. Additionally, the facility did not attempt a Gradual Dose Reduction (GDR) or provide evidence to support the denial of a GDR for another resident. This resident had a complex medical history, including schizoaffective disorder and other mental health conditions, and was on antipsychotic medication. Despite pharmacy reviews and team discussions, the facility's records lacked documentation of behaviors justifying the continued use of psychotropic medication or evidence of clinical GDR attempts. Interviews with facility staff revealed that previous GDR attempts were considered failed due to the resident's family discontinuing medications when taking the resident home. The psychologist and nursing staff acknowledged the lack of supporting documentation for the resident's continued medication use. The facility's policy required GDR attempts unless clinically contraindicated, but the documentation did not adequately support the decision to forgo these attempts.
Improper Labeling of Insulin Pen
Penalty
Summary
The facility failed to ensure proper labeling of medication for one of the medication carts reviewed. During an observation, an undated and opened Novolog insulin pen was found in the 200 B hall medication cart, which was labeled for a resident. The insulin pen did not have an open date, and the LPN interviewed was unaware of how long the pen had been opened. Another LPN confirmed that insulin pens should have an open date and are good for 28 days once opened. The resident associated with the insulin pen had a diagnosis of type 2 diabetes mellitus with diabetic neuropathy. A physician's order indicated the resident was to receive 15 units of Novolog insulin before meals. The facility's policy on medication storage required that an open date sticker be placed on medications with a specified usable duration after opening, which was not adhered to in this instance.
Infection Control Lapses in Medication Administration and Laundry Room
Penalty
Summary
The facility failed to ensure proper infection control practices during medication administration for a resident with type II diabetes mellitus. During an observation, an LPN used a glucometer without following the correct cleaning protocol. The LPN wiped the glucometer with an alcohol pad instead of using bleach wipes as required by the facility's policy. Additionally, the glucometer was placed on the resident's bedside table without a protective barrier, and a used lancet was improperly disposed of in the trash can instead of a sharps container. The facility's policy mandates the use of bleach wipes for cleaning glucometers and the use of barriers when placing them on surfaces, which was not adhered to in this instance. In a separate incident, the facility failed to maintain proper separation of clean and dirty items in the laundry room. During an observation, clean mechanical lift slings and mop heads were found in the soiled linen area, contrary to the facility's infection control policy. The Laundry Supervisor acknowledged that the clean items were improperly stored in the soiled area. The facility's policy requires that clean linens and equipment be stored separately from soiled items to prevent cross-contamination, which was not followed in this case.
Failure to Supervise Dementia Resident Leads to Altercation
Penalty
Summary
The facility failed to adequately supervise and implement effective interventions for a resident with dementia, known for intrusive wandering behaviors, which led to an altercation with another resident. Resident B, who had a history of pacing, fighting with staff, and invading personal space, entered Resident C's room, resulting in Resident C hitting Resident B. At the time of the incident, Resident B was under one-on-one observation, but the staff was unable to redirect her effectively. This incident resulted in a physical altercation, causing a reddened area on Resident B's right temple. Resident B had a complex medical history, including Alzheimer's dementia, schizoaffective disorder, and bipolar disorder, which contributed to her challenging behaviors. Despite being on a secured unit and having a care plan in place, the interventions lacked specificity and personalization to address her needs effectively. The care plans did not include detailed, person-centered interventions, and there was a lack of documentation regarding the efficacy of the interventions implemented. Staff were aware of Resident B's behaviors, such as touching other residents and not understanding personal space, but the interventions were not sufficient to prevent the incident. The facility's documentation indicated that Resident B had been exhibiting aggressive behaviors towards staff and other residents, with multiple incidents of physical aggression noted in the weeks leading up to the altercation. Despite being on one-on-one supervision, the facility did not have adequate measures in place to prevent Resident B from entering other residents' rooms or to manage her manic episodes effectively. The lack of specific interventions and documentation of their effectiveness contributed to the failure to prevent the incident, highlighting deficiencies in the facility's approach to managing residents with complex behavioral needs.
Failure in Narcotic Reconciliation Leads to Drug Diversion
Penalty
Summary
The facility failed to maintain a system for the reconciliation of narcotic medications, resulting in two separate occasions of drug diversion for a resident. The first incident involved a missing card of Norco, a narcotic medication prescribed to Resident C for moderate to severe pain. The facility's investigation could not determine who took the missing medication card, despite suspending two staff members, QMA 6 and RN 5, pending investigation. The investigation revealed discrepancies in the narcotic count sheets and the facility's inability to track the medication accurately. Resident C was informed of the missing medication, but this was not documented in the electronic health record. The second incident involved a missing card of tramadol, another narcotic medication prescribed to Resident C. Again, the facility could not determine the whereabouts of the medication card, leading to the suspension of QMA 6 and LPN 13. The investigation included a facility-wide search and interviews with staff, but the missing medication card and count sheet could not be located. The facility's documentation practices were found lacking, as there was no discharge medication documentation for Resident C's discharge to home. The facility's policy on medication controlled drugs and security was not adhered to, as evidenced by the discrepancies in narcotic counts and the failure to maintain accurate records. The facility's procedures for handling narcotic keys and conducting narcotic counts were not followed, leading to the inability to account for the missing medications. The facility's failure to maintain a proper system for narcotic reconciliation resulted in the misappropriation of resident property and a breach of regulatory compliance.
Failure to Ensure Dignified Transfer to Medical Appointment
Penalty
Summary
The facility failed to ensure that Resident B was transferred to a doctor's appointment in a dignified manner. Resident B, who has multiple diagnoses including volvulus, neuropathic bladder, autistic disorder, and profound intellectual disabilities, was transported to a urology appointment by an ambulance service. Upon arrival at the urology office, Resident B was found wrapped in a sheet covered in feces, wearing only an adult diaper, with a catheter falling out and a full, leaking colostomy bag. His skin was red and excoriated around his stoma and back. The record review indicated that Resident B was dependent on staff for care and had no documented episodes of rejecting care or pulling out his catheter or colostomy bag. However, the care plan did not address these behaviors or provide strategies for managing them. Interviews with staff revealed that Resident B was known to be resistive to care, often pulling off his colostomy bag and catheter. On the day of the appointment, staff attempted to clean him but were unsuccessful, and the transport team did not allow further cleaning before departure. The Director of Nursing confirmed that it was the facility's expectation for residents to be properly clothed and cleaned before appointments, and that extra clothing was available if needed. However, this protocol was not followed in Resident B's case. The report highlights a significant lapse in the facility's duty to provide dignified care and proper preparation for medical appointments, resulting in Resident B being transported in an undignified and unhygienic state.
Failure to Accurately Document IV Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation of medical records for Resident D, who was receiving intravenous (IV) medication administration. Resident D had multiple diagnoses, including metabolic encephalopathy, acute kidney failure, and type 2 diabetes. A physician's order dated 1/29/24 indicated that cefazolin sodium injection solution was to be administered intravenously every 8 hours until 2/9/24. However, the February 2024 medication administration record (MAR) lacked documentation of IV medication administration on several occasions, including 2/3/24 at 10:00 p.m., 2/9/24 at 2:00 p.m., and 2/17/24 at 11:00 p.m. There was no documentation for omission or resident refusal for these missed doses. Additionally, the MAR lacked documentation for heparin sodium lock flush and sodium chloride flush on the same dates and times. A nurse's note dated 2/14/24 indicated that Resident D's wife was concerned about missed doses of IV antibiotics. The Registered Nurse (RN) changed the administration times to avoid shift changes and ensure doses were not missed. Licensed Practical Nurses (LPNs) interviewed on 4/3/24 indicated they did not understand the blanks in the MAR and that it should not have been blank. The Director of Nursing (DON) indicated that if the resident was out of the facility during the scheduled administration time but returned within two hours, he should have received his medications. If a dose was missed, they were required to call telehealth, notify the family, and document the reason. Leave of absence records indicated Resident D signed out on 2/3/24 and 2/9/24, but there was no documentation for a leave of absence on 2/17/24. The facility's medication administration policy indicated that medications should be charted when given, and any refused or withheld medications should be documented. The policy also required follow-up with the physician for critical medications that were refused. The facility failed to adhere to these policies, resulting in incomplete documentation of Resident D's IV medication administration.
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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 Terre Haute
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westminster Village Health & Rehab | 1 mi | ★★★★★ | 1 | 0 |
| Springhill Village | 1.8 mi | ★★★★★ | 5 | 0 |
| Westridge Health Care Center | 1.9 mi | ★★★★★ | 10 | 0 |
| Majestic Care Of Deming Park | 2.2 mi | ★★★★★ | 4 | 2 |
| Cobblestone Crossings Health Campus | 3.6 mi | ★★★★★ | 10 | 0 |
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