Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Access Mental Health during CMS and state inspections, most recent first.
Failure to Report Resident Abuse Allegations: A resident with schizophrenia, MDD, and other behavioral symptoms alleged that a nurse placed hands around his neck and that another staff member showed him marijuana and inappropriate pictures. Staff discussed a witness statement with the resident, but the allegation was not reported to the State Agency, and contracted consultant staff did not share the resident’s abuse concerns with facility leadership. Facility admin later stated the incident should have been reported.
Improperly Covered Outdoor Trash Receptacle: During a kitchen tour, the outside garbage receptacle was observed with three of eight lids open. Dietary staff, maintenance staff, and administrative staff all stated the dumpster lids should be closed when not in use, and the facility policy documented that outdoor trash receptacles would be kept covered.
A resident with schizoaffective disorder, bipolar type, hallucinations, delusions, and psychotropic medication use had repeated exit-seeking tied to voices telling him to leave or go to church. Staff redirected him, but the incidents were not reported or assessed as a change, and the psych provider’s medication review did not address the recent hallucinations. The resident later exited the facility unsupervised, was found outside in cold weather near a highway, and his behavioral manifestations were not assessed by the mental health provider until several days later.
Damaged mattresses left residents with unsanitizable sleep surfaces. During an environmental tour, multiple residents’ mattresses were found torn, worn, or ripped, including several with tears on the top, side, or bottom and exposed filling or bed cover. One resident reported the mattress was uncomfortable, and staff confirmed the mattresses were in disrepair and needed replacement to provide a comfortable, sanitizable sleep surface.
Inaccurate MDS coding affected three residents. One resident’s bed side-rail was coded as a restraint even though it was used to assist with transfers and bed mobility, another resident was coded as always continent despite having a catheter leg bag that staff were to empty routinely, and a third resident’s MDS failed to capture broken, missing, and carious teeth along with reported tooth pain and infection. Staff acknowledged the MDS entries were inaccurate.
A resident with chronic pain and left shoulder limited mobility had physician-ordered therapy, orthopedic follow-up, MRI evaluation, and pain medication, but the care plan did not include the shoulder pain or therapy needs. Another resident with COPD, sleep apnea, oxygen dependence, and CPAP use had documented care refusals and hypoxia, yet the care plan lacked oxygen and CPAP interventions. Staff confirmed the care plans were not current with the residents’ needs.
A resident with bipolar disorder, COPD, and sleep apnea had repeated episodes of hypoxia, confusion, and refusal of care, but the EMR lacked documentation of oxygen/CPAP use, refusals, and provider notifications. Progress notes described very low O2 sats, dark purple discoloration, mottling, and declining respirations before the resident died, and staff interviews confirmed they did not document changes in condition or physician contact in the EMR.
A resident with a Foley catheter, neurogenic bladder, DM2, and psychiatric diagnoses had catheter care concerns when staff failed to secure the tubing and did not follow infection control practices during leg bag emptying. The leg bag was observed full and bulging, and when a CNA emptied it, the drain port contacted the urinal, was not sanitized or capped, and the CNA later readjusted the bag without hand hygiene or EBP. Staff also reported no catheter securement device was used, and there was no documentation of refusal or failed attempts, despite the facility policy requiring the catheter to be taped or anchored and the drainage bag to be emptied properly.
A CNA emptied a resident’s leg bag into a urinal, allowed the drain port to contact the urinal, and did not clean or sanitize the port or place a cap over it. When the resident said the catheter was pulling, the CNA removed EBP, consulted with an LPN, then returned to readjust the leg bag without reapplying EBP or performing hand hygiene. The facility also did not provide an EBP policy, and an Administrative Nurse stated catheter cleaning should be done with soap and water and that the drain spout should not contact the urinal.
Surveyors found multiple food items in the kitchen and storage areas left open to air, including shredded potatoes, sausage patties, pudding mix, chocolate chips, dressing mix, and shredded cheese. Dented cans of apples and mushrooms were also present. Dietary staff were unaware of the requirement to keep food containers closed, and administrative staff confirmed that all food should be properly stored and dented cans returned or discarded, as per facility policy.
Staff transported soiled laundry in uncovered and overflowing containers through hallways, and clean laundry was processed on a damaged, unsanitizable table. Both CNA and laundry staff confirmed these practices, which did not comply with the facility's infection control policy for handling and processing linens.
The facility did not complete required Care Area Assessments (CAAs) with analysis of findings for several residents who triggered areas such as psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia. Staff interviews confirmed that the responsible nurse lacked education on proper CAA documentation, resulting in incomplete assessments and missing analysis of underlying causes and risk factors.
Several residents had inaccuracies in their MDS assessments, including incorrect documentation of hypoglycemic medications, misclassification of a bed positioning device as a restraint, and failure to record the use of WanderGuard alarms. These errors were acknowledged by the MDS nurse, who cited limited time and infrequent facility presence as contributing factors, and were identified through interviews, observations, and record reviews.
A medication error rate above five percent was identified when a nurse failed to prime insulin pens, did not verify orders with the MAR, and did not follow manufacturer instructions for injection duration while administering insulin to a resident with diabetes. The nurse was unsure of the correct technique, and facility policy requiring verification and proper administration was not followed.
Staff prepared and served a water-thin mixture described as broth instead of gravy over turkey and dressing, without following a written recipe or menu guidelines. Administrative staff confirmed the mixture was not appealing and did not meet expectations for palatability. The facility could not provide a policy on food palatability when requested.
Two residents and/or their representatives were not properly informed or provided with documented consent for the use of psychotropic medications, as required. Consent forms for several medications lacked the necessary signatures, and electronic medical records did not contain evidence of informed consent. Staff interviews revealed confusion about the consent process and responsibilities, leading to incomplete documentation.
A resident was admitted and did not have a complete person-centered baseline care plan developed within the required 48-hour timeframe. Key components of the care plan, including General Information and Initial Goals and Health Conditions, remained incomplete for an extended period. Staff interviews indicated a lack of awareness regarding the 48-hour requirement for baseline care plan completion.
Three residents were not offered the pneumococcal vaccine, and there was no documentation in their EMRs to show that the vaccine was provided or that informed declination was obtained. An administrative nurse confirmed the lack of documentation and cited insurance coverage issues as a barrier.
A resident experienced significant weight loss due to the facility's failure to implement timely nutritional interventions. Despite the resident's medical history and cognitive impairments, the facility did not provide adequate dietary support or communicate effectively with the registered dietician. The resident's care plan was only updated months after the initial weight loss, and the facility lacked a certified dietary manager, leading to continued weight decline and risk of malnourishment.
The facility did not ensure the director of food and nutrition services had the required CDM qualifications. Dietary BB, who lacked CDM certification, was unaware of the requirement, and the registered dietician was only available monthly. Administrative Staff A mistakenly believed that a registered dietician's presence sufficed. The facility failed to provide a policy on CDM qualifications, risking residents' dietary and nutritional needs.
The facility failed to adhere to proper meat thawing procedures, as a pork loin was observed thawing in a sink without running water. This practice, confirmed by dietary staff as incorrect, placed residents at risk for food-borne illnesses.
The facility failed to document and offer influenza and pneumococcal vaccinations to several residents, lacking informed declinations, consent, or physician-documented contraindications. This oversight increased the risk of influenza and pneumonia. Staff interviews revealed inconsistencies in offering vaccinations due to concerns about upsetting legal guardians and Medicaid coverage issues.
A resident with a history of mental health disorders was transferred to a psychiatric hospital without proper documentation, placing them at risk for uninformed care choices. The facility was unaware of the transfer until contacted by the hospital, revealing a deficiency in managing resident transfers and discharges.
The facility failed to provide written notification of transfers for two residents with mental health disorders, leading to uninformed care choices. One resident was transferred to a psychiatric hospital without documentation, while another was transferred to the hospital multiple times without written notice. The facility relied on phone notifications, lacking a policy for written transfer notifications.
The facility failed to accurately code the MDS for two residents, leading to potential risks for inappropriate care. One resident's MDS included incorrect treatments not received, while another's omitted a PTSD diagnosis due to documentation issues. These inaccuracies risked inadequate care planning.
The facility failed to develop individualized trauma-based care plans for two residents with PTSD, placing them at risk for impaired care. R30's care plan lacked specific interventions to address her PTSD, while R39's care plan did not include strategies to mitigate triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness and training regarding trauma-based care, and the facility was unable to provide a policy for person-centered care plans.
A facility failed to update a resident's care plan to address incontinence and behavioral needs. Despite a comprehensive assessment, the plan lacked specific interventions for managing the resident's incontinence and resistance to care, influenced by a history of homelessness. Staff acknowledged the need for individualized interventions, but the facility lacked a policy for developing person-centered care plans.
A resident with limited ROM and a history of cerebral infarction and hemiplegia did not receive a ROM program to maintain mobility. Despite the resident's desire to remain independent, the administrative nurse had not evaluated the resident for a restorative program due to time constraints. Facility policy required such evaluations, but this was not conducted, resulting in a deficiency.
A facility failed to implement individualized toileting interventions for a resident with bowel and bladder incontinence. Despite being a good candidate for retraining, the resident's care plan lacked specific instructions for a toileting program and did not address behaviors linked to previous homelessness. Staff were expected to provide reminders, but no structured retraining program was in place, placing the resident at risk for complications.
The facility failed to provide trauma-informed care for three residents with PTSD, as it did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. Despite having policies in place, the facility's staff were unaware of the residents' PTSD diagnoses and did not perform necessary assessments or create care plans with specific interventions. This placed the residents at risk for decreased psychosocial well-being and ineffective treatment.
The facility failed to provide individualized behavioral care interventions for three residents with mental health diagnoses, including schizophrenia, PTSD, and bipolar disorder. The care plans lacked specific interventions for managing behaviors such as resistance to care, inappropriate toileting, and verbal outbursts. Staff interviews revealed a lack of awareness of individualized interventions, and the facility's policy on behavioral health services was not effectively implemented, placing residents at risk for continued behavioral episodes and unmet care needs.
The facility's Consultant Pharmacist failed to identify and report deficiencies in medication orders for two residents. One resident's diclofenac order lacked a specified dosage, while another resident's heart rate was outside physician-ordered parameters, and required lab tests were missing. These oversights placed the residents at risk for unnecessary medications and complications.
The facility failed to follow physician orders for lab tests and vital sign monitoring for a resident with diabetes and hypertension, and did not ensure proper dosing instructions for Voltaren gel for two residents. This led to risks of unnecessary medication use and potential side effects. The facility lacked policies related to physician orders and medication dosing.
The facility failed to ensure that PRN psychotropic medications for two residents had a 14-day stop date or specified duration, placing them at risk for unnecessary medication administration. One resident had PRN orders for hydroxyzine, Seroquel, and Haloperidol without proper documentation, while another had a PRN order for Trazodone lacking a stop date. Staff interviews revealed uncertainty about medication order requirements, and the facility lacked a policy for monitoring psychotropic medications.
The facility failed to document the COVID-19 vaccination status for two residents, lacking records of offers, declinations, or contraindications. Interviews indicated that the responsibility for tracking immunizations was with the Infection Preventionist, but the facility could not provide a policy or signed consents. This oversight increased the residents' risk for COVID-19.
A resident with a history of self-harm and aggressive behaviors was physically and chemically restrained by facility staff without proper physician orders or documentation. The resident, diagnosed with multiple mental health disorders, became combative and attempted self-harm, leading staff to use restraints without adequate assessment or care planning.
A resident with multiple mental health diagnoses exhibited severe aggressive and self-harming behaviors, leading to the use of unauthorized chemical and physical restraints by the facility. The facility failed to effectively implement the resident's care plan and lacked a policy for restraint use, resulting in inadequate management of the resident's agitation and placing him in immediate jeopardy.
Failure to Report Resident Abuse Allegations
Penalty
Summary
The facility failed to report allegations of abuse involving a resident with schizophrenia, major depressive disorder, adverse effect of methamphetamines, and adjustment disorder with anxiety to the State Agency as required. The resident’s EMR and MDS documented intact cognition with a BIMS of 15, daily wandering, verbal and other behavioral symptoms, and independence with ADLs. The resident’s behavioral CAA noted refusal of care including medications, rare participation in activities, behavior that interfered with others, and that some behavior was provoked but most was unprovoked. The care plan identified a potential for aggressive behavior, both physical and verbal, related to schizoaffective and bipolar disorder and directed staff to de-escalate and keep the situation calm when aggressive behavior occurred. A progress note documented staff met with the resident after a reported incident in which the resident stated a charge nurse had placed her hands on his neck. Staff offered a written witness statement so the allegation could be formally submitted to the appropriate state agency, but the resident declined to pursue it further at that time and gave no additional details. A later therapy note from the mental health consultant documented the resident reported that a facility nurse had put her hands around his neck and another staff member had shown him marijuana and inappropriate pictures during a smoke break. Consultant staff stated the documentation of these concerns had not been shared with the facility and would be brought to the survey team. Facility administrative staff later stated the named nurse had not been employed there, that the state agency should have been notified, and that they had not received notes from the contracted company reporting the resident’s allegations. The facility policy required all employees to immediately report actual or potential abuse, neglect, or misappropriation to the team leader, Administrator, or State Agency Complaint Hotline.
Improperly Covered Outdoor Trash Receptacle
Penalty
Summary
The facility failed to maintain and dispose of kitchen garbage and refuse properly. During a kitchen tour, the outside garbage receptacle was observed with three of the eight lids open. Dietary Staff E stated that all of the lids were supposed to be closed. Maintenance Staff B later stated that all lids on the outside trash dumpster should always be closed, and Administrative Staff A stated she expected all trash dumpster lids to be closed when not being used. The facility's 2020 policy, Garbage and Rubbish Disposal, documented that outdoor trash receptacles would be kept covered.
Failure to Address Resident’s Auditory Hallucinations and Exit-Seeking Behavior
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with schizoaffective disorder, bipolar type, auditory hallucinations, delusions, and a history of psychotropic medication use. The resident’s records showed intact cognition on MDS assessments, but also documented hallucinations, delusions, and later other behaviors including wandering and behaviors directed toward others. The care plan addressed psychosocial well-being, auditory hallucinations, psychotropic medication use, and elopement risk, including a history of attempts to leave the facility unattended. On 09/23/25, the resident reported telepathic messages and tried to leave through the front door. Staff told him the voices were confused and that he was not leaving that day, and he returned to his room. The incident was not reported as a change in condition, and the resident was not assessed for possible triggers or given new behavioral interventions related to the auditory hallucinations. A psychiatric visit on 10/07/25 was for medication review, but the note did not address the recent hallucinations or the exit-seeking behavior. On 11/02/25, the resident again experienced auditory hallucinations telling him to go outside, entered the door code, and exited the facility without staff knowledge or supervision. He was outside alone for about 1.5 hours and was found two blocks away walking toward the highway in 39-degree weather. After return, he was cold, had a low temperature, tachycardia, and a small scratch. The resident’s behavioral manifestations were not assessed by the mental health provider until 11/05/25, and the report states the failure to identify and implement behavioral health interventions placed the resident in immediate jeopardy.
Damaged mattresses left residents with unsanitizable sleep surfaces
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for nine residents because multiple mattresses were observed to be uncomfortable, torn, damaged, and/or worn with exposed filling, making the surfaces unsanitizable. During an environmental tour with Maintenance Staff V and Maintenance Staff W, R33's mattress was observed to be worn, R2's mattress had a tear at the bottom, R31's mattress had multiple tears on the bottom side, R49's mattress had multiple tears on both the bottom and top, R17's mattress had tears along the side with a worn and ripped bed cover, and R42's mattress had a tear along the side. Additional observations showed R10's mattress had multiple tears and rip areas in the cover at the top of the bed, R15's mattress had multiple tears and rips on the side, and R16's mattress had multiple tears. All nine mattresses were noted to have visible tears and unsanitizable surfaces. R33 stated his mattress was uncomfortable. Housekeeping Staff U reported she would notify nursing staff and/or Consultant Staff HH of mattresses in disrepair, and Consultant Staff HH, along with Maintenance V and Maintenance W, verified the findings and the need to replace the mattresses to ensure a comfortable and sanitizable sleep surface. Consultant Staff HH stated staff should report damaged mattresses to maintenance staff or the administrator and that she had not been made aware of the need to replace the mattresses.
Inaccurate MDS Coding for Restraint, Catheter, and Dental Status
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for three residents. For one resident, the annual MDS documented a bed rail as a daily physical restraint, but observation showed a half side-rail secured to the right side of the bed, and the resident stated he used it to transfer in and out of bed. A CMA reported the resident used the side-rail to help him be independent with transfers, and an Administrative Nurse stated she had been instructed to code any bed rail as a restraint even though this resident’s bed positioning rail was used to assist with transfers and bed mobility and was not a restraint for him. For another resident, the annual MDS recorded the resident as always continent of urine, but the care plan directed staff to provide reminders so staff could assist with emptying the leg bag, and a physician order required the leg bag to be emptied four times daily and as needed every two hours for neuropathic bladder. During observation, the catheter leg bag was full of urine, and the resident said he would alert staff for assistance. For a third resident, the admission MDS recorded no dental issues, but the admit screener documented broken or carious teeth. Observation showed missing and broken teeth on the bottom gumline, and staff reported the resident had teeth missing and cavities, had recently completed an antibiotic for tooth pain and infection, and had a pending dental appointment. The Administrative Nurse stated the MDS was coded inaccurately and that the dental issues were not captured.
Incomplete Care Plans for Pain, Therapy, Oxygen, and CPAP Needs
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents with identified needs. For one resident, the electronic record showed diagnoses of osteoporosis and chronic pain, and the resident reported left shoulder pain with limited motion. The resident’s physician documented shoulder pain without injury or trauma, ordered physical therapy, and later ordered meloxicam and orthopedic follow-up with MRI evaluation. Although therapy and orthopedic services were involved, the care plan did not include documentation or interventions for the left shoulder pain or therapy needs. For the second resident, the electronic record showed diagnoses of bipolar disorder, COPD, and sleep apnea, with orders for continuous oxygen and CPAP use. The resident’s MDS documented that the resident rejected evaluation or care daily and required oxygen and a non-invasive ventilator. The CAA documented frequent refusal of care, hypoxia with oxygen saturation below 80 percent, confusion with low oxygen saturation, resistance to wearing oxygen, and CPAP use at night due to increased hypoxia. Despite these documented needs, the care plan lacked documentation regarding oxygen and CPAP use. Survey findings also showed related resident events and staff statements. One resident was observed eating lunch without obvious issues and reported waiting for therapy because of limited left shoulder motion and a rotator cuff tear causing pain. Staff reported the resident had recently started complaining of shoulder pain and was receiving medication for it. For the second resident, staff documented very low oxygen saturation on room air, oxygen administration with improvement in saturation, and that the resident had agreed to try CPAP at bedtime. Administrative nursing staff confirmed that the care plans lacked the needed documentation and that the plans were expected to reflect residents’ concerns, goals, and interventions.
Failure to Document Physician Notifications and Hospital Refusal
Penalty
Summary
The facility failed to ensure services met professional standards of care when staff did not maintain appropriate documentation in a resident’s EMR regarding physician notifications and refusals to transfer to the local hospital. The resident had diagnoses of bipolar disorder, COPD, and sleep apnea, and the MDS documented a BIMS score of 15, indicating intact cognition. The resident also required oxygen and CPAP use, and the CAA documented frequent refusal of care, including refusal related to hypoxia and low oxygen saturation. However, the care plan did not include documentation about oxygen or CPAP use, and it also lacked the resident’s refusal-of-care behaviors. The MAR reviewed for the resident did not include an area to document continuous oxygen applied or refused. Progress notes documented episodes of severe hypoxia, confusion, discoloration, and decline. One note recorded the resident’s oxygen saturation at 52 percent on room air, with oxygen applied at 3 liters increasing saturation to 84 percent, but the note did not document that the provider was called about the dark purple discoloration of the lower extremities. Another note documented the resident was not waking during vital sign assessment, had oxygen saturation of 82 percent on 3 liters, dark purple lips, mottling over the body, and increased confusion, but again lacked documentation that the provider was notified of the change in condition. A later note documented the resident repeatedly removed oxygen, with room-air saturations ranging from 57 to 73 percent, shallow and slow respirations, and death shortly thereafter. Staff interviews confirmed they did not document changes in condition or provider notifications in the EMR, and the administrative nurse and physician both stated they expected documentation of physician contact, response, and the resident’s refusal to go to the hospital.
Inadequate catheter securement and infection control during Foley care
Penalty
Summary
The facility failed to provide adequate catheter care for a resident with schizoaffective disorder, DM2, and a neurogenic bladder who had an indwelling Foley catheter connected to a leg bag. The resident’s assessments documented intact cognition, hallucinations, delusions, and a history of resistance to catheter care and emptying the leg bag. The care plan directed staff to monitor the catheter, empty the leg bag regularly, and use Enhanced Barrier Precautions when draining or emptying the bag, but the record did not include documentation of any catheter tubing securement device being used or any failed attempts to use one. During observation, the resident’s leg bag was concealed under the left pant leg and appeared full and bulging, and the resident stated he would alert staff to assist with emptying it. Later, a CNA emptied the leg bag into an urinal while wearing EBP, but allowed the drain port to contact the side of the urinal, did not clean or sanitize the drain port afterward, and did not place a cap or barrier over the drain port. When the resident complained that the catheter was pulling, the CNA readjusted the leg bag without reapplying EBP or performing hand hygiene. Interviews confirmed staff responsibilities for catheter care and emptying the drainage bag, but the CNA stated she did not sanitize the drainage port and did not use the appropriate EBP when adjusting the leg bag. Administrative nursing staff stated the facility did not utilize catheter securement devices because the resident was the only resident with a catheter and would not allow them, yet there was no documentation of refusal or failed attempts to secure the tubing. The facility policy stated catheter care should be provided at least twice daily, the catheter should be taped or anchored to the upper thigh to avoid tension, and the drainage bag should be emptied into a measured container with the total documented in the EHR.
Infection Control Failure During Catheter Care and EBP Use
Penalty
Summary
The facility failed to implement and maintain an effective infection control program when staff did not provide catheter care using adequate infection control practices and did not implement Enhanced Barrier Precautions during high-contact care for one resident with a leg bag catheter. During an observation, a CNA emptied the resident’s leg bag into an empty urinal after entering the room, performing hand hygiene, and applying EBP. While emptying the urine collection bag, the drain port of the leg bag came into contact with the side of the urinal, and the CNA did not clean or sanitize the drain port afterward. The CNA also did not place a cap or other barrier over the end of the drain port on the leg bag. When the resident complained that the catheter was pulling, the CNA removed the EBP and performed hand hygiene, then consulted with an LPN. The CNA returned to the room and readjusted the resident’s leg bag without reapplying the appropriate EBP or performing hand hygiene. During interview, the CNA confirmed she did not sanitize or clean the drainage port and stated she did not utilize the appropriate EBP when adjusting the leg bag. An Administrative Nurse stated catheter cleaning was performed with showers and should be done with soap and water only, and also stated that when a leg bag was emptied, the drain spout should not contact the urinal and should be cleaned with an isopropyl alcohol wipe before being stowed. The facility did not provide a policy related to Enhanced Barrier Precautions.
Improper Food Storage and Handling in Dietary Department
Penalty
Summary
Surveyors observed multiple instances of improper food storage during a tour of the facility's kitchen and storage areas. In the standing freezer, a package of shredded potatoes was found open to air, and in a chest freezer, a box of pork sausage patties was also open to air. In the dry storage area, a package of lemon pudding mix, a large package of butterscotch chocolate chips, and a large package of Italian dressing mix were all found open to air. Additionally, a large can of sliced apples and a small can of sliced mushrooms were noted to be dented. In the standing refrigerator, a large package of yellow/white shredded cheese mixture was open to air. During interviews, dietary staff indicated they were not aware that food containers should be closed, and administrative staff confirmed that all food items should be closed and dented cans should be returned or discarded. The facility's policy required food and non-food supplies to be stored under sanitary and safe conditions, with dented cans to be returned or destroyed. The facility had a census of 42 residents, with one central kitchen and one dining area at the time of the survey.
Deficient Infection Control in Laundry Handling and Processing
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically regarding the handling and processing of laundry. Observations revealed that a CNA transported soiled laundry in an uncovered bin down the hallway, with laundry overflowing from the container. On another occasion, the same CNA transported a closed dirty laundry bin with an open basket of soiled laundry placed on top, also overflowing. The CNA confirmed she was unaware that soiled laundry needed to be covered during transport. Administrative nursing staff confirmed that all laundry should be covered during transport to prevent cross-contamination and the spread of infection. Further observation in the laundry area, with laundry staff present, identified a wood table used for folding and processing clean laundry that had chipped laminate and exposed bare wood, creating a surface that could not be properly sanitized. Laundry staff acknowledged the unsanitizable condition of the table and agreed it required repair. The facility's infection surveillance policy requires proper cleansing and disinfection of surfaces and equipment used for handling, processing, and transporting linens, which was not followed in these instances.
Incomplete Care Area Assessments for Multiple Residents
Penalty
Summary
The facility failed to complete Care Area Assessments (CAAs) that addressed the individual underlying causes, contributing factors, and risk factors for five residents. For these residents, the CAAs triggered by the Minimum Data Set (MDS) assessments, such as those related to psychotropic drug use, dental care, behavioral symptoms, and cognitive loss/dementia, lacked required analysis of findings. The documentation did not include an analysis of the residents' conditions or the factors contributing to their care needs, as required by facility policy and federal guidelines. Staff interviews revealed that the MDS nurse responsible for completing the CAAs was not adequately educated on how to complete the CAA notes, resulting in incomplete documentation. Administrative staff confirmed that the CAAs were not completed as they should have been and lacked necessary analysis and risk findings. The facility's policy required that each triggered CAA be fully assessed and documented, but this was not done for the identified residents, placing them at risk for inadequate care due to unidentified care needs.
Inaccurate MDS Documentation for Medications, Restraints, and WanderGuard Alarms
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for seven residents, resulting in documentation errors related to medication administration, use of physical restraints, and the presence of WanderGuard alarms. Specifically, two residents had their non-insulin hypoglycemic medications (Ozempic, Metformin, and Trulicity) incorrectly coded as insulin, and these medications were not properly documented in the MDS. One resident was incorrectly coded as having a physical restraint due to the use of a bed positioning device, despite using it for mobility and independence rather than restraint. Four residents with physician orders for WanderGuard alarms were not accurately documented as having these devices in their MDS assessments. These inaccuracies were identified through observation, interviews, and record reviews. The MDS nurse responsible for completing the assessments acknowledged making errors in coding medications and WanderGuard alarms, attributing some mistakes to limited time and infrequent presence in the facility. Another administrative nurse reported that she expected the MDS to be accurate and that she reviewed and signed off on the assessments, but errors still occurred. The facility's policy requires that assessments accurately reflect the resident's status at the time of assessment, which was not met in these cases.
Medication Error Rate Exceeds Five Percent Due to Insulin Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required, when two insulin administration errors were observed out of 25 medication opportunities, resulting in an eight percent error rate. Specifically, a licensed nurse administered insulin to a resident with diabetes mellitus without priming either the insulin lispro or insulin glargine pens, did not verify the insulin orders against the medication administration record at the time of preparation, and did not follow manufacturer instructions for the duration the pen button should be depressed during injection. The nurse kept the insulin pen button pressed for only two seconds for both types of insulin, despite manufacturer instructions specifying five seconds for insulin lispro and ten seconds for insulin glargine to ensure full dose delivery. Interviews revealed that the nurse was unsure of the required duration for keeping the insulin needle in the skin and did not follow the facility's policy, which mandates verification of medication orders and adherence to proper administration technique. The administrative nurse confirmed the expectation that all medication orders be verified with the medication administration record prior to administration. The facility's policy also requires that the medication be administered at the proper time, in the prescribed dose, and by the correct route, with specific instructions for insulin pen use that were not followed in this instance.
Failure to Ensure Palatable and Properly Prepared Meals
Penalty
Summary
The facility failed to ensure that meals were prepared in a manner that preserved or promoted palatability for its residents. During the preparation of a noon meal consisting of turkey, stuffing, mixed vegetables, and a dinner roll, a dietary staff member prepared a gravy by combining chicken base, water, and an unspecified amount of corn starch without following a written recipe. The resulting mixture was water-thin and described as a broth rather than a traditional gravy. The dietary staff member was unable to provide a recipe for the gravy, stating that she had memorized it from experience. Administrative staff observed the meal service and confirmed that the mixture served over the turkey and dressing did not resemble gravy and was not appealing. Additionally, the facility was unable to provide a policy related to food palatability when requested. The lack of adherence to standardized recipes and absence of a relevant policy contributed to the deficiency in meal preparation and presentation.
Failure to Obtain and Document Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents and/or their representatives were properly informed and provided with documented consent regarding the use of psychotropic medications. Review of the Psychoactive Medication Therapy Informed Consent Form logbook revealed that consent forms for multiple psychotropic medications, including Invega, Haldol, Abilify, lithium, Ativan, trazodone, and Zyprexa, lacked signatures from the appropriate residents or their guardians. Specifically, consent forms for one resident were missing the resident's signature, while consent forms for another resident were missing the guardian's signature. Additionally, the electronic medical records for both residents did not contain documentation of informed consent for these medications. Interviews with facility staff indicated confusion and lack of clarity regarding the process for obtaining and documenting informed consent. Social Services staff reported being newly assigned to the task and were unaware of the requirement for guardian signatures when applicable. Administrative nursing staff acknowledged the missing signatures and described a practice of signing consent forms in advance or delegating the task to others, which resulted in incomplete documentation. The facility's policy required discussion of risks and benefits with residents or responsible parties, but this was not consistently documented or followed.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
The facility failed to develop a person-centered baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident's electronic health record showed that only some components of the baseline care plan were completed over a period of days, with two essential components—General Information and Initial Goals and Health Conditions—remaining incomplete as of nearly two weeks after admission. Interviews revealed that the nurse responsible for admitting the resident did not complete the baseline care plan as required, and administrative staff were unaware of the 48-hour completion requirement. The facility's policy stated that an initial person-centered care plan should be developed within 48 hours of admission, but this was not followed in the case reviewed.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer the pneumococcal vaccine to three residents, as evidenced by the absence of documentation in their electronic medical records showing that the vaccine was offered, provided, or that informed declination was obtained. Specifically, the records for these residents did not contain evidence of education regarding the benefits and potential side effects of the immunization, nor any indication that the vaccine was administered or declined. An administrative nurse confirmed these findings and noted that while the facility attempts to vaccinate eligible residents, insurance coverage issues sometimes prevent administration. The facility's immunization policy requires that each resident or their representative receive current education and be offered the influenza and pneumococcal vaccines, but this process was not documented for the affected residents.
Failure to Implement Nutritional Interventions for Resident
Penalty
Summary
The facility failed to identify and implement nutritional interventions for a resident, referred to as R27, who experienced significant weight loss over two separate periods. Initially, between January and June, R27 lost 19.52% of her body weight without any documented intervention or prescribed weight loss program. Despite the resident's medical history, which included schizophrenia, asthma, and a history of fractures, the facility did not provide adequate nutritional support or monitoring during this time. In the subsequent period from August to January, R27 continued to lose weight, amounting to a 16.84% decrease. The facility's records showed a lack of timely dietary supplementation and intervention, as R27's care plan was only updated in November to include one-to-one assistance during meals and supplemental shakes. The facility's failure to act promptly on R27's weight loss and dietary needs was compounded by inadequate communication with the registered dietician, who was not informed of the resident's significant decline and was not included in care plan meetings. Observations and interviews with staff revealed that R27 required constant supervision and assistance during meals due to cognitive impairments and behaviors that affected her eating. Despite these needs, the facility did not have a certified dietary manager, and the registered dietician reported a lack of communication regarding changes in residents' weights and dietary intake. The facility's nutritional services policy, which required monitoring and intervention for residents at risk of significant weight loss, was not effectively implemented, leading to R27's continued weight decline and risk of malnourishment-related complications.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that the director of food and nutrition services possessed the required qualifications of a Certified Dietary Manager (CDM). During an observation on January 13, 2025, at 07:17 AM, Dietary BB admitted to not having CDM certification, although she had completed her Safe Serv courses. She was unaware of the need to obtain CDM certification. Additionally, the registered dietician was only present at the facility once a month. On January 15, 2025, at 03:42 PM, Administrative Staff A expressed the belief that the presence of a registered dietician negated the necessity for the dietary manager to be certified. The facility was unable to provide a policy regarding the CDM qualifications when requested. This deficiency placed residents at risk for unmet dietary and nutritional needs.
Improper Thawing of Meat in Kitchen
Penalty
Summary
The facility, with a census of 45 residents, was found to have a deficiency in its food handling practices. During an initial tour of the kitchen, a pork loin was observed thawing in a three-bin wash sink without water running over it. This method of thawing meat does not comply with professional standards, which require meat to be thawed on the bottom shelf of the refrigerator or in a tub with running water if thawed in the sink. Dietary staff confirmed the correct procedures for thawing meat, indicating a failure to adhere to these standards. This oversight placed residents at risk for food-borne illnesses due to potential bacterial growth.
Failure to Document and Offer Vaccinations
Penalty
Summary
The facility failed to offer or obtain informed declinations, consent, or a physician-documented contraindication for influenza and pneumococcal vaccinations for several residents, including R5, R16, R19, R27, and R30. The clinical records of these residents lacked documentation indicating whether the influenza and PCV20 vaccinations were offered, declined, or administered, and there was no physician-documented contraindication. This oversight placed the residents at an increased risk for influenza, pneumonia, and related complications. Interviews with facility staff revealed that the pharmacy administered immunizations annually, and residents were typically offered vaccinations upon admission. However, it was noted that some residents or their legal guardians reported prior immunizations, and in some cases, the facility did not offer vaccinations due to concerns about upsetting legal guardians. Additionally, the facility did not offer the PCV20 vaccine to residents at risk of pneumonia because Medicaid did not cover the cost. The facility's immunization policy emphasized the importance of offering vaccines unless contraindicated or refused after appropriate education, but this policy was not consistently followed, leading to the identified deficiencies.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
The facility failed to document the transfer of a resident, identified as R39, to an acute hospital, which placed the resident at risk for uninformed care choices. R39 had a history of mental health disorders, including PTSD, major depressive disorder, suicidal ideations, bipolar disorder, anxiety, and borderline personality disorder. Despite having intact cognition and being independent with her functional abilities, R39 was transferred to a psychiatric hospital without proper documentation of when, where, and why the transfer occurred. The facility's records, including the Electronic Medical Record (EMR) and Progress Notes, lacked documentation regarding the transfer, and the facility did not provide a policy on transfer and discharge when requested. Interviews with facility staff revealed that R39 was on therapeutic leave with her mother when she attempted suicide and was subsequently taken to a psychiatric hospital by her mother. The facility was unaware of R39's admission to the hospital until they received a call from the hospital stating that R39 had been discharged and needed to be transported back to the facility. The lack of documentation and communication regarding R39's transfer to the psychiatric hospital highlights a deficiency in the facility's procedures for managing resident transfers and discharges.
Failure to Provide Written Notification of Transfers
Penalty
Summary
The facility failed to provide written notification of transfer for two residents, R39 and R20, during facility-initiated transfers. R39, who had a history of mental health disorders including PTSD, major depressive disorder, and bipolar disorder, was transferred to a psychiatric hospital without written notification. The facility did not document the transfer in R39's progress notes, and staff stated that since R39 was on leave with her mother at the time of the transfer, they did not issue a written notification. This oversight placed R39 at risk for uninformed care choices. R20, who had diagnoses of bipolar disorder, epilepsy, and anxiety, was transferred to the hospital on multiple occasions without receiving written notification of the transfers. The facility's records showed that R20 was transferred and admitted to the hospital on several dates, but there was no evidence of written notice provided to R20 or his legal representative. The facility relied on phone notifications to the resident's legal guardian or family representatives, which did not meet the requirement for written notification. The facility was unable to provide a policy related to facility-initiated transfers for both residents. This lack of documentation and failure to provide written notifications for transfers placed both residents at risk of uninformed choices and miscommunication regarding their care needs.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for two residents, leading to potential risks for inappropriate comprehensive care. Resident 28's MDS was incorrectly coded to include treatments and services such as dialysis, hospice care, and mechanical ventilation, which the resident did not receive. This error was acknowledged by the administrative nurse responsible for completing the MDS, who admitted to making a mistake. The facility was unable to provide an MDS Accuracy policy upon request, highlighting a lack of procedural guidance. Resident 39's MDS assessments failed to include a diagnosis of post-traumatic stress disorder (PTSD), despite the resident having a documented history of PTSD. The omission was attributed to difficulties in obtaining documentation from the resident's previous facility, resulting in the PTSD diagnosis being excluded from the MDS. This oversight meant that the resident's care plan did not address PTSD-related triggers or interventions, potentially impacting the resident's care and well-being. Both cases demonstrate a failure in the facility's processes for accurately completing MDS assessments, which are crucial for developing appropriate care plans. The inaccuracies in the MDS coding for these residents placed them at risk for receiving care that did not fully address their needs. The facility's inability to provide relevant policies further underscores the deficiencies in their assessment and documentation procedures.
Failure to Develop Individualized Trauma-Based Care Plans
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, R30 and R39, which included individualized person-centered interventions for their trauma-based care. R30's care plan lacked specific interventions to address her PTSD, despite her diagnoses of PTSD, tardive dyskinesia, schizoaffective disorder, and anxiety. The care plan did not identify ways to decrease exposure to triggers that could re-traumatize her. Staff interviews revealed a lack of awareness and training regarding trauma-based care plans, with some staff unaware of which residents had PTSD or how to prevent re-traumatization. R39's care plan also failed to address her PTSD, despite her diagnoses of PTSD, major depressive disorder, suicidal ideations, anxiety, bipolar disorder, and borderline personality disorder. The care plan included general interventions for aggressive behaviors but did not include specific strategies to mitigate triggers or prevent re-traumatization related to her PTSD. Interviews with administrative nurses confirmed that R39's care plan was not individualized to her specific needs and behaviors. The facility was unable to provide a policy related to the development of person-centered care plans, and staff interviews indicated a lack of trauma-based assessments and individualized interventions. The absence of a social service staff member further contributed to the deficiency in addressing the residents' trauma-based care needs. This lack of comprehensive care planning placed both residents at risk for impaired care and re-traumatization due to uncommunicated care needs.
Failure to Revise Care Plan for Resident's Incontinence and Behavioral Needs
Penalty
Summary
The facility failed to revise the care plan for Resident 3 to accurately reflect his care needs related to incontinence, activities of daily living (ADLs), and behaviors. Despite having a comprehensive assessment that identified his needs, the care plan lacked specific interventions and instructions for managing his incontinence and behavioral issues. The resident, who has a history of schizophrenia, diabetes mellitus, and asthma, was noted to be occasionally incontinent of his bladder and required supervision during ADLs. However, the care plan did not include a toileting program or strategies to address his resistance to care, which was influenced by his previous lifestyle of homelessness. Observations and interviews revealed that the care plan did not provide individualized interventions for the resident's behaviors, such as defecating in inappropriate places due to his past experiences. Staff members, including a Certified Medication Aide and an Administrative Nurse, acknowledged the resident's history of rejecting care and the need for a care plan that includes specific behaviors and interventions. The facility was unable to provide a policy related to the development of a person-centered care plan, which contributed to the deficiency in addressing the resident's care needs effectively.
Failure to Implement ROM Program for Resident
Penalty
Summary
The facility failed to implement a range of motion (ROM) program for Resident 16, who was at risk of decreased mobility and potential development of contractures. Resident 16's medical history included schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD. The resident had limited ROM on one side of the body and required partial to moderate assistance with dressing. Despite these needs, there was no evidence in the electronic medical record (EMR) that ROM or restorative care was provided to the resident. Observations and interviews revealed that Resident 16 expressed a desire to maintain mobility and independence. However, the administrative nurse responsible for evaluating residents for restorative programs had not assessed Resident 16 due to time constraints. Both the certified medication aide and a licensed nurse acknowledged that the resident would benefit from a ROM program. The facility's policy stated that residents should be evaluated for restorative programs upon admission and after significant changes in condition, but this was not done for Resident 16, leading to the deficiency.
Failure to Implement Individualized Toileting Interventions
Penalty
Summary
The facility failed to implement individualized toileting interventions for a resident, identified as R3, who was occasionally incontinent of bowel and bladder. Despite being noted as a good candidate for retraining in multiple assessments, R3's care plan lacked specific instructions for a toileting program or the use of incontinence products. The care plan also failed to address R3's history of defecating and urinating in his room, a behavior linked to his previous homelessness. Staff were expected to provide reminders for toileting every two hours, but there was no evidence of a structured retraining program being in place. R3's medical history included schizophrenia, diabetes mellitus, and asthma, with a BIMS score indicating intact cognition. The resident was independent in most activities of daily living but required supervision and encouragement due to resistive behavior. Interviews with staff revealed that R3's incontinence and behavioral needs were not adequately documented in the care plan, and the facility did not have a retraining program for incontinence. This oversight placed R3 at risk for complications related to incontinence, as the facility's policy required individualized continence management programs based on pattern evaluations.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for three residents diagnosed with posttraumatic stress disorder (PTSD), namely R30, R16, and R39. The facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization. For R30, the care plan lacked specific interventions to decrease exposure to triggers, despite her intact cognition and history of verbal behaviors. Staff members, including a Certified Medication Aide and a Licensed Nurse, were unaware of which residents had PTSD or required trauma-based care plans. R16, who had moderately impaired cognition and a history of schizophrenia and PTSD, also did not have a care plan with individualized interventions to prevent re-traumatization. The facility's staff, including the MDS coordinator and an administrative nurse, acknowledged the absence of trauma-based assessments and interventions, citing the facility's small size and lack of social service staff as reasons for not having individualized care plans. R39's care plan did not address her PTSD, despite her intact cognition and history of major depressive disorder and bipolar disorder. The facility failed to perform a trauma-informed care assessment upon her admission, and staff were unaware of her PTSD diagnosis until a month after her admission. The facility's Behavioral Health Services policy stated that residents with a history of trauma should receive appropriate treatment, but this was not implemented for R39, placing her at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Implement Individualized Behavioral Care Interventions
Penalty
Summary
The facility failed to implement individualized behavioral care interventions for three residents, R3, R30, and R39, who were reviewed for behavioral services. For R3, the facility did not provide adequate interventions for his behavioral symptoms, which included resistance to care, defecating on the floor, and urinating in inappropriate places. Despite having a care plan that identified potential aggressive behaviors, the plan lacked specific interventions for his refusals to complete self-care and his incontinence issues. Progress notes repeatedly documented his resistance to care and inappropriate toileting behaviors, but they did not specify what behavioral interventions were used during these episodes. R30's care plan was also found lacking in individualized interventions for her behavioral symptoms, which included verbal behaviors and refusal to take medications. Although she had a history of PTSD and other mental health diagnoses, her care plan did not include specific interventions to address her triggers or prevent re-traumatization. Staff interviews revealed a lack of awareness of individualized interventions for her behaviors, and the facility's policy on behavioral health services was not adequately implemented to ensure person-centered care. Similarly, R39's care plan did not address her PTSD diagnosis or provide specific interventions for her anxiety, depression, and bipolar disorder. Her care plan included general strategies for managing aggressive behaviors but did not identify triggers or interventions specific to her mental health needs. Interviews with administrative nurses confirmed that her care plan was not individualized, and the facility's policy on behavioral health services was not effectively applied to meet her needs. These deficiencies placed the residents at risk for continued behavioral episodes and unmet care needs.
Consultant Pharmacist Fails to Identify Medication Order Deficiencies
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported deficiencies in medication orders for two residents, R5 and R19. For R5, the CP did not report that the physician's order for diclofenac, a non-steroidal anti-inflammatory medication, lacked a specified dosage. This oversight was noted in the Medication Regimen Review (MRR) for November and December 2024. Interviews with facility staff revealed a lack of awareness regarding the necessity of specifying a dosage for topical medications like diclofenac, which placed R5 at risk for unnecessary medications and related complications. For R19, the CP failed to identify and report that the resident's heart rate was outside the physician-ordered parameters on multiple occasions over a 73-day period. Additionally, the CP did not report the absence of physician-ordered laboratory test results in R19's clinical record. The facility was unable to provide these test results upon request, indicating a lapse in monitoring and documentation. Interviews with staff highlighted a breakdown in communication and responsibility for notifying physicians about out-of-parameter vital signs and ensuring laboratory tests were conducted as ordered. The facility's Drug Regimen Review policy mandates that the CP perform a drug regimen review for each resident at least monthly, including monitoring for irregularities in medication orders and ensuring appropriate documentation and notification of any issues. The failure to adhere to this policy for both R5 and R19 resulted in deficiencies that placed the residents at risk for unnecessary medications and related complications.
Failure to Follow Physician Orders and Ensure Proper Medication Dosing
Penalty
Summary
The facility failed to ensure that the physician's orders were followed for Resident 19's laboratory tests to monitor high-risk medications and did not notify the physician when heart rates were outside the ordered parameters. Resident 19, who had diagnoses of diabetes mellitus and hypertension, was supposed to have regular laboratory tests and monitoring of vital signs as per physician orders. However, the facility's records lacked evidence of these tests being conducted, and there was no documentation of physician notification when the resident's heart rate was outside the specified parameters on multiple occasions. For Resident 16, the facility did not ensure proper dosing instructions for the application of Voltaren gel, a topical pain reliever. Resident 16, who had multiple diagnoses including schizophrenia and chronic pain, was prescribed Voltaren gel to be applied to specific areas. However, the facility staff were unsure about the dosage requirements, and the facility was unable to provide a policy related to physician orders, leading to a risk of unnecessary medication use and potential side effects. Similarly, Resident 5's physician order for diclofenac gel lacked a specified dosage amount. Resident 5, who had a history of schizophrenia and a stress fracture, was at high risk of falls and was prescribed diclofenac gel for knee pain. The facility failed to identify and report the missing dosage information, which could lead to unnecessary medication use and related complications. The facility was unable to provide a policy regarding unnecessary medications, further contributing to the deficiencies observed.
Failure to Ensure PRN Psychotropic Medications Have Stop Dates
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medications for two residents, R30 and R16, had a 14-day stop date or a specified duration with supporting physician documentation. This oversight was identified during a review of the residents' electronic medical records (EMR) and interviews with facility staff. The absence of a stop date or specified duration for these medications placed the residents at risk for unnecessary medication administration and potential adverse side effects. Resident R30 had a history of posttraumatic stress disorder, tardive dyskinesia, schizoaffective disorder, and anxiety. The resident's care plan included the administration of psychotropic medications as ordered by the physician. However, the EMR revealed that PRN orders for hydroxyzine, Seroquel, and Haloperidol lacked a 14-day stop date or a physician-ordered specific duration. Additionally, a physician order to discontinue Seroquel was not followed, as it was not discontinued as ordered. Interviews with facility staff indicated a lack of clarity regarding the requirement for a duration in PRN psychotropic medication orders. Resident R16, diagnosed with schizophrenia, cerebral infarction, hemiplegia, chronic pain, insomnia, and PTSD, also had PRN orders for Trazodone without a 14-day stop date or specified duration. The facility was unable to provide a policy related to monitoring psychotropic medications, and staff interviews revealed uncertainty about the requirements for PRN psychotropic medication orders. This deficiency in medication management practices placed both residents at risk for unnecessary medication administration and possible adverse side effects.
Failure to Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to offer or obtain informed declinations or a physician-documented contraindication for the COVID-19 vaccinations for two residents, identified as R16 and R5. Upon review of their clinical records, it was found that there was no documentation under the Immunization tab indicating that the COVID-19 vaccination was offered, declined, or administered. Additionally, there was no physician-documented contraindication present in their records. This lack of documentation and action placed these residents at an increased risk for COVID-19. Interviews with facility staff revealed that the responsibility for tracking immunizations was with Administrative Nurse D, who also served as the facility's Infection Preventionist. It was noted that the pharmacy visited the facility annually to administer immunizations, and residents were offered vaccinations upon admission. However, the facility was unable to provide a policy related to the administration of COVID-19 vaccinations, nor could they provide signed consents or declinations for the residents in question. This oversight in documentation and procedure led to the identified deficiency.
Failure to Ensure Resident Remained Free from Restraints
Penalty
Summary
The facility failed to ensure that a resident, who had a history of self-harm and aggressive behaviors, remained free from physical and chemical restraints. On multiple occasions, the resident attempted to injure himself and became combative with staff, leading to the use of both chemical and physical restraints. The facility did not have physician orders for the use of these restraints, nor did they document any assessments or person-centered care planning related to the restraint use. The resident had multiple diagnoses, including bipolar disorder with psychotic features, major depressive disorder, ADHD, PTSD, and autistic disorder. Despite these conditions, the facility did not assess the resident's mental status adequately and failed to identify any medical or behavioral symptoms that warranted the use of restraints. The care plan for the resident included monitoring behavior episodes and attempting to determine underlying causes, but it did not include any specific strategies for managing the resident's aggressive behaviors without resorting to restraints. During the incidents, the resident exhibited severe agitation and aggression, including making threats, attempting self-harm, and physically attacking staff. The facility staff responded by physically restraining the resident with the help of multiple staff members and using a bedsheet to further restrain him. The resident was also chemically sedated with medications like Haldol and Ativan. These actions were taken without proper documentation or physician orders, placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
Inadequate Response to Resident's Aggressive Behavior
Penalty
Summary
The facility failed to appropriately acknowledge and respond to a resident's behaviors related to his psychosocial disorder and physical aggression. The resident, diagnosed with bipolar disorder, major depressive disorder, ADHD, PTSD, and autistic disorder, exhibited severe aggressive and self-harming behaviors over several days. On multiple occasions, the resident made threats to harm himself and others, engaged in self-injurious actions, and became physically aggressive towards staff, necessitating intervention to prevent harm. The facility's response included the use of chemical and physical restraints without proper physician orders, as evidenced by the lack of documentation in the Electronic Medical Record. The resident's care plan, which was supposed to address his behavior problems, was not effectively implemented. Staff interventions were inadequate, as they failed to de-escalate the resident's agitation and resorted to physical restraint methods that were not authorized or documented. The facility also lacked a policy for the use of restraints, further complicating the situation. The resident's aggressive episodes were exacerbated by anxiety related to legal issues, and the facility's attempts to manage these episodes included calling law enforcement and administering medications like Haldol and Ativan. Despite these efforts, the facility's actions were insufficient to prevent the resident from harming himself and others, leading to the use of unauthorized restraints and placing the resident in immediate jeopardy.
Removal Plan
- The facility completed a violence risk screening on all current residents.
- The facility revised care plan for residents identified at high risk for assault identified in the screening tool.
- The facility began educating staff on the Federal Guidelines on the use of restraints.
- The facility assigned online training for Handling Aggressive Behaviors, Overview of Abuse and Neglect of Individuals with IDD, Understanding Wandering and Elopement, and the Meaning Behind Behaviors.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 111 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Peabody
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peabody Health And Rehab | 0.2 mi | ★★★★★ | 0 | 0 |
| Parkside Homes | 12.9 mi | ★★★★★ | 0 | 0 |
| Salem Home | 13.1 mi | ★★★★★ | 0 | 0 |
| St Luke Living Center | 13.3 mi | ★★★★★ | 19 | 0 |
| Bethesda Home | 13.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.