Below average — CMS composite of the measures below.
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 Clearwater Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to supervise a cognitively impaired resident at high risk for wandering led to an elopement from an unsecured smoking area. While a CNA was assisting another resident, the resident walked out of the parking lot smoking area, passed the front entrance, and was not recognized as missing until lunch tray pickup. Staff later found him about 0.8 miles away after he had crossed busy streets and railroad tracks; he returned without injury.
Failure to Maintain Required RN Coverage: The facility did not have an RN in the building for at least 8 consecutive hours a day, 7 days a week on multiple dates. Administrative Nurse D verified that no RN was present for the required coverage or serving as charge nurse on those dates, despite the facility policy requiring daily RN coverage and a full-time DON.
Incomplete CNA In-Service Training and Performance-Based Education: Record review showed the facility failed to ensure all CNA staff received the required annual in-service hours and education based on performance reviews. Five CNAs lacked the required 12 hours of in-service training, and an administrative nurse stated she could not locate the documentation or provide the needed hours for staff. The facility’s program required regular in-service classes, annual performance reviews, and training to address identified weaknesses.
Lack of Certified Dietary Manager: The facility failed to employ a full-time CDM for the 32 residents receiving meals from the kitchen. Dietary CC was observed overseeing meal prep, but he stated he was not CDM certified and had not been enrolled in any certification classes. An admin nurse verified he was not certified, while the facility policy required the Food Services manager to be CDM certified or enrolled in an accredited CDM program.
Kitchen sanitation and temperature monitoring failures: The kitchen and dining areas had multiple cleanliness issues, including food debris on the stove, oven, burners, shelving, microwave, and unbagged food items in the freezer, along with dirty water under sinks from leaking pipes. The facility also lacked consistent documentation for refrigerator, freezer, meal temperature, and dish machine sanitizer logs, and expired sanitizer test strips were observed.
The facility failed to consistently provide nourishing evening snacks to residents, including residents with DM. Two residents reported that snacks were not always available at night and that only limited items such as fruit, fig bars, and cheese crackers were offered, with no sandwiches available when requested. Dietary and nursing staff confirmed that snacks were kept under the nurses’ station, could be taken by some residents in excess, and that protein snacks for residents with DM were not consistently provided. Staff also stated that late-night sandwich requests could not always be met after dietary staff left for the night.
QAA Committee Failed to Address Multiple Deficient Practices: Surveyors found that the facility's QAA/QAPI process did not adequately identify or correct multiple deficient practices affecting residents. Deficiencies included failure to post survey results, provide bed hold policy information, develop a comprehensive wound care plan, ensure accurate treatment documentation, provide ordered edema care, supervise for elopement, follow infection control practices, verify insulin competency and labeling, maintain RN coverage, provide required in-service training, employ a certified Dietary Manager, provide a nourishing evening snack, and properly store, prepare, and serve food.
A resident with DM, stroke history, chronic respiratory failure, hypoxemia, and syncope was transferred to the hospital after reporting chest pain and shortness of air. Although she had intact cognition, the record lacked evidence that the facility provided written bed hold policy information to the resident or her representative at the time of transfer, and an administrative nurse verified the bed hold notice was missing.
Care Plan Lacked Instructions for Surgical Wound Care: A resident with mastoiditis, osteomyelitis, and surgical wounds had a care plan that acknowledged the wounds but did not include instructions for staff on how to provide wound care. The resident’s MDS showed intact cognition and need for supervision with most ADLs, and staff verified that the skin integrity section lacked wound care interventions, with one nurse stating she relied on the TAR for those details.
False documentation of ordered Ace wrap treatments. Staff charted that an LPN had applied ordered Ace wraps to a resident with edema and heart failure even though observations showed the wraps were not on the resident. The resident said the wraps were supposed to be done daily but rarely were unless he reminded staff, and an LN acknowledged charting the treatment as completed despite it not being provided.
Failure to Apply Ordered Ace Wraps for Dependent Edema: A resident with edema, CHF, and daily diuretic use was ordered Ace wraps for his legs, but staff did not consistently apply them and sometimes charted them as applied when they were not. Surveyors observed the resident without the wraps on multiple occasions, and the resident said the wraps rarely happened unless he reminded staff. An LPN acknowledged the inaccurate charting, and an Administrative Nurse stated refusals should be documented instead of recording application when the wraps were not on.
A resident with COPD, pleural effusion, SOB, continuous O2, and daily BiPAP use had her nebulizer mouthpiece left on the bed and her BiPAP tubing disconnected from the O2 concentrator and lying unbagged on the floor during repeated observations. Staff acknowledged the tubing should be stored in the provided bags, and the facility policy required nebulizer masks and tubing to be kept in labeled and dated plastic bags.
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to label one resident’s Humalog FlexPen with an open date and expiration date when first used and failed to discard another resident’s expired Lantus FlexPen. During treatment cart observation, one insulin pen had no date labels and the other had already passed its expiration date, despite the facility policy requiring dates to be recorded and expired meds to be removed.
Staff failed to change gloves or perform hand hygiene during incontinent care for a resident after stool was present on the resident’s backside and wound dressing area; one CNA used the same soiled gloves for front peri-care and brief placement, and both CNAs left without washing hands. Staff also left another resident’s breathing tx mask and tubing uncovered on the floor by a recliner instead of storing the equipment in a bag as expected.
A facility failed to post the most recent survey results in a place readily accessible to residents, family members, and legal representatives. Observation showed there was no sign identifying where the survey binder was located, and an LPN found the survey in a black binder on the front reception desk without any notice directing people to it. The facility policy stated the survey results should be kept in a binder in a common area frequented by residents.
A resident with dementia and poor communication abilities, who was dependent on staff for hygiene, had a long-standing, well-maintained beard that was an important part of his identity. The care plan did not address his grooming or beard preferences, and staff shaved off his beard due to food in it without obtaining input from his representative. Family members later reported they did not recognize him without the beard and felt his dignity and identity were stripped. Staff interviews showed uncertainty about who should obtain and document resident grooming preferences at admission, and social services acknowledged a grievance had been filed about shaving the resident without contacting the representative, while administrative staff confirmed that such preferences should be incorporated into the care plan, particularly for residents with confusion.
A resident with dementia and severe cognitive impairment, known to wander and exhibit physical behavioral symptoms, repeatedly entered other residents’ rooms uninvited, sometimes wearing only a brief and not leaving when asked. Other residents reported having to tell the resident to leave, physically push the resident out in a wheelchair, keep a bed in a high position to prevent the resident from getting in, and waking to the resident touching a foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged the resident’s frequent wandering and described redirecting, offering snacks and fluids, and brief one-on-one engagement, but the resident remained constantly on the go and did not stay at activities. Despite a care plan and a dementia protocol calling for identification of support needs and adjustment of interventions, the facility failed to provide effective supervision and behavioral management to prevent ongoing intrusive wandering into other residents’ rooms.
A resident with MRSA, osteomyelitis, DM, renal failure, CHF, and sepsis-related wound infection was discharged on IV Daptomycin and Piperacillin-Tazobactam with specific dosing frequencies. After an ID clinic visit, new orders increased the frequency and extended the duration of both IV antibiotics, and staff were directed to use the revised regimen. However, the EMAR was never updated, and the resident continued to receive the original, less frequent dosing until hospitalization, with no physician notification of the discrepancy. An ID provider later documented that the corrected frequencies had not been given and also found the PICC dressing unchanged and the clave connector exposed, while facility policy required medications and treatments to follow safe and effective order writing principles.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse: A resident with dementia and severe cognitive impairment repeatedly engaged in physical and sexual abuse toward cognitively impaired female residents, including grabbing, biting, slapping, and inappropriate touching while residents slept. The resident’s prior behavior history was not captured on the baseline care plan, several incidents lacked completed investigations, and an ordered medication for sexual behaviors was not administered as scheduled. Staff interviews showed gaps in awareness of the resident’s history and interventions.
A resident with DM, HTN, MI, atrial fibrillation, and prior stroke-related deficits, who was cognitively intact and used a wheelchair, repeatedly stated he needed to eat before taking his meds because they made him sick. Staff confirmed his preference was known, but his care plan and physician orders lacked direction to give meds after meals, and he refused morning meds on multiple occasions when they were offered before he ate.
Failure to Submit Timely Abuse Investigations: The facility failed to submit completed investigations to the SA within the required timeframe for two resident-to-resident abuse allegations. Staff witnessed two residents slapping each other and one resident grabbing the other's arm, and in a separate incident staff observed a resident touching another resident in the genital area. The facility reported both incidents, but could not provide evidence that the investigations were completed and sent to the SA on time.
Failure to Investigate Allegations of Resident-to-Resident Abuse: The facility failed to thoroughly investigate two allegations involving a resident and two other residents. Staff documented one incident in which two residents were slapping each other and one resident grabbed the other's arm, and another incident in which a resident was observed touching a female resident in the genital area. The facility submitted initial reports to the SA, but could not provide completed investigations for either event, and the ADM stated he was unable to produce them.
A resident with a history of cerebral infarction was injured during transport in a facility van when a CMA failed to use the safety belt, instead using a gait belt to secure the resident's wheelchair. The resident slid forward out of the wheelchair onto the floor of the van after the CMA had to brake suddenly, resulting in multiple injuries. The CMA had been misinformed about the seatbelt's functionality and had not reported the issue to the administration.
The facility failed to protect residents from abuse, particularly resident-to-resident abuse, involving a resident with a history of aggressive behavior. This resident continued to hit others on multiple occasions, and the facility's care plan lacked specific interventions to prevent such altercations. Another resident exhibited aggressive and inappropriate sexual behaviors, which were not adequately addressed or reported. The facility's failure to follow its abuse investigation and reporting policies resulted in a deficiency that placed residents at risk for continued abuse.
The facility failed to report incidents of resident-to-resident abuse to the State Agency or law enforcement. A resident with a history of aggression physically assaulted two other residents, and another resident with a history of sexual behaviors and aggression was involved in two incidents of abuse. Despite staff notifying management, these incidents were not reported as required, placing residents in immediate jeopardy.
The facility failed to investigate and address multiple incidents of resident-to-resident abuse involving residents with aggressive behaviors and cognitive impairments. Despite having care plans, the facility did not implement effective interventions or report incidents as required, leading to continued altercations and placing residents at risk.
The facility failed to maintain safe hot water temperatures, with levels reaching hazardous degrees in resident rooms and a beauty shop, posing burn risks. Additionally, the facility did not adequately document or implement effective fall prevention measures for residents at high risk, leading to repeated falls and major injuries, including hip fractures, for two cognitively impaired residents.
The facility failed to implement necessary interventions to prevent pressure injuries for three residents, leading to the development of preventable, facility-acquired stage 3 pressure injuries. One resident with cognitive impairment and a history of femur fractures did not have appropriate interventions in place, resulting in pressure injuries on the buttocks. Another resident developed a stage 3 pressure ulcer on the heel due to a lack of preventive measures in the care plan. A third resident, admitted with an unstageable pressure ulcer, also developed stage 3 pressure injuries due to inadequate care planning and intervention.
The facility failed to provide a homelike environment due to inadequate room temperature control and compromised privacy. Residents were unable to control their room temperatures, with thermostats shared among multiple rooms. A resident's door was held open with a gait belt, affecting privacy. Maintenance staff confirmed these issues, and the facility lacked a policy for room temperatures.
The facility failed to provide adequate staffing, lacking 8-hour RN coverage for 29 days and 24-hour LN coverage for 127 days in 2023. Residents reported delays in staff response to call lights, with some waiting over 45 minutes for assistance. The survey team observed residents calling out for help and noted constant call light sounds without visual indicators. Direct care staff expressed concerns about low staffing levels. The deficiency resulted in multiple citations, including Immediate Jeopardy (IJ) and substandard quality of care.
The facility failed to maintain the required 8-hour RN coverage daily, as observed during a survey where residents reported staffing issues. The 2023 PBJ data showed multiple dates without RN coverage, especially on weekends, leading to citations for Immediate Jeopardy and substandard care. Observations revealed residents calling for help and staff being difficult to locate, with staff confirming low staffing concerns.
The facility failed to serve food that was palatable and at the appropriate temperature. A resident reported receiving cold meals, and a sample meal tray confirmed that vegetables were served below the required temperature. Both the survey team and Dietary Staff O found the vegetables unpalatable. The facility also lacked a policy for ensuring food palatability.
The facility failed to maintain sanitary conditions in food storage and preparation, risking foodborne illness. Issues included undated and uncovered food items in the main refrigerator and walk-in freezer. Dietary staff confirmed the need for proper labeling and covering of food items, but the facility lacked specific policies on these practices.
The facility failed to ensure the dumpster lid was closed at all times, as observed during a survey. Dietary staff were unaware of their responsibility to keep the lid closed, and the facility lacked a policy to enforce this requirement. Administrative Nurse B acknowledged the expectation for the lid to be closed, but no policy was in place.
The facility failed to effectively manage its resources, resulting in multiple deficiencies affecting resident care and well-being. Issues included inadequate QAPI implementation, improper handling of abuse allegations, failure to maintain a homelike environment, and insufficient care planning. Additionally, the facility did not manage medications properly, maintain sanitary conditions, or report accurate staffing data, compromising resident safety and care quality.
The facility failed to submit accurate RN staffing information to CMS, missing RN coverage documentation for eight hours every 24 hours on 29 dates in 2023. The PBJ report was found inaccurate, and the facility lacked a policy for accurate PBJ completion.
The facility was cited for multiple deficiencies, including five Immediate Jeopardy citations, affecting all residents. Issues included hazardous hot water temperatures, failure to prevent and report abuse, inadequate care planning, and insufficient staffing. The facility also failed to maintain a clean environment, provide necessary treatments, and accurately report staffing information to CMS.
The facility failed to maintain an effective infection control program, as observed in two instances. A laundry aide left a clean linen cart unattended with the cover raised, indicating a lack of adherence to infection control protocols. Additionally, a licensed nurse and two CNAs did not implement enhanced barrier precautions during wound care for a resident with a chronic wound, despite acknowledging the necessity of such precautions. These actions demonstrate a failure to follow the facility's infection prevention policies.
The facility failed to ensure dignity in resident dining by serving meals in Styrofoam containers to seven residents who chose to eat in their rooms due to a lack of sufficient plates, cups, and flatware. The Dietary Manager cited supply chain issues, and the Administrative Nurse was unaware of the regulatory requirement for non-disposable flatware. The facility could not provide a policy on disposable flatware use.
The facility failed to accurately complete the MDS for several residents, leading to uncommunicated care needs. A resident's CAA lacked documentation for hospice services and high-risk medications, while another's did not include insulin use or dialysis care. A third resident's CAA failed to reflect their fall risk, and another's MDS did not capture antidepressant medications. These oversights risked the residents' well-being.
The facility failed to develop comprehensive care plans for residents, including those with diabetes, pressure ulcers, and hospice needs. Care plans lacked critical interventions for insulin use, dialysis, wound care, and end-of-life care, despite existing physician orders and staff awareness. This deficiency could negatively impact residents' well-being.
A resident with severe cognitive impairment and dementia exhibited increased behaviors, including hitting another resident, leading to one-on-one supervision. The facility failed to notify the resident's Durable Power of Attorney (DPOA) about these changes, contrary to its policy requiring prompt notification of the resident's representative.
A facility failed to recognize a significant change in a resident's condition and did not perform a comprehensive MDS assessment within the required 14-day period. The resident, with a history of diabetes, dementia, and fractures, required substantial assistance for all cares. However, the facility did not document the necessary level of assistance in the EHR or progress notes. Administrative staff confirmed the oversight, acknowledging that the assessment should have been a Significant Change comprehensive assessment.
The facility failed to update fall care plans for three residents, leading to repeated falls without appropriate interventions. Despite being identified as high risk for falls, the care plans lacked updates for incidents, placing residents at risk for impaired well-being. The facility's policy required intervention updates, but this was not followed, resulting in a deficiency in care planning.
A resident with cognitive impairment and specific medical conditions was not provided timely assistance with facial hair removal, despite facility policies emphasizing person-centered care. Observations and staff interviews revealed that the resident, who preferred to be clean-shaven, had untrimmed facial hair over several days, indicating a failure in adhering to scheduled care routines.
A facility failed to coordinate care for a resident receiving hospice services, resulting in a lack of guidance in the care plan. Despite the resident's severe cognitive impairment and multiple diagnoses, staff were unclear about hospice roles, and administrative nurses were unaware of the need for care coordination. The facility also lacked a hospice care policy.
A resident requiring hemodialysis three times a week did not have a comprehensive care plan addressing dialysis care and catheter management. The resident experienced unreliable transportation to dialysis, leading to shortened sessions, and staff failed to consistently check the dialysis port or document post-dialysis care. Facility staff acknowledged the care plan's deficiencies, which lacked essential instructions for dialysis and insulin administration.
A resident with PTSD and a history of trauma did not receive adequate behavioral health care in a facility. The resident's care plan lacked necessary interventions, and staff were unaware of the resident's PTSD diagnosis and how to approach them properly. This deficiency in care placed the resident at risk for impaired quality of life.
A facility failed to follow up on pharmacy recommendations for a resident's lorazepam prescription, which lacked a 14-day end date requirement. The resident, with multiple diagnoses including anxiety disorder and major depressive disorder, was prescribed lorazepam for anxiety. Despite the consulting pharmacist's review noting the absence of a 14-day requirement, the facility did not obtain a timely physician response. Observations revealed the resident exhibited behaviors controlled with medication, but the facility lacked a policy for pharmacy reviews.
Failure to Supervise High-Risk Resident During Smoking Break
Penalty
Summary
The facility failed to provide adequate supervision to prevent an elopement for a cognitively impaired resident who was identified as high risk for wandering. The resident had diagnoses including hallucinations, bipolar disorder, schizophrenia, major depressive disorder, and anxiety. His MDS documented a BIMS score of 8, indicating moderate cognitive impairment, and his care plan identified him as an elopement risk/wanderer due to a history of attempts to leave the facility unattended. He also had a WanderGuard applied to his wrist and was known to ambulate without his wheelchair despite staff encouragement to use it. On the day of the incident, the resident was taken to the unsecured smoking area in the facility parking lot with staff and other residents. While CNA M was assisting another resident, the resident walked away from the smoking area, continued through the parking lot, and exited past the front door. Camera review later showed him leaving the unsecured area and heading west toward the church parking lot. Staff did not realize he was missing until dietary staff went to his room to pick up his lunch tray and found that he was not there and had not eaten lunch. After the resident was identified as missing, staff began searching the building and grounds and later located him approximately 0.8 miles from the facility. The resident had to cross multiple busy streets and railroad tracks to reach the area where he was found. He was returned to the facility without injuries. The report also states that the resident was later observed pushing on an exit door leading to the patio/gazebo smoking area and that staff redirected him back inside to wait for a supervised smoke break.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. Review of the Registered Nursing Staffing Schedule for March 2026, April 2026, and May 2026 showed the facility lacked an RN on 03/16/26, 03/21/26, 03/22/26, 04/04/26, 04/18/26, 05/02/26, 05/03/26, 05/16/26, 05/23/26, 05/24/26, and 05/31/26. On 06/03/26 at 09:00 AM, Administrative Nurse D verified that the facility did not have an RN in the building for eight consecutive hours or working as a charge nurse on those dates. The facility's RN policy, dated January 2024, stated the facility would employ an RN for at least eight consecutive hours a day, seven days a week and would designate an RN to serve as the DON on a full-time basis, with the DON serving as charge nurse only when the average daily census was 60 or fewer residents.
Incomplete CNA In-Service Training and Performance-Based Education
Penalty
Summary
The facility failed to provide regular in-service education based on the outcome of performance reviews and failed to ensure that all nurse aides received the required number of in-service training hours per year. Record review showed the facility employed eleven nurse aides for at least one year, and in-service records showed that 5 of the nurse aides reviewed had not completed the required 12 hours of in-service training in the past year. The records identified CNA N, CNA O, CNA P, CNA Q, and CNA X as lacking the required number of in-service hours and the in-services based on performance evaluations. The report also noted that the Social Service Director and CNA X were among those without the required in-service documentation. On interview, Administrative Nurse D stated she had been employed at the facility for approximately six weeks and was unable to find the documentation and failed to provide the hours needed by the nurse aide staff. The facility's In-Service Training Program, Nurse Aide, dated May 2021, stated that nurse aides would participate in regularly scheduled in-service training classes, that performance reviews were completed at least every 12 months, and that in-service training was based on the outcome of annual performance reviews and addressed areas of weakness.
Lack of Certified Dietary Manager
Penalty
Summary
The facility failed to employ a full-time certified dietary manager for the 32 residents who received meals from the facility kitchen. During observation of the noon meal on 06/02/2026, Dietary CC was seen in the kitchen overseeing preparation of pork loin, oven-roasted potatoes, carrots, and a Jello parfait. On 06/01/2026 at 08:00 AM, Dietary CC stated that he was not a Certified Dietary Manager (CDM) and had not been enrolled in any dietary certification classes. On 06/03/2026 at 09:00 AM, Administrative Nurse D verified that he was not certified and planned to enroll him in classes at the end of June. The facility’s Food and Nutrition Services policy dated 10/2021 stated that the Food Services manager would be CDM certified or enrolled in an accredited CDM program and on pace for completion.
Kitchen sanitation and temperature monitoring failures
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards for food service safety. During the initial kitchen tour on 06/01/2026, the stove had dried food and a greasy substance down the side and front, the inside of the oven door had layers of black, stuck-on crusty food substances, the burners had blackened food particles, and the shelf holding pots and pans had dried food particles throughout. The walk-in freezer contained several unbagged tater tot potatoes and other unknown food items on the floor. The microwave in the dining room was dirty inside, with dried orange-colored substance stuck on the top and food particles on the bottom and sides. Under a hand sink and a food preparation sink, containers of dirty water were present from leaking pipes. The facility also failed to consistently document required temperature and sanitation monitoring. Review of the May 2026 logs showed missing documentation for the dining room refrigerator, walk-in refrigerator, and walk-in freezer temperatures on multiple morning and evening checks. Dietary CC was unable to produce the daily meal temperature logs for May 2026 except for five days, and was also unable to provide a recent dish machine PPM sanitizer record log. Dietary DD stated she used precision chlorine test strips daily for sanitizer testing, but the strips observed were expired in 05/2026. The facility policies stated that food temperatures are monitored throughout meals, refrigerators and freezers are checked daily, and monthly tracking sheets are posted to record temperatures.
Inconsistent Access to Evening Snacks
Penalty
Summary
The facility failed to consistently provide a nourishing evening snack to residents, including 11 residents with diabetes mellitus. During the resident council meeting, two residents stated that they did not always have snacks available at night and reported that the snacks previously kept at the nurse’s station were not reliably available because some residents took too many while others did not receive any. They also stated that there were no sandwiches available if they wanted one, only items such as apples, bananas, fig bars, and cheese crackers. Dietary staff and nursing staff confirmed that evening snacks were not consistently available in a way that ensured access for all residents. The Dietary CC stated he was working on a better selection of evening snacks, that the current options included Jell-O, pudding, and Cheetos, and that he had not consistently provided protein snacks for residents with DM. He also stated that residents could request sandwiches only when dietary staff were in the building, and that evening snacks were handed off to staff before dietary staff left. An LN stated the snacks were kept in a container under the nurses’ station and given to residents if they asked. An Administrative Nurse stated some residents took multiple snacks, leaving too few for others, and that some residents had requested grilled cheese sandwiches late at night after dietary staff had already left. The facility’s Food and Nutrition Services policy stated nourishing snacks were available 24 hours a day and could be requested as desired or scheduled between meals.
QAA Committee Failed to Address Multiple Deficient Practices
Penalty
Summary
The facility failed to ensure its QAA Committee adequately identified deficient areas of practice and developed and implemented appropriate plans of action to correct deficient practices for the 68 residents residing in the facility. The report states that the facility's QAPI plan was intended to use data collection tools and monitoring systems for proactive analysis, system failure analysis, and corrective action, and that at least annually or as needed a QAPI self-assessment would be completed with input from the QAPI team and organizational leadership to identify gaps in care and service delivery. Survey findings identified multiple deficient practices that were not adequately addressed through the facility's QAA/QAPI process. These included failure to post the most recent survey results in a readily accessible location, failure to provide written bed hold policy information when a resident was transferred to the hospital, failure to develop a comprehensive care plan for surgical wound care, staff documenting treatments as provided when they had not been performed, failure to wrap a resident's legs for dependent edema as ordered, failure to provide adequate supervision for elopement, failure to follow infection control practices with nebulizer and oxygen tubing, failure to ensure staff competency for insulin administration, failure to use an RN for at least eight consecutive hours a day seven days a week, failure to provide regular in-service education and required nurse aide training hours, failure to label and discard insulin properly, failure to employ a certified Dietary Manager, failure to consistently provide a nourishing evening snack, failure to store, prepare, and serve food properly in the kitchen, and failure to follow infection control practices including PPE use and cleaning in an isolation room.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide Resident 22 with written information regarding the bed hold policy when she was transferred to the hospital. Resident 22 had diagnoses including DM, cerebral infarction, chronic respiratory failure, hypoxemia, and syncope. Her Quarterly MDS documented a BIMS score of 14, indicating intact cognition, and she required staff assistance for toileting hygiene, personal hygiene, and bathing. Her care plan directed staff to monitor and report signs and symptoms of coronary artery disease, including chest pain, shortness of breath, nausea, vomiting, and excessive sweating. On 02/07/26, Resident 22 complained of chest pain and shortness of air, was alert and oriented, and had vital signs taken showing a blood pressure of 147/98 mm Hg and pulse of 111 beats per minute. EMS transported her to the hospital for further evaluation and treatment, and progress notes later documented that she was admitted for observation. Her clinical record lacked evidence that a copy of the bed hold policy was provided to the resident or her representative at the time of transfer. Administrative Nurse D later verified that Resident 22 did not have a bed hold in her records and stated that a bed hold notice should have been provided to the resident and her responsible party.
Care Plan Lacked Instructions for Surgical Wound Care
Penalty
Summary
The facility failed to develop a comprehensive care plan with instructions to staff for surgical wound care for R34. R34’s EMR documented diagnoses of mastoiditis and osteomyelitis, and his admission MDS documented a BIMS score of 15, indicating intact cognition, along with a need for supervision with most ADLs. The MDS also documented that he had surgical wounds and received surgical wound care. The CAA dated 05/04/26 documented that the resident triggered for potential skin breakdown due to supervision needed to maintain ADL function and surgical wound care. R34’s care plan, revised 05/20/26, acknowledged that he had surgical wounds, but it lacked instructions to staff on how to care for them. On 06/03/26 at 02:00 PM, observation showed R34 sitting in a wheelchair in the therapy room with a dressing on the top of his head and behind his left ear. On 06/02/26 at 09:25 AM, LN G verified that the skin integrity section of the care plan lacked interventions or instructions for staff on wound care and stated she relied on the TAR for wound care instructions. She also stated that an agency nurse could not know how to care for R34’s wounds by looking at the care plan. On 06/02/26 at 01:00 PM, Administrative Nurse E verified that the skin integrity section of the care plan lacked instructions for staff on how to care for the resident’s surgical wounds and stated they should be included.
False documentation of ordered Ace wrap treatments
Penalty
Summary
The facility failed to follow standards of practice when staff documented that they had applied ordered Ace wraps to a resident even though the wraps had not actually been provided. The resident had documented diagnoses of edema, heart failure, and urinary retention, and the quarterly MDS noted intact cognition, independence in toileting, personal hygiene, and mobility, supervision with transfers, lower functional impairment on both sides, and daily diuretic use. The care plan directed staff to inspect the resident’s skin daily, administer medications as ordered, monitor vital signs and laboratory results, and monitor and report dependent edema, but it did not include direction about wrapping the resident’s legs with Ace wraps or that he refused them. The physician order required Ace wraps to be applied up to mid-thigh in the morning and removed at bedtime, and the June 2026 TAR documented that staff applied the wraps on two days. However, on multiple observations the resident was wearing gripper socks and did not have the Ace wraps on as ordered. The resident stated that his legs were supposed to be wrapped every day but that it rarely happened unless he reminded staff. An LN stated that staff tried to get him to wear the wraps every day but he would refuse, and that she had charted the wraps as applied even though they had not been on the resident. The LN then questioned whether she should change the charting, and an Administrative Nurse stated that if the resident did not want the wraps, staff should document refusal and not chart that they were applied when they were not.
Failure to Apply Ordered Ace Wraps for Dependent Edema
Penalty
Summary
The facility failed to provide treatment and care according to orders, resident preferences, and goals when staff did not consistently apply ordered Ace wraps to R39's legs for dependent edema. R39 had diagnoses of edema, heart failure, and urinary retention, and his MDS documented intact cognition, independence with toileting hygiene, personal hygiene, and mobility, lower functional impairment on both sides, and daily diuretic use. His care plan addressed monitoring for dependent edema and related care, but it did not include direction for staff to wrap his legs with Ace wraps or note that he refused them. A physician order dated 12/08/2025 directed staff to apply Ace wraps up to mid-thigh in the morning and remove them at bedtime, yet the TAR documented application only on selected days in May and June 2026. Nurse notes for the May dates documented that R39 did not have the wraps when staff went to remove them or that he had refused them. On 06/01/2026 and 06/02/2026, surveyors observed R39 wearing gripper socks and not wearing the Ace wraps as ordered, and R39 stated that his legs were supposed to be wrapped every day but that it rarely happened unless he reminded staff. An LN stated staff tried to get him to wear the wraps every day but he would refuse, and also acknowledged charting that the wraps had been applied when they had not been. An Administrative Nurse stated that if R39 did not want the Ace wraps, staff should document refusal and should not document that they were applied when they were not.
Respiratory Equipment Left Unstored and Unprotected
Penalty
Summary
The facility failed to provide infection control practices for R16 when staff left her nebulizer mouthpiece lying on the bed next to her and left her BiPAP tubing disconnected from the oxygen concentrator and lying unbagged on the floor. R16’s EMR documented diagnoses of COPD and pleural effusion, and the quarterly MDS documented intact cognition, dependence on staff for all ADLs, shortness of breath with exertion, at rest, and when lying flat, and daily use of oxygen therapy and a non-invasive mechanical ventilator. R16’s care plan directed staff to assist with respiratory compromise, monitor breathing patterns, position her for optimal breathing, administer medications as ordered, ensure BiPAP settings were as ordered, and provide continuous oxygen at 3 liters via nasal cannula. A physician’s order directed nebulizer treatments every four hours for shortness of breath. During multiple observations, the nebulizer mouthpiece remained on the bed and the BiPAP tubing remained disconnected from the oxygen concentrator and on the floor. A CMA stated the tubing should be in the bags provided, and an Administrative Nurse stated the BiPAP tubing should be placed in the bag on the oxygen concentrator; she also stated R16 liked to have the nebulizer mouthpiece lying next to her on the bed and said she would make sure that preference was on the care plan. The facility’s oxygen administration policy stated staff are to store all nebulizer masks and tubing in labeled and dated plastic bags.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Insulin Pens Not Properly Labeled or Discarded
Penalty
Summary
The facility failed to label Resident 6’s Humalog FlexPen with an open date and an expiration date when it was initially opened for use. During observation of the treatment cart, the insulin pen was found without either date recorded. The facility also failed to discard Resident 43’s Lantus FlexPen after it had expired; the pen was observed with an opened date and an expired date already documented on the label. Administrative Nurse D verified that nurses should label insulin FlexPens with the date opened and discard expired insulin FlexPens. The facility’s Administering Medications policy states that the expiration or beyond-use date is checked before administration, that the date is recorded when opening a multi-dose container, and that insulin pens are for single-resident use only and must be clearly labeled with the resident’s name or other identifying information.
Failure to Maintain Hand Hygiene and Sanitary Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment when staff did not change gloves or perform hand hygiene during incontinent care for a resident who was in bed and reported needing care after having a bowel movement. Two CNAs entered the room, donned gowns and gloves, and provided peri-care after stool was observed covering the resident’s backside and wound dressing area. One CNA removed the brief and dressing and cleaned the buttock area, then the other CNA used the same soiled gloves to provide peri-care to the resident’s front peri area and place a new incontinent brief underneath the resident and fasten it. Both CNAs then removed their gloves, put on new gloves to assist the resident with his pants, doffed their gowns with gloves, bagged the gowns, and left the room without washing their hands or using hand sanitizer. One CNA later confirmed she had not changed gloves or washed her hands after the incontinent care. The facility also failed to store a resident’s breathing treatment mask and tubing in a sanitary manner. During observation, the mask and tubing were found lying uncovered on the floor by a recliner, on top of a blue cloth bag. A nurse verified the finding and asked the resident where the plastic bag was for the mask and tubing, but the resident did not answer. The nurse then placed the uncovered mask on an end table and stated she would get a bag and take care of the mask and tubing. Administrative staff stated they expected the breathing treatment mask and tubing to be stored in a bag, and the facility’s policy instructed staff to store equipment in a dated plastic bag and leave it at the bedside.
Survey Results Not Readily Posted
Penalty
Summary
The facility failed to post the results of the most recent surveys in a place readily accessible to residents, family members, and legal representatives of residents. On 06/01/26 and 06/02/26, observation showed there was no readily accessible posting identifying where the most recent survey results could be found. On 06/02/26 at 12:20 PM, when asked where the most recent survey was located, Nurse Consultant CC found it in a black binder on the front reception desk, but there was no sign notifying residents, family members, or representatives where the results were located. Nurse Consultant CC stated the facility should have a sign indicating where the survey results were located so residents, family members, or residents' representatives could view them. The facility policy stated that copies of the most recent survey and related reports would be maintained in a three-ring binder in an area frequented by most residents, such as the main lobby or resident activity room.
Failure to Honor Grooming Preferences and Dignity for Cognitively Impaired Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care in a respectful and dignified manner to a dependent, cognitively impaired resident when staff shaved off his beard without consideration of his preferences or those of his representative. The resident had diagnoses including dementia with psychotic disturbances and failure to thrive, and his Baseline Care Plan documented poor communication and comprehension but did not address his grooming or beard-maintenance preferences. Upon admission, he required total assistance with hygiene after a bowel movement, indicating dependence on staff for personal care decisions. Progress notes show that the resident’s family later contacted the facility to express that they were upset because staff had shaved off his beard. The family reported that his beard was part of his identity, was well cared for, and that they and his grandchildren did not initially recognize him without it. They stated that the resident, due to dementia, would not recognize himself in the mirror and that they felt he had been stripped of his dignity and identity. The family reported being told by staff that the beard was shaved because there was food in it and that staff claimed they had tried to call but had the wrong number. Interviews with staff revealed uncertainty and gaps in practice regarding obtaining and documenting resident preferences, particularly for residents with dementia. A CNA and a licensed nurse both stated they did not recall the resident and were unclear about who was responsible for obtaining preference information at admission, though they acknowledged that such information should be collected from residents or representatives. The social services staff member stated she did not ask about shaving preferences and did not know if consent was required to shave a resident with a full beard, but acknowledged that preference information for ADLs should be obtained and that a grievance had been filed about shaving the resident without contacting the representative. Administrative staff confirmed that residents’ and representatives’ histories and preferences should be incorporated into the care plan, especially for confused residents, and acknowledged awareness of the grievance about the beard being shaved without having responded to the reporter as of the survey date.
Failure to Adequately Supervise and Manage Intrusive Wandering in a Dementia Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision, treatment, and services for a resident with dementia who exhibited intrusive wandering behaviors into other residents’ rooms. The resident had diagnoses of dementia, Alzheimer’s disease, hypertension, and unspecified protein-calorie malnutrition, with a Quarterly MDS documenting severe cognitive impairment, physical behavioral symptoms toward others, and frequent wandering. The resident’s care plan identified a potential for physical aggression related to dementia, triggers such as abrupt approaches, and interventions including redirection, distraction, offering snacks, and documenting behaviors and interventions. Despite this, the resident’s behavior log and care planning adjustments in response to ongoing intrusive wandering and room entries were not described, and the resident continued to enter other residents’ rooms uninvited and sometimes partially clothed. Multiple residents reported specific incidents of this resident entering their rooms and not leaving when asked. One resident reported that the wandering resident entered her room wearing only a diaper and had to be told to leave. Another resident stated that the wandering resident came into her room in a wheelchair, requiring her to get out of bed and physically push the resident out. A further resident reported keeping her bed in a high position so the wandering resident could not get into it, and another incident where she awoke to the resident touching her foot. Staff, including CNAs, LNs, a CMA, and Social Services, acknowledged that the resident wandered into other rooms and described efforts to redirect, offer snacks and fluids, and engage the resident in activities, but the resident did not consistently stay at activities and remained “on the go.” The facility’s dementia clinical protocol required the IDT to identify the resident’s level of support, review changing needs, and adjust interventions as needed, but the ongoing intrusive wandering and repeated room entries showed that the resident’s behaviors continued despite these general redirection efforts, leading to the cited deficiency in supervision and behavioral management.
Failure to Implement Revised IV Antibiotic Orders and Notify Physician of Medication Errors
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received IV antibiotics as ordered and to notify the physician of the resulting medication errors. The resident had multiple serious diagnoses, including wound infection, osteomyelitis, DM, renal failure, CHF, MRSA in a right heel wound, and sepsis likely due to a necrotic right heel wound with palpable bone and cellulitis. Hospital discharge instructions and an Infectious Disease (ID) Outpatient Antibiotic Order dated 02/17/26 initially directed Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily until 03/14/26, with further antibiotic orders to come from the ID clinic after the first appointment. At an ID clinic visit on 02/28/26, the provider issued a Final Report ID Outpatient Antibiotic Order, which changed the frequency and duration of both antibiotics: Daptomycin 750 mg IV every 24 hours until 03/17/26 and Piperacillin-Tazobactam 4.5 g IV every eight hours until 03/17/26. The facility was directed to use this new order. However, the resident’s EMAR for February and March 2026 continued to show the original orders—Daptomycin 750 mg IV every 48 hours and Piperacillin-Tazobactam 4.5 g IV twice daily—starting 02/18/26, and these orders were not discontinued until 03/05/26 after the resident went to the hospital. The orders were not updated to reflect the increased frequency specified by the ID provider. On 03/05/26, during a follow-up ID office visit, the provider documented that the resident had not received the corrected medication frequency for either antibiotic. The provider also noted that the PICC line dressing, which was to be changed weekly and as needed, was loose and had not been changed since 02/17/26, and that the PICC line clave connector had been exposed for an unknown amount of time. The physician was notified, the PICC line was removed, and the resident was sent to the hospital for worsening wounds and concern for blood infection. Subsequent observation on 03/23/26 showed a nurse administering IV medication via the PICC lumen, but the underlying deficiency centered on the facility’s failure to update and implement the revised ID antibiotic orders and to notify the physician of the medication errors.
Failure to Prevent Resident-to-Resident Physical and Sexual Abuse
Penalty
Summary
The facility failed to ensure residents remained free from physical and sexual abuse. A resident with diagnoses of dementia and depression, and a BIMS score of 7 indicating severely impaired cognition, had a documented history of inappropriate behaviors before and after admission. The resident’s prior facility record noted repeated attempts to grab female staff during care and the need for constant supervision when out of bed and 15-minute checks while in bed. On admission, the baseline care plan did not include the resident’s behavior history or interventions related to those behaviors, and the resident’s MDS did not capture the behaviors that were later documented in the chart. After admission, the resident was involved in multiple incidents with cognitively impaired female residents. Staff documented that the resident grabbed and hit one resident, bit another resident’s finger causing bleeding, slapped and grabbed a resident during an altercation, placed a hand on another resident’s clothed genital area, grabbed a resident’s breast while she slept, and later placed a hand inside another resident’s brief while she slept. The facility’s records showed some incidents were documented in progress notes and incident reports, but the report states the facility could not provide investigations for several of the events, including the incidents on 06/21/25 and 06/28/25. The resident was also documented attempting to grab a staff member’s private area and engaging in sexually inappropriate behaviors toward staff. The resident’s chart showed behavior monitoring orders and psychotropic medications, including Depo-Provera ordered for behaviors, Paxil, and Seroquel. Although the resident had repeated sexual and physical behaviors, the record showed the ordered Depo-Provera dose on 08/07/25 was not administered because the medication was not in stock, and the chart lacked evidence that the physician was notified. Staff also discontinued one-to-one supervision after a period of monitoring. Interviews with staff showed some were unaware of the resident’s prior abuse history and did not know where to find the resident’s interventions for recurring behaviors. The facility’s failure to implement effective interventions and to complete investigations into the resident-to-resident abuse events was cited as placing the cognitively impaired residents involved in immediate jeopardy.
Failure to Honor Resident Preference for Medication Timing
Penalty
Summary
The facility failed to ensure staff acknowledged and implemented a resident’s preference to receive medications after meals. The resident had diagnoses including DM with hyperglycemia, long-term insulin use, cerebral infarction, chest pain, HTN, MI, atrial fibrillation, hemiplegia, and hemiparesis following non-traumatic intracerebral hemorrhage. His MDS documented a BIMS score of 13, indicating he was cognitively intact, and he used a wheelchair with functional limitations in both lower extremities. He received high-risk medications, including insulin injections and anticoagulants. The resident’s care plan addressed aggression, poor impulse control, and medication side effects, but it did not include direction for staff to give medications 30 minutes to an hour after meals to prevent nausea, which was the resident’s stated preference. His physician orders for seven medications, including an antibiotic, cardiac medications, an anticonvulsant, an anticoagulant, insulin, and indigestion medication, also lacked instructions to administer medications with food or after food. The MAR showed he refused morning medications on multiple occasions during the review period. During interviews and observations, the resident stated he became angry when meals were not provided on time and that he could not take medications on an empty stomach because they made him sick. He said staff did not listen to his repeated requests and that he would refuse medications rather than take them before eating. Staff members confirmed he had voiced this preference, that the EHR lacked guidance to give medications with food, and that his care plan had not been updated to reflect his mealtime and medication preference. Administrative staff also confirmed the resident’s request had not been communicated as expected and had not been followed up.
Failure to Submit Timely Abuse Investigations
Penalty
Summary
The facility failed to submit completed investigations for allegations of resident-to-resident abuse to the State Agency within five working days for two separate incidents involving three residents. One incident occurred when staff witnessed two residents slapping each other on the arms in the dining room, and one resident grabbed the other resident's arm before staff intervened and separated them. A second incident occurred when staff observed one resident touching a female resident in the genital area, and the resident was placed on one-to-one monitoring. The facility reported both incidents to the State Agency, but it could not provide the completed investigations for either event. The facility was unable to provide evidence that the investigations for the two incidents were completed and submitted to the State Agency within the required time frame. During interview, Administrative Staff A stated that reportable incidents were expected to be thoroughly investigated and the completed investigation submitted within the allowable time frame, but he could not provide the investigations and was not sure whether they had been submitted. The facility policy stated that the Administrator or designee would provide the appropriate agencies or individuals with a written report of the findings of the investigation within five working days of the occurrence of the incident.
Failure to Investigate Allegations of Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident abuse involving Resident 1 and Resident 2 on 06/21/25 and Resident 1 and Resident 3 on 06/28/25. The facility submitted initial reports to the State Agency for both incidents, but it could not provide any investigation related to either event. For the 06/21/25 incident, a progress note documented staff witnessed Resident 1 and a female resident in the dining room slapping each other on the arms, with Resident 1 grabbing the female resident's arm before staff intervened and separated them. For the 06/28/25 incident, a progress note documented staff notified Resident 1's representative that staff observed Resident 1 touching a female resident in the genital area and that Resident 1 would be monitored on a one-to-one basis. The note also recorded the representative's statement that they did not know how staff would stop Resident 1 from doing that. During interview, Administrative Staff A stated he expected all reportable incidents to be thoroughly investigated and submitted within the allowable time frame, but he was unable to provide completed investigations and said he was not working at the facility at the time of the events. The facility's Abuse Prevention Program policy stated the Administrator would assign the investigation, keep the resident and representative informed, and ensure further potential abuse, neglect, exploitation, or mistreatment was prevented.
Resident Injured Due to Improper Securing in Facility Van
Penalty
Summary
The facility failed to ensure a resident remained free from accidents during transportation in the facility van. A Certified Medication Aide (CMA) did not utilize the safety belt for the resident before transporting her in the van. The resident, who had a history of cerebral infarction and required assistance with mobility, was not secured properly in her wheelchair with the van's safety belt. Instead, the CMA used a gait belt to loop around the armrests of the wheelchair. During the transport, the CMA had to slam on the brakes to avoid an accident, causing the resident to slide forward out of her wheelchair onto the floor of the van, resulting in multiple injuries including skin tears and a laceration. The resident involved had been admitted to the facility with diagnoses including cerebral infarction, abnormality of gait and balance, lack of coordination, weakness, and unsteadiness of feet. She required partial to moderate assistance with transfers and ambulated independently with a cane and self-propelled with a walker. At the time of the incident, the resident was alert and oriented, but presented with left-sided weakness to her upper and lower extremities. The failure to secure the resident properly in the van led to her sustaining injuries during the transport. The CMA reported that she had been informed by another staff member that the seatbelt in the facility van was not functioning properly, and she had not been trained on its use. However, an inspection of the van revealed that the seatbelt was working as intended. The CMA did not report the alleged malfunction of the seatbelt to the administration, and the incident occurred when she entered a busy highway and had to brake suddenly. The lack of proper safety measures during the transport directly contributed to the resident's injuries.
Removal Plan
- The facility suspended CMA R. She was terminated.
- The facility suspended CNA M. She self-terminated.
- The facility van was immediately taken out of service until the van could be inspected.
- The facility van was inspected, and it was discovered that the passenger safety belt was not in despair but rather working as was intended.
- All staff members were trained in lock out/tag out for equipment that was out of order.
- All staff members were trained on when to report equipment that was not functional and how to use the work order system to alert the administration.
- Staff members who transported residents for passenger pick up were educated on van safety and asked to demonstrate how to use the safety equipment in the van.
- All staff were educated that passenger safety was the responsibility of both the driver and transportation companion.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving a resident with a history of aggressive behavior. This resident, identified as R22, had a history of hitting other residents and continued to do so on multiple occasions. Despite having severely impaired cognition and requiring assistance with daily activities, R22 was independent with ambulation and exhibited physical behavioral symptoms directed toward others. The facility's care plan for R22 lacked specific interventions to prevent resident-to-resident altercations, and staff failed to appropriately identify and respond to these incidents, placing residents in immediate jeopardy for continued abuse. Another resident, R16, also exhibited problematic behaviors, including physical aggression and inappropriate sexual conduct. R16 had a history of intermittent explosive disorder, bipolar disorder, and dementia, which contributed to his aggressive and inappropriate behaviors. Despite these known issues, the facility did not adequately address or report incidents involving R16, such as when he hit another resident or engaged in inappropriate sexual behavior in public areas. The facility's failure to report these incidents to the appropriate authorities and to implement effective interventions further contributed to the deficiency. The facility's policies for abuse investigation and reporting were not followed, as evidenced by the lack of documentation and reporting of incidents involving both R22 and R16. Staff interviews revealed a lack of awareness and appropriate response to the incidents, and the facility's internal investigations were insufficient. The facility's failure to ensure staff identified and responded appropriately to all allegations of abuse, including resident-to-resident abuse, resulted in a deficiency that placed residents at risk for continued abuse.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure and would be completed. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one on one and would remain a one on one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement meeting.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure the timely reporting of alleged abuse to the State Agency or local law enforcement, as required. This deficiency was identified through observations, interviews, and record reviews, revealing that the facility did not report two incidents of resident-to-resident abuse involving a resident with a history of hitting others. On two separate occasions, this resident physically assaulted other residents, yet these incidents were not reported to the appropriate authorities, placing residents in immediate jeopardy for continued abuse. The first incident involved a resident with severely impaired cognition and a history of physical behavioral symptoms. This resident punched another resident in the jaw and later raised a fist to another resident, making contact with their face. Despite staff notifying management of these incidents, they were not reported to the state agency or law enforcement. The facility's policy required all allegations of abuse to be promptly reported and thoroughly investigated, but this was not adhered to in these cases. Another resident with a history of sexual behaviors and physical aggression was involved in two incidents of abuse. This resident hit an unknown resident after a minor altercation and later grabbed the breast of another resident. Again, these incidents were not reported to the state agency, as required by the facility's policy. The failure to report these incidents highlights a significant deficiency in the facility's handling of abuse allegations, leaving residents vulnerable to further harm.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one-on-one and would remain a one-on-one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement (QAPI) meeting.
Failure to Investigate and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate and address multiple incidents of resident-to-resident abuse, particularly involving a resident with a history of aggressive behavior. This resident, diagnosed with vascular dementia and major depressive disorder, exhibited severely impaired cognition and required significant assistance with daily activities. Despite these needs, the resident was involved in several altercations, including hitting other residents and causing physical harm. The facility's care plan for this resident lacked specific interventions to prevent such altercations, and there was insufficient documentation and investigation into these incidents. Another resident with a history of sexual behaviors and physical aggression also engaged in inappropriate conduct, including hitting another resident and making unwanted physical contact. The facility did not thoroughly investigate these incidents, allowing the behavior to continue. The care plan for this resident also lacked interventions to manage these behaviors effectively, and there was a failure to report these incidents to the appropriate authorities as required by the facility's policy. Interviews with staff revealed a lack of awareness and reporting of these incidents, indicating a breakdown in communication and adherence to the facility's abuse investigation and reporting policies. The facility's policy required all allegations of abuse to be promptly reported and thoroughly investigated, but this was not consistently followed, placing residents at risk of further harm.
Removal Plan
- Staff in-serviced on the facility's Abuse Neglect and Exploitation policy and procedure. Staff will not be allowed to work until signatures received.
- Inter-Disciplinary Team was in-serviced for ANE reporting.
- Staff placed R22 on a one on one and would remain a one on one until deemed no longer a threat or discharged from the facility.
- Referrals would be sent to Behavior Units for temporary placement.
- Hospice and Medical Director to complete a medication review.
- Quality Assurance Performance Improvement (QAPI) meeting.
Deficiencies in Hot Water Safety and Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards, specifically regarding hot water temperatures in resident rooms and a beauty shop. During an annual survey, it was observed that the hot water in four resident rooms and a beauty shop measured at hazardous levels ranging from 138 to 157 degrees Fahrenheit. This posed a significant risk of burns and injury to residents, particularly affecting six residents, two of whom were cognitively impaired and independently mobile. The facility's maintenance staff was unaware of the elevated temperatures, and it was discovered that a small hot water tank had been inadvertently adjusted to a higher setting, which had not been monitored for at least three months. Additionally, the facility failed to adequately document and implement effective interventions for fall prevention for residents at high risk of falls. One resident, identified as having severe cognitive impairment and a history of falls, experienced multiple falls resulting in major injuries, including fractures of both hips. The facility's fall reports lacked thorough investigations, identification of causal factors, and immediate or permanent interventions to prevent future falls. Despite being identified as high risk for falls, the resident continued to fall repeatedly without appropriate measures being taken to mitigate the risk. Another resident, also identified as having severe cognitive impairment and a high risk for falls, experienced multiple falls over a two-month period. The facility's care plan for this resident lacked corresponding interventions for each fall, and the fall assessments were incomplete or lacked necessary details. The facility's failure to provide necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being for these residents resulted in a deficient practice for quality of life and placed the residents at risk for further injury and delayed healing.
Removal Plan
- Staff in-serviced on facility Physical Environment - Water Temps Policy and Procedure. Staff would not be allowed to work until signatures were received.
- The facility drained the hot water tank at the end of the 200 hall.
- The facility checked the temperature of all rooms after the tank was drained and all were below 120 degrees.
- The facility ordered a new temperature gauge for the hot water tank.
- The facility will check the water temperatures daily for rooms 209, 210, 211, 212, and then resume weekly temperature checks per policy.
- We will have a QAPI meeting to review.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to implement necessary interventions to prevent pressure injuries for three residents, leading to the development of preventable, facility-acquired stage 3 pressure injuries. Resident 30, who had a history of femur fractures, diabetes, and cognitive impairment, was identified as at risk for pressure injuries but did not have appropriate interventions such as pressure-reducing devices or a turning/repositioning program in place. Despite being identified at risk, the resident's care plan lacked updates and interventions to prevent pressure injuries, resulting in the development of stage 3 pressure injuries on the buttocks. Resident 3, who had intact cognition but required maximal assistance with activities of daily living, developed a stage 3 pressure ulcer on the right heel after admission to the facility. The care plan for this resident did not include documentation or interventions related to pressure ulcer prevention, despite the resident's risk factors such as incontinence and dependence on staff for transfers. The facility's failure to update the care plan and implement preventive measures contributed to the development of the pressure ulcer. Resident 26, who had intact cognition and was admitted with an unstageable pressure ulcer, was also at risk for pressure injuries. However, the care plan lacked documentation related to pressure ulcer prevention or interventions for wound healing. Despite being identified at risk, the resident's care plan was not updated to include necessary interventions, leading to the development of stage 3 pressure injuries on the buttocks. The facility's policy on pressure injuries lacked guidance on actual care, contributing to the deficiencies in care planning and intervention implementation.
Deficiency in Room Temperature Control and Privacy
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, specifically regarding room temperature control and privacy. During an environmental tour, it was observed that four residents had blankets over their vents, indicating an inability to control the temperature in their rooms. One resident reported that the thermostat controlling his room's temperature was located in a neighboring room, making it too warm for him. Additionally, a resident's room door was held open with a gait belt tied to the doorknob and a dresser drawer handle, compromising privacy. Maintenance staff confirmed that thermostats were shared among every third resident room, affecting multiple residents' ability to control their room temperatures. They acknowledged that this setup was not conducive to a homelike environment and confirmed the issue with the blocked door, which could prevent privacy. The facility lacked a policy for resident room temperatures, contributing to the deficiency in maintaining a comfortable and homelike environment for all residents.
Inadequate Staffing Leads to Deficiencies in Resident Care
Penalty
Summary
The facility failed to ensure adequate staffing to meet the needs of its residents, as evidenced by the lack of 8-hour Registered Nurse (RN) coverage for 29 days and 24-hour Licensed Nurse (LN) coverage for 127 days in 2023. This deficiency affected all residents, as reported during the annual survey that began on May 28, 2024. Residents reported significant delays in staff response to call lights, with some waiting over 45 minutes for assistance. The survey team observed numerous instances of residents calling out for help and noted the constant sound of call lights in the hallways without visual indicators of which rooms were activated. Direct care staff also reported concerns about low staffing levels. The facility's reported PBJ data highlighted specific infraction dates for both RN and LN coverage, with a notable number of infractions occurring on weekends. The lack of staffing was directly linked to the number of citations found on the current recertification survey, including four Immediate Jeopardy (IJ) citations, harm, and substandard quality of care. During the survey, Administrative Nurse B acknowledged the staffing issues and reported that the working schedules were updated and reported to the state, although the surveyor did not have access to the current quarter's report at that time. The deficiency in staffing had the potential to negatively affect all residents, placing them at risk for decreased quality of life, treatment, and care.
Failure to Ensure 8-Hour RN Coverage
Penalty
Summary
The facility failed to ensure the required 8-hour Registered Nurse (RN) coverage each day, which is necessary to meet the needs of the residents. This deficiency was identified during an annual survey that began on May 28, 2024, where several residents reported issues related to a lack of staff. The facility's 2023 Payroll-Based Journal (PBJ) data revealed multiple dates across several months where the required RN coverage was not met, particularly on weekends. This lack of staffing was directly linked to the number of citations found during the current recertification survey, including five Immediate Jeopardy (IJ) citations, harm, and substandard quality of care. Observations during the recertification survey from May 28 to June 3, 2024, revealed numerous instances of residents calling out for assistance and the constant sound of call lights in the hallways, with no visual indication of which room was activated. Surveyors observed residents asking for help and waiting for staff assistance, with staff being difficult to locate as they were busy between rooms. Interviews with direct care staff confirmed concerns about low staffing levels. Administrative Nurse B reported that the working schedules were updated and reported to the state, but acknowledged that there was one day in May 2024 without the required 8-hour RN coverage.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and served at the appropriate temperature to its residents. During an interview, a resident reported that meals delivered to his room were consistently cold. A sample meal tray was requested by the survey team, and upon delivery, the vegetables on the tray were found to be at 122 degrees Fahrenheit, below the required serving temperature of 135 degrees Fahrenheit. The survey team and Dietary Staff O both tasted the vegetables and confirmed they were not palatable due to the inadequate temperature. Additionally, the facility lacked a policy for ensuring food palatability.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food preparation and storage, which could potentially lead to foodborne illness among residents. During an inspection of the kitchen, several issues were identified, including multiple opened containers of sour cream, salad dressings, and cheese-pimento salad in the main refrigerator that lacked open dates. Additionally, spoiled lettuce and a half-spoiled onion were found, both undated, along with an unidentified meat product without a label or date. Uncovered blocks of butter and cheese slices were also noted, as well as an uncovered box of uncooked cookies in the walk-in freezer, all lacking open dates. Dietary Staff O confirmed that opened items should be labeled with an open date and a use/discard by date, typically seven days for most foods and 30 days for salad dressings and other multi-use packages. It was also noted that items in the refrigerator and freezer should be covered to prevent spoilage. The facility did not provide a policy regarding the dating of foods or the storage of staff items in resident refrigerators. The only documentation provided was a Refrigerator & Freezer Storage Chart from the US FDA, which did not address the specific storage issues observed.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to properly dispose of garbage and refuse by not ensuring the dumpster lid was always closed. During an observation on 05/28/24 at 08:20 AM, it was noted that the lid of the dumpster used for garbage and refuse was open. Dietary staff O was unaware that maintaining the dumpster lid in a closed position was part of the kitchen staff's responsibilities. On 06/06/24 at 01:50 PM, Administrative Nurse B acknowledged the expectation for the dumpster lid to be closed at all times and was aware of the regulatory requirement. However, the facility lacked a policy to ensure the dumpster lid remained closed.
Facility Administration and Resource Management Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to multiple deficiencies that compromised the quality of care and well-being of its residents. The administration did not implement an effective Quality Assessment and Performance Improvement (QAPI) program, as evidenced by numerous deficient practices and substandard quality of care. Specific issues included the use of Styrofoam containers for meal trays, failure to inform a resident's representative about behavioral changes, and inability to maintain a clean, comfortable, and homelike environment due to lack of temperature control in residents' rooms. The facility also failed to address allegations of abuse appropriately, including resident-to-resident abuse, and did not report these incidents to the State Agency or local law enforcement as required. Investigations into these allegations were inadequate, and the facility did not provide sufficient supervision or care-planned interventions to prevent further incidents. Additionally, the facility did not recognize significant changes in residents' physical conditions, failing to perform timely Comprehensive Minimum Data Set (MDS) assessments, and did not develop comprehensive person-centered care plans for several residents. Further deficiencies included the failure to provide necessary care and services to prevent falls and pressure ulcers, inadequate coordination with hospice services, and improper medication management. The facility also did not maintain sanitary conditions in food preparation and disposal, failed to report accurate staffing information to CMS, and did not uphold effective infection control practices. These failures collectively placed residents at risk for decreased quality of care, treatment, and overall well-being.
Inaccurate RN Staffing Reporting to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) as required. Specifically, the facility did not accurately report Registered Nurse (RN) coverage for eight hours every 24 hours on 29 different dates between January 1, 2023, and September 30, 2023. This deficiency was identified through a review of the Payroll Base Journal (PBJ) Staffing Data Report for fiscal year quarters 2, 3, and 4 of 2023. The report revealed multiple instances where RN coverage was not documented as required, indicating a failure to meet the CMS specifications for staffing information submission. During an interview on June 3, 2024, Administrative Nurse B stated that the facility had an RN on duty on all days except for May 4, 2024, suggesting that the PBJ report was inaccurate. Additionally, the facility lacked a policy for the accurate completion of the PBJ report, contributing to the submission of incomplete and inaccurate staffing data. This oversight in reporting and policy implementation led to the deficiency noted by the surveyors.
Multiple Deficiencies and Immediate Jeopardy Citations in LTC Facility
Penalty
Summary
The facility was found to have multiple deficiencies during the current survey, including five Immediate Jeopardy citations, which indicated substandard quality of care. These deficiencies were not identified by the facility's Quality Assurance and Performance Improvement (QAPI) program, affecting all 43 residents. The surveyors discovered issues such as hazardous hot water temperatures, failure to prevent and report resident-to-resident abuse, and inadequate investigation and protection against further abuse. These findings were consistent with previous surveys, indicating a failure to maintain corrective measures in known areas of concern. The survey also revealed that the facility failed to treat residents with dignity and respect, as evidenced by the use of Styrofoam containers for meal trays and the lack of temperature control in residents' rooms. There were also failures in communication with residents' representatives regarding behavioral changes and the need for one-to-one observation. Additionally, the facility did not maintain a clean and homelike environment, and there were significant lapses in the reporting and investigation of abuse allegations. Further deficiencies included the failure to perform timely and accurate assessments, develop comprehensive care plans, and provide necessary treatments to prevent pressure ulcers and falls. The facility also lacked adequate staffing, with significant gaps in RN and LN coverage, and failed to follow up on pharmacy recommendations. Issues with food service, infection control, and accurate reporting of staffing information to CMS were also noted. Overall, the facility's administration failed to identify and address these quality deficiencies, placing residents at risk for decreased quality of care and well-being.
Infection Control Deficiencies in Laundry and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program due to two main deficiencies. Firstly, the laundry services did not adhere to proper infection control protocols. On one occasion, a laundry aide was observed pushing a laundry cart with the cover down, delivering laundry items to a resident's room, and leaving the cart unattended in the hallway with the cover raised. The aide was unsure if linen carts were required to be covered when unattended, indicating a lack of training or awareness of the facility's infection control policies. Secondly, the facility did not implement enhanced barrier precautions (EBP) during wound care for a resident with a chronic wound. A licensed nurse, assisted by two certified nurse aides, provided wound care without using the necessary EBP, which includes targeted gown and glove use during high-contact care activities. The nurse acknowledged that EBP should have been in place for residents with vectors of infection, such as chronic wounds. This oversight was confirmed by an administrative nurse, highlighting a failure to follow the facility's policy on infection prevention and control.
Failure to Ensure Dignity in Resident Dining
Penalty
Summary
The facility, with a census of 43 residents, failed to ensure dignity in resident dining by serving meals in Styrofoam containers to seven residents who chose to eat in their rooms. This was due to a lack of sufficient plates, cups, and flatware. Observations on May 30, 2024, revealed that dietary staff delivered meals in Styrofoam containers to each hall, and CNAs then delivered these trays to the residents. The Dietary Manager acknowledged the use of Styrofoam containers prior to her hire and cited an unknown supply chain issue with the supplier, which hindered the acquisition of adequate tableware and silverware for all residents. The Administrative Nurse stated that only residents under isolation precautions or those taking meals to-go should be served with disposable containers and flatware. However, she was unaware of the regulatory requirement for serving residents with non-disposable flatware and utensils. The facility was unable to provide a policy related to the use of disposable flatware and utensils when requested. This oversight resulted in a failure to uphold the dignity of residents during dining, as meals were served in disposable containers due to insufficient supplies.
Inaccurate MDS Completion Leads to Uncommunicated Care Needs
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for several residents, leading to uncommunicated care needs. For Resident 1, the Care Area Assessment (CAA) lacked documentation related to hospice services and psychotropic drug use, despite the resident being on hospice care and receiving high-risk medications. The administrative nurse admitted to not spending much time on the development of the CAA, which should have been used to generate the care plan process. This oversight placed the resident at risk for uncommunicated care needs. Resident 32's CAA did not include documentation related to insulin use or dialysis, despite the resident having diabetes mellitus type 2 and end-stage renal disease requiring dialysis. The care plan also lacked documentation related to the care of the resident's implanted dialysis catheter. The administrative nurse acknowledged that the CAAs lacked crucial information regarding the resident's condition, which could negatively impact the resident's well-being. Resident 30's CAA failed to accurately reflect the resident's status related to falls, despite the resident having a history of repeated falls and fractures. The care plan did not address the actual falls that occurred, and the facility's fall reports lacked documentation of injuries sustained during some falls. Additionally, Resident 39's MDS did not capture the resident's antidepressant medications, which were crucial for managing the resident's PTSD and dementia. The administrative nurse confirmed that the medications should have been documented on the MDS, highlighting a failure to communicate the resident's needs effectively.
Deficient Care Plans in LTC Facility
Penalty
Summary
The facility failed to develop comprehensive person-centered care plans for several residents, leading to potential negative impacts on their physical, mental, and psychosocial well-being. For instance, one resident with diagnoses of diabetes mellitus type 2, anemia, stage four chronic kidney disease, and end-stage renal disease did not have a care plan that included interventions related to insulin use or dialysis. Despite having physician's orders for dialysis and insulin administration, the care plan lacked documentation of these critical treatments, which were confirmed by administrative staff as needing to be added. Another resident with a diagnosis of diabetes mellitus type 2 and an unstageable pressure ulcer on admission did not have a care plan addressing pressure ulcer prevention or wound care. Although physician's orders were in place for wound treatment, the care plan did not reflect these interventions. Staff interviews revealed that the resident was non-compliant with turning and getting out of bed, which could exacerbate the pressure ulcer, yet these issues were not addressed in the care plan. Additionally, a resident receiving hospice care for cachexia did not have a care plan that included interventions related to hospice or end-of-life care. The resident's care plan was missing crucial information despite receiving multiple medications, including those with black box warnings. The facility's interdisciplinary team policy required comprehensive care plans within seven days of the MDS completion, but this was not adhered to, resulting in incomplete care plans for residents with complex medical needs.
Failure to Notify Resident's Representative of Behavioral Changes
Penalty
Summary
The facility failed to ensure the right of a resident's representative to be informed of changes in the resident's condition. The resident, who had a diagnosis of dementia with severe cognitive impairment, exhibited an increase in behaviors, including hitting another resident. As a result, the staff placed the resident on one-to-one observation. However, the facility did not notify the resident's Durable Power of Attorney (DPOA) about these behavioral changes or the implementation of one-on-one supervision. The facility's policy requires prompt notification of the resident's representative in the event of changes in the resident's medical or mental condition. Despite this policy, the resident's DPOA was not informed of the incident or the subsequent actions taken by the staff. Interviews with the facility's staff, including a Licensed Nurse and an Administrative Nurse, confirmed the expectation to notify the DPOA immediately in such situations, highlighting the facility's failure to adhere to its own notification policy.
Failure to Conduct Comprehensive MDS Assessment After Significant Change
Penalty
Summary
The facility failed to recognize a significant change in a resident's physical condition and did not perform a comprehensive Minimum Data Set (MDS) assessment within the required 14-day period. The resident, identified as R30, had a history of diabetes mellitus type 2, metabolic encephalopathy, dementia, repeated falls, and fractures in both femurs. The resident's condition required substantial or maximal assistance from staff for all cares, yet the facility did not document the level of assistance needed in the progress notes or the electronic health record (EHR) during the 14-day look-back period. The most recent comprehensive MDS assessment was dated several months prior, and the subsequent assessment failed to capture the significant change in the resident's care needs. The facility's failure to conduct a comprehensive MDS assessment following the resident's significant change in condition was confirmed by Administrative Nurse E, who acknowledged that the assessment should have been a Significant Change comprehensive assessment. Additionally, the facility's policy indicated reliance on the Resident Assessment Instrument (RAI) manual for MDS development, yet the necessary assessment was not completed. This oversight had the potential to lead to uncommunicated needs and placed the resident at risk of further deterioration in physical, mental, and psychosocial well-being.
Failure to Revise Fall Care Plans for Residents
Penalty
Summary
The facility failed to revise the fall care plans for three residents, placing them at risk for impaired physical and emotional well-being due to uncommunicated care needs. Resident 16 had a history of falls and was identified as a high risk for falls on multiple occasions. Despite this, the care plan lacked updated interventions for falls that occurred on specific dates. The facility's policy required staff to identify interventions based on evaluations and current data, but this was not followed, leading to repeated falls without appropriate care plan updates. Resident 30 also experienced multiple falls, some resulting in injuries such as fractures, yet the care plan was not revised to include updated interventions for these incidents. The resident was assessed as a high risk for falls, and the facility's fall reports documented several falls with varying degrees of injury. However, the care plan did not reflect these incidents, and the facility failed to implement necessary interventions to prevent further falls. Similarly, Resident 24 had multiple falls within a short period, but the care plan lacked corresponding interventions. The resident was identified as a high risk for falls, and the facility's policy required staff to monitor and document responses to interventions. Despite this, the care plan was not updated to address the falls, and the facility did not take appropriate action to prevent future incidents. The failure to revise care plans for these residents highlights a deficiency in the facility's care planning process.
Failure to Provide Timely ADL Assistance for Facial Hair Removal
Penalty
Summary
The facility failed to provide appropriate and timely assistance with Activities of Daily Living (ADLs) for a resident, specifically regarding the removal of facial hair. The resident, identified as R17, had diagnoses including acute and subacute infective endocarditis and dysphagia following a cerebral infarction. The resident's Admission Minimum Data Set (MDS) indicated moderately impaired cognitive function, requiring assistance with daily care. Despite the care plan indicating the need for assistance with ADLs to prevent complications, there was no specific guidance on the frequency of facial hair removal. Observations over several days revealed that the resident had untrimmed facial hair, which he reported was bothersome and had not been shaved for a long time. Interviews with staff, including CNAs and a Licensed Nurse, indicated that the resident was supposed to be shaved during showers, which were scheduled twice weekly. However, there was a lack of documentation in the electronic medical records for facial shaves in April and May 2024. The facility's policy emphasized person-centered care, prioritizing individual preferences and needs, yet the resident's preference for being clean-shaven was not met. The deficiency was identified as a failure to provide the necessary care for the resident's facial hair removal, as per his preference and the facility's policy.
Failure to Coordinate Hospice Care for Resident
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards by not coordinating resident care with hospice services. A resident with severe cognitive impairment and multiple diagnoses, including chronic atrial fibrillation, anxiety disorder, and diabetes mellitus, was receiving hospice care due to cachexia. Despite being admitted to hospice services, the resident's care plan lacked documentation and guidance related to hospice care. Observations and interviews revealed that staff, including a CNA and a licensed nurse, were aware of the hospice services but did not have a clear understanding of the hospice staff's role or the need for coordination between nursing and hospice care. Further interviews with administrative nurses highlighted a lack of awareness regarding the inclusion of hospice services in the care plan and the necessity of coordinating care between nursing and hospice services. The care plans were found to be lacking crucial information about the resident's condition and the plan for care. Additionally, the facility was unable to provide a policy regarding hospice care when requested, indicating a systemic issue in ensuring coordinated care for residents receiving hospice services.
Failure to Develop Comprehensive Dialysis Care Plan
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for a resident, identified as R32, who required hemodialysis three times a week. Despite having a diagnosis of diabetes mellitus type 2, anemia, stage four chronic kidney disease, and end-stage renal disease, the resident's care plan lacked specific instructions and interventions related to dialysis care and the management of the resident's implanted dialysis catheter. The Care Area Assessment and Care Plan did not document necessary details about insulin use or dialysis, which are critical for the resident's care. Observations and interviews revealed several deficiencies in the care provided to R32. The resident reported that the transportation service to dialysis appointments was unreliable, leading to shortened dialysis sessions. Additionally, the facility staff did not consistently check the dialysis port or obtain vital signs after dialysis sessions. The Dialysis Communication sheets, intended to facilitate communication between the Dialysis Center and the facility, were often incomplete, indicating a lack of proper documentation and follow-up on dialysis care. Interviews with facility staff confirmed the lack of a comprehensive care plan for R32. Certified Nurse Aide J and Licensed Nurse H acknowledged the presence of an implanted dialysis port and the need for monitoring, but the care plan did not reflect these requirements. Administrative Nurse E and Administrative Nurse B admitted that the care plan was missing essential information related to dialysis and insulin administration, which should have been documented according to the facility's policy. This oversight had the potential to lead to uncommunicated needs and negatively impact the resident's well-being.
Failure to Provide Adequate Behavioral Health Care for Resident with PTSD
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with a history of personal trauma and a diagnosis of post-traumatic stress disorder (PTSD). The resident, identified as R39, had diagnoses including metabolic encephalopathy, PTSD, and dementia adjustment disorder. The resident's electronic health record (EHR) and care plan lacked guidance and interventions related to the PTSD diagnosis, despite the resident's history of military-related trauma and behaviors that put others at risk. Observations and interviews revealed that staff were unaware of the resident's PTSD diagnosis and how to appropriately approach the resident to prevent agitation or triggers. The care plan did not include instructions to avoid approaching the resident from behind, a crucial intervention noted in the trauma assessment. Staff, including a licensed nurse and a certified nurse aide, were not informed about the resident's condition or the necessary approaches to care, indicating a lack of communication and training. The facility's policy for Trauma Informed Care, which was intended to guide staff in providing appropriate care for individuals with trauma, was not effectively implemented. The policy included education about trauma and PTSD, but staff were not adequately trained or informed about the resident's specific needs. This deficiency in care placed the resident at risk for impaired quality of life due to untreated and ongoing mental health concerns.
Failure to Follow Pharmacy Recommendations for Lorazepam Prescription
Penalty
Summary
The facility failed to follow up on pharmacy recommendations in a timely manner for a resident regarding the administration of lorazepam, a medication used for severe agitation. The resident's electronic medical record revealed multiple diagnoses, including chronic atrial fibrillation, anxiety disorder, violent behavior, major depressive disorder, intermittent explosive disorder, delusional disorder, and personality disorder. The resident was prescribed lorazepam 1 mg every six hours as needed for anxiety, with no specified end date. The consulting pharmacist's monthly medication review noted the absence of a 14-day requirement end date for the lorazepam prescription, but the electronic medical record lacked a timely physician response to this recommendation. Observations and interviews conducted during the survey revealed that the resident exhibited behaviors such as vocal abuse and yelling obscenities, which were usually controlled with medication. Despite these behaviors, the facility did not have a policy for pharmacy reviews, and the administrative nurse confirmed the untimeliness of the physician's response to the pharmacy's recommendations. The deficiency was identified as the facility's failure to obtain a new prescription for lorazepam every 14 days, as recommended by the pharmacy, to minimize or prevent adverse consequences related to medication therapy.
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 278 citations issued within 25 miles in the last 12 months — including the 6 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clearwater
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Diversicare Of Haysville | 8.8 mi | ★★★★★ | 0 | 0 |
| Rolling Hills Health And Rehab | 11.4 mi | ★★★★★ | 0 | 0 |
| Medicalodges Goddard | 11.5 mi | ★★★★★ | 17 | 0 |
| Family Health & Rehabilitation Center | 11.6 mi | ★★★★★ | 7 | 0 |
| Spring View Manor Healthcare And Rehabilitation | 11.7 mi | ★★★★★ | 14 | 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.