Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmhaven East during CMS and state inspections, most recent first.
Unsafe Food Storage and Preparation Practices: Surveyors found extensive food storage and sanitation problems in the kitchen, including blackened cookware, expired and undated food, unsealed packaging, food stored on bakeware, and uncovered eggs stored beneath open food items. A chest freezer lacked a thermometer, and staff reported entering temperatures on the log even when they were not observed. Dietary staff also described inconsistent dating, labeling, and storage practices for food items and temperature monitoring.
CNA/CMA in-service education was not documented as required. Several CNAs had no specific hours tracked, and the facility’s sign-in sheets only showed names and signatures without staff position, certification, or specific topic times. Leaders stated training occurred through videos, huddles, handouts, and meetings, but they did not have records showing the required hours were completed for each aide.
Infection control practices were not followed during wound care, catheter care, and shared equipment use. A nurse applied lotion and performed wound care on a resident with multiple wounds without changing gloves or performing hand hygiene between tasks, placed clean dressing supplies on a visibly blood-soiled sheet, and touched a clean dressing with a bare hand. The same nurse also used a Hoyer lift without sanitizing it between rooms and flushed another resident’s urinary catheter without wearing the gown required for EBP.
Failure to maintain resident dignity during ADL care: A resident with intact cognition, wheelchair use, and extensive ADL dependence was left fully naked on the bed while an LN and two CNAs provided post-bowel-movement care and dressing. Her breasts remained exposed unnecessarily, and staff later stated that a sheet or other dignity cover should have been used along with privacy measures such as closing the curtain, door, and blinds.
A resident with anxiety, cerebral palsy, and dementia with delusions/hallucinations had a PRN Ativan order that was continued without the required stop date or documented physician rationale for extending it beyond 14 days. The resident’s care plan included multiple psychotropics, and staff stated the order was called in every two weeks but still lacked a stop date and rationale, contrary to facility policy.
Failure to Provide Written Transfer Notification: A resident with severe sepsis, renal failure, and a below-the-knee amputation was found with acute changes including slurred speech, rapid breathing, and inability to communicate, then was sent to the hospital by ambulance. The EMR lacked evidence that written transfer notification was provided to the resident or his representative, and staff stated they were unaware of the requirement to notify the representative in writing of the transfer and reason.
A resident with anxiety, depression, weakness, hemiplegia, and hemiparesis after a stroke had a DNR directive in the EMR, and staff identified her as DNR by the red heart sticker on her door and name tag. However, her care plan still stated CPR would be initiated if her heart or respirations ceased, and administrative staff confirmed the care plan was not updated to reflect the resident’s current code status.
The facility failed to document offering or obtaining informed declination for the flu vaccine for two residents. One resident and one resident’s legal representative had prior refusals on file, but the EMR lacked evidence of a 2025 flu season offer or informed declination. An admin nurse stated the residents were verbally offered the vaccine and declined, but it was not documented, and another admin nurse said residents were to be offered flu immunizations annually and documented in the chart.
The facility did not ensure RN coverage for at least eight consecutive hours on multiple occasions, as confirmed by staff postings and administrative interview. The facility also lacked a policy to guarantee this required RN coverage, affecting a census of 30 residents.
The facility did not complete the required Care Area Assessments (CAAs) as part of the comprehensive Minimum Data Set (MDS) process for several residents. Review of electronic medical records showed that, although comprehensive and quarterly MDS assessments were conducted, the triggered CAAs were not completed as required by the Resident Assessment Instrument (RAI).
A resident dependent on staff for mobility and toileting was left uncovered during peri-care, with the privacy curtain not drawn. Another staff member entered the room and spoke with the door open, making the resident visible from the hallway. Staff and administrative interviews confirmed this violated facility policy on resident dignity and privacy.
A resident with multiple serious health conditions and intact cognition was admitted to hospice care and expressed a wish to remain DNR. However, the facility failed to ensure the DNR directive was signed by the resident or representative, and inconsistencies were found in the resident's code status across records. Staff acknowledged the missing signature and the lack of a clear policy for advanced directives.
A resident with CHF on a diuretic experienced multiple significant daily weight gains, but nursing staff did not notify the physician as required by care plan and physician orders. Interviews confirmed that staff were expected to notify the physician for such changes, but no documentation of notification was found, and the facility lacked a policy for provider notification of weight changes in these cases.
A resident with multiple mental health and neurological diagnoses did not receive a required quarterly MDS assessment within the mandated timeframe. The resident, who was routinely administered antidepressant and anticonvulsant medications and exhibited moderate cognitive decline, was observed to be frequently sleeping and unresponsive. Staff confirmed the expectation for timely and accurate MDS completion, but the assessment was not performed as required.
A resident with neurogenic bladder and a Foley catheter did not have catheter care addressed in the baseline care plan upon admission. Staff observed the resident with dark red urine in the catheter bag, and administrative nurses confirmed that catheter care should have been included in the initial care plan, as required by facility policy.
A resident with a history of CVA and one-sided impairment required substantial assistance for transfers, as documented in her care plan. Staff did not consistently document the assistance needed, and during observation, two CNAs provided total assist with a gait belt, with the resident unable to bear weight and her feet not flat on the floor as required. Staff interviews confirmed inconsistency in the resident's weight-bearing ability, and the facility's ADL policy was unavailable.
Several residents with conditions such as multiple sclerosis and cerebrovascular accident did not receive restorative care or proper positioning as outlined in their care plans. Staff failed to perform or document required range of motion exercises, and one resident was observed with unsupported feet while seated in a Geri-chair. Facility policies for restorative nursing and wheelchair positioning were not followed, and staff interviews confirmed the deficiencies in care.
A resident receiving continuous oxygen therapy was repeatedly observed with oxygen tubing dragging on the floor and tangled around the wheelchair axle. Multiple staff members acknowledged that the tubing should have been secured in a pouch on the wheelchair, but the facility's policy did not address proper storage or management of oxygen equipment to prevent contamination.
A review of staffing records revealed that actual hours worked by nursing personnel were not documented on daily staffing sheets, contrary to facility policy. An administrative nurse reported being unaware of the requirement to include actual hours worked in daily postings.
Unsafe Food Storage and Preparation Practices
Penalty
Summary
The facility failed to provide sanitary conditions for food storage and preparation in its kitchen. During an initial tour, surveyors observed numerous baking sheets, baking pans, and cooking pots with black staining on the interior and exterior, ground nutmeg and ground cloves dated 11/11/2019, an undated and unsealed bag containing a biscuit, an unsealed and undated loaf of bread, and a box of brown rice dated 05/20/2026 with an expiration date of 03/04/2026. Additional items were observed that were not clearly dated or were unsealed, including ketchup, picante sauce, relish, spicy mustard, meat, butter, horseradish mustard, whole carrots, mandarin oranges, fruit cobbler, and chocolate chip cookies. Some food items were sitting on top of baking sheets and pans underneath the cooks prep table, and several items in the cooler and pantry were also undated, unsealed, or expired. Surveyors further observed five uncovered crates of eggs on the bottom of the cooler beneath open packages of meat and food on the shelf above them, as well as frozen and refrigerated items without proper dating or labeling, including sausage patties, sausage links, roll dough, protein shakes, tortillas, oranges, grapes, cheesecake mix, walnut pieces, powdered sugar, sugar, potato chips, dried cranberries, and spaghetti noodles. A chest freezer contained several packages of frozen food without a thermometer inside, and the temperature log documented temperatures that were not consistently recorded or were recorded when not observed. During interview, Dietary Staff DD stated that if the thermometer was not found, staff would not dig through the freezer and would instead enter a temperature close to prior readings, and that blackened pans were covered with tin foil before use. Other dietary staff stated that temperatures should only be documented when observed, thermometers should always be present and working, food items should be dated with a visible day, month, and year, expired items should be removed, packaging should be secured, eggs should not be stored below potentially contaminating food, and food should never be stored on bakeware.
CNA/CMA In-Service Training Hours Not Tracked
Penalty
Summary
The facility failed to ensure that mandatory 12 hours of education were completed for CNA/CMA staff as required. A review of the staffing list showed several CNAs employed for more than 12 months, including CNA M, CNA O, CNA LL, CNA PP, and CNA QQ, but there were no specific in-service hours tracked for them. When the facility was asked for CNA in-service hours, it provided monthly sign-in sheets from 05/2025 through 05/2026 that listed staff names and signatures, but the sheets did not identify staff certification or position and did not include specific times for the required topics. During interviews, Administrative Staff A stated that CNA/CMA training occurred throughout the year through policy review, in-house videos, huddles, education, and in-service meetings, and initially said this was acceptable because it tracked meeting hours. He later stated there was nothing showing that the hours and training were completed for specific topics, only timecards showing staff clocked in and out for the day, and that the facility had sign-in sheets for in-service meetings. Administrative Nurse F stated the facility did not use computer-based training, used written sign-in sheets and handouts, and did not keep track of specific hours. CNA M stated staff received annual abuse, neglect, and exploitation training and attended group video meetings with paperwork to refer to by clocking in if not already clocked in. The facility policy stated all nurse aide personnel would participate in regularly scheduled in-service training classes and that annual in-services must be no less than 12 hours per employment year.
Infection Control Failures During Wound Care, Catheter Care, and Equipment Use
Penalty
Summary
The facility failed to implement adequate infection control practices related to hand hygiene, sanitization of shared equipment, and Enhanced Barrier Precautions (EBP). During observation on 06/09/2026 at 07:58 AM, a Licensed Nurse performed hand hygiene, donned a gown and gloves, and applied skin lotion to a resident with a skin tear on the left forearm, a scabbed wound on the left hand, a deep tissue wound on the right heel, and a wound on the right shin with Steri-strips. The nurse did not change gloves or perform hand hygiene between applying lotion to different limbs. After removing gloves and performing hand hygiene, the nurse placed clean dressing supplies directly on the resident’s bed sheet, which was visibly soiled and had a large amount of blood near the resident’s head, and then performed wound care on the right leg and heel without placing a barrier under the limb, changing gloves, or performing hand hygiene between steps. The nurse also touched the clean dressing with a bare hand when dating it. The facility also failed to sanitize shared equipment and did not follow EBP during urinary catheter care. On 06/09/2026 at 08:50 AM, a Hoyer lift was taken into the resident’s room without being sanitized, used, and then removed from the room and taken to another room without being sanitized. Later, at 08:57 AM, the same nurse performed hand hygiene, donned clean gloves, and flushed another resident’s urinary catheter without wearing a gown for EBP. The nurse stated she should have changed gloves and performed hand hygiene between each step of the wound care, used a barrier on the sheet, avoided placing clean supplies directly on the sheet, and worn a gown with gloves for the catheter flush. Administrative Nurse E stated that catheter care required gloves and a gown, the Hoyer lift should be sanitized after every use, and gloves and hand hygiene should be used when moving from dirty to clean areas during wound care.
Failure to Maintain Resident Dignity During ADL Care
Penalty
Summary
The facility failed to protect the dignity of a resident during ADL care when staff left her fully naked on the bed and did not place a cover over areas not being cared for. The resident had diagnoses including anorexia nervosa, a history of falls, gout, type 2 diabetes mellitus with diabetic neuropathy, and major depression. Her admission MDS documented a BIMS score of 13, indicating intact cognition, and showed that she used a wheelchair, required substantial to maximum assistance with oral and personal hygiene and upper-body dressing, and was dependent on staff for all other ADLs and all transfers. The resident’s care plan documented that she was dependent on staff for toileting hygiene and lower body dressing and required substantial staff assistance for personal hygiene and upper body dressing. During observed care, after the resident had a bowel movement, an LN and two CNAs cleaned her and dressed her, but throughout the entire ADL care process she remained fully naked with no dignity cover placed over her body and her breasts exposed unnecessarily. A CNA later stated that a sheet should have been placed over the resident’s upper body for dignity, and administrative nurses stated that staff should have used a dignity cover and ensured privacy by closing the curtain, door, and blinds. The facility policy stated that employees would treat all residents with kindness, respect, and dignity.
PRN Psychotropic Order Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure Resident 7’s psychotropic PRN medication had the required 14-day stop date or a documented physician rationale for extending the duration. Resident 7’s EMR listed diagnoses of anxiety, cerebral palsy, and dementia with delusions and/or hallucinations, and the 12/10/2025 MDS documented a BIMS of 15 with intact cognition. The MDS also recorded use of an antipsychotic, antidepressant, anticonvulsant, and opioid, and the psychotropic drug use CAA noted behaviors, transfer to a behavior unit, and that the resident returned cheerful and no longer tried to exit without staff knowledge. The care plan documented two antianxiety medications, an antidepressant, and an antipsychotic. The physician’s order for Ativan 0.5 mg twice daily PRN, started 12/24/2025, did not include a stop date. Administrative Nurse E stated the doctor was called every two weeks to continue the PRN Ativan order, but the order still did not have a stop date and no rationale was documented for extending it beyond two weeks. Administrative Nurse D stated she was unaware that PRN antianxiety medications required a two-week stop date unless there was a documented rationale for an extended duration. The facility policy stated that continuing PRN psychotropic orders beyond 14 days requires practitioner documentation of the rationale for the extended order and that the duration must be indicated in the order.
Failure to Provide Written Transfer Notification
Penalty
Summary
The facility failed to provide Resident 3 with written notification of transfer to the resident and/or his representative as soon as practicable after he was transferred to the hospital. Resident 3’s EMR showed diagnoses of severe sepsis, renal failure, and below-the-knee amputation. On 04/27/2026 at 10:04 AM, a nurse documented that Resident 3 was lying on his bed staring off, with dilated pupils, sluggish response, slurred speech, inability to finish a sentence or communicate what was wrong, and rapid breathing. The nurse notified the doctor, and Resident 3 was transported to the hospital by ambulance. Resident 3’s EMR did not contain evidence that written notification of the transfer was provided to him or his representative. When asked, the facility was unable to provide evidence of such notification. On 06/09/2026, Social Services stated she had obtained the signed bed holds but was not aware of the regulation requiring residents or their representative to be notified in writing of transfers and the reason for the transfer. Administrative staff stated he had notified the ombudsman when a resident was transferred out of the facility but had not notified the resident’s representative in writing of the discharge or transfer. The facility’s undated Transfer or Discharge Documentation policy stated that upon a transfer or discharge, appropriate notice would be provided to the resident or legal representative and documented in the chart.
Care Plan Not Updated for DNR Status
Penalty
Summary
The facility failed to review and revise a resident’s care plan to reflect her current and accurate advance directives. The resident had diagnoses including anxiety, depression, weakness, hemiplegia, and hemiparesis following a cerebral infarction, and her quarterly MDS documented a BIMS score of seven, indicating severe impairment. Her care plan, dated and later revised, stated that CPR would be initiated if her heart function or respirations ceased and would continue until emergency medical staff arrived to transport her to the emergency department. The resident’s EMR, under the Documents tab, contained a DNR directive signed by the resident. Observation of the resident’s name tag showed a red heart sticker, and staff interviews confirmed that the red sticker indicated DNR status. A CNA stated the resident had a red sticker next to her name outside her door and that a list at the nurse’s station documented her as DNR. An LN stated the resident showed DNR on her door and that this should be indicated on the MAR, nurse shift report sheet, and care plan. Administrative staff were unsure whether code status should be documented in the care plan, and one administrative nurse confirmed the care plan was not updated to show DNR status.
Failure to Document Influenza Vaccine Offers and Declinations
Penalty
Summary
The facility failed to offer and administer, or obtain an informed declination for, the influenza immunization for R21 and R12. R21’s EMR contained a signed vaccine record showing he declined the influenza immunization on 08/09/2023, but the EMR lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. R12’s EMR contained a signed vaccine record showing her legal representative declined the influenza immunization on 05/10/2024, but the EMR likewise lacked evidence that the vaccine was offered and/or lacked evidence of informed declination for the 2025 flu season. Administrative Nurse E stated on 06/08/2026 that there were no vaccine refusals for the 2025/2026 influenza season for R21 and R12 and said they were verbally offered the immunizations and declined, but it was not documented. Administrative Nurse D stated on 06/09/2026 that she did not know when or how often the influenza immunization was offered and later stated residents were to be offered influenza immunizations annually regardless of past refusals and then documented in the chart. The facility policy stated the infection preventionist would promote and administer the seasonal influenza vaccine and that, unless contraindicated, all residents and staff would be offered the vaccine.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide Registered Nurse (RN) coverage for at least eight consecutive hours per day as required, with documented lapses on multiple dates. Review of the facility's Daily Staff Posting from 05/01/24 through 07/30/24 showed that on nine specific dates, there was no evidence of the required RN coverage. During an interview, the administrative nurse was unable to verify RN presence for the required hours on those dates. Additionally, the facility did not provide a policy ensuring RN coverage for at least eight consecutive hours every 24 hours. The facility had a reported census of 30 residents at the time of the deficiency.
Failure to Complete Required Care Area Assessments in MDS
Penalty
Summary
The facility failed to complete the comprehensive Minimum Data Set (MDS) assessments for several residents as required. Specifically, for six residents, the comprehensive MDS assessments did not include the completion of the triggered Care Area Assessments (CAAs), as mandated by the Resident Assessment Instrument (RAI). Record reviews showed that for each of these residents, both quarterly and comprehensive MDS assessments were present in the electronic medical records, but the required CAAs were missing. This deficiency was identified through review of the residents' electronic medical records and confirmed by staff interviews.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
Staff failed to maintain a resident's dignity and privacy during morning care. A resident with multiple sclerosis, who was cognitively intact but dependent on staff for bed mobility and toileting, was observed lying uncovered on her bed while staff provided peri-care. During this time, the privacy curtain was not drawn around the bed. Another staff member knocked, was told care was in progress, but still entered the room and spoke to the staff with the door open, leaving the resident visible to others in the hallway. Interviews with staff and administrative personnel confirmed that facility expectations and policy require staff not to enter a resident's room during care and to maintain privacy. The facility's policy on promoting and maintaining resident dignity specifically states that residents' rights to privacy and dignity must be protected during care. The actions observed were inconsistent with these expectations and policies.
Failure to Verify and Document Resident's DNR Directive
Penalty
Summary
The facility failed to verify and properly document a resident's advanced directives, specifically regarding a Do-Not-Resuscitate (DNR) order. The resident, who had diagnoses including Parkinson's disease, atherosclerotic heart disease, epilepsy, heart failure, and hypertension, was documented as having intact cognition and had recently started hospice care with a terminal diagnosis. The care plan indicated the resident wished to remain a DNR, but a review of the electronic health record (EHR) revealed inconsistencies: the hospice certificate listed the resident as full code, while the EHR home screen and physician orders listed the resident as DNR. The DNR directive in the EHR was signed by the physician but not by the resident or their representative, as required. Interviews with the resident confirmed her wish to be a DNR, and staff acknowledged the missing resident signature on the DNR directive. Staff also indicated that, in the event of discrepancies between DNR and full code orders, the most recent advanced directive should be honored. However, the facility did not provide a policy for advanced directives, and the lack of a resident signature on the DNR directive represented a failure to ensure the resident's wishes were properly documented and verified.
Failure to Notify Physician of Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to notify the physician when a resident with a diagnosis of congestive heart failure (CHF) and on a diuretic experienced significant weight gains within 24-hour periods. The resident's care plan and physician orders required daily weight monitoring due to the use of a diuretic, and the facility's records showed multiple instances where the resident gained between four and seven pounds in a single day. Despite these notable weight increases, there was no documentation that the physician was notified on any of these occasions. Interviews with nursing staff revealed that the expectation was for the nurse on duty to notify the physician of significant weight changes, particularly if there was a three-pound or greater gain in a day, even if specific parameters were not outlined in the physician's order. However, the facility did not have a policy in place regarding provider notification for weight changes in residents with CHF on diuretics. Observations of the resident showed swelling in the legs and episodes of shortness of breath, but there was no evidence that these changes prompted physician notification as required.
Failure to Complete Timely MDS Assessment for Resident with Complex Needs
Penalty
Summary
The facility failed to complete the required Minimum Data Set (MDS) assessment for a resident within the mandated timeframe. Specifically, the quarterly MDS due on 03/18/25 was not completed for a resident with multiple complex diagnoses, including schizoaffective disorder, panic disorder, seizure disorder, PTSD, anxiety, insomnia, and depressive disorder. Previous MDS assessments documented moderate cognitive decline and no depression, with the resident routinely receiving antidepressant and anticonvulsant medications. The resident's care plan included monitoring for side effects of these medications, which have Black Box Warnings, and interventions to support mental health. Observations showed the resident was frequently sleeping and unresponsive to verbal stimuli, and staff reported that she slept a lot. The administrative nurse confirmed the expectation that MDS and Care Area Assessments (CAAs) should be completed accurately and on time. The Resident Assessment Instrument (RAI) guidelines require quarterly assessments every 92 days, which was not met in this case, resulting in a failure to ensure an accurate and timely assessment for the resident.
Failure to Include Catheter Care in Baseline Care Plan
Penalty
Summary
The facility failed to address catheter care needs for a resident with a diagnosis of neuromuscular dysfunction of the bladder and neurogenic bladder, who was unable to bear weight and required assistance with activities of daily living. The resident's electronic medical record documented the presence of a Foley catheter with dependent drainage, initiated to manage her bladder condition and prevent skin breakdown. Despite this, the baseline care plan created upon admission did not include any documentation or instructions regarding the resident's catheter or its care, focusing only on wound assessment and pain management. Observations revealed the resident in bed with a catheter bag containing dark red urine, and staff interviews confirmed that the resident consistently had red, dark urine. Certified Medication Aides reported referencing the matrix for care information, and administrative nursing staff acknowledged that catheter care should have been included in the baseline care plan. The facility's policy required a baseline care plan to be developed and implemented within 48 hours of admission to address immediate care needs, which was not followed in this case.
Failure to Assess and Implement Proper Transfer Assistance for Resident with CVA
Penalty
Summary
The facility failed to recognize, assess, and implement appropriate interventions for a resident with a history of cerebrovascular accident (CVA) who required assistance with transfers. The resident's medical record indicated substantial to maximal assistance was needed for transfers due to impairments on one side of her body, and her care plan specified that her feet should be flat on the floor during transfers. However, staff documentation did not consistently reflect the level of assistance required, and there was no analysis of findings in the resident's Care Area Assessments (CAA). During observation, two CNAs transferred the resident using a gait belt and provided total assistance, as the resident was unable to bear weight on either leg and her feet were not flat on the floor, contrary to care plan instructions. Interviews with the CNAs revealed inconsistency in the resident's ability to bear weight, and the administrative nurse confirmed that residents should be able to bear weight during transfers. The facility's policy for activities of daily living (ADLs) was not available for review.
Failure to Provide Restorative Care and Proper Positioning for Residents with ROM Needs
Penalty
Summary
The facility failed to provide restorative care and proper positioning for multiple residents with documented needs for range of motion (ROM) and mobility support. One resident with multiple sclerosis, who was dependent on staff for transfers and wheelchair mobility and had limitations in lower extremity ROM, did not receive restorative care as outlined in her care plan. Observations showed her feet were left unsupported while seated in a Geri-chair at the dining table, contrary to facility policy and her care plan instructions. Staff interviews confirmed a lack of awareness regarding the need for foot support and acknowledged that restorative care had not been performed as required. Another resident with a history of cerebrovascular accident (CVA) and lower extremity ROM limitation was also not consistently provided with restorative care. Although her care plan specified daily active and passive ROM exercises, documentation revealed that restorative care was only provided sporadically over several months. Staff confirmed that the resident was not receiving the prescribed daily restorative care, and administrative staff acknowledged the deficiency in care delivery and documentation. A third resident with multiple sclerosis, who had no current ROM impairment but was prescribed upper extremity exercises with weights, did not receive the restorative care outlined in her care plan. The care area assessment for this resident triggered but lacked analysis, and staff interviews confirmed that restorative care was not being provided daily as required. Facility policies required maintenance and restorative services to maintain or improve residents' abilities, but these were not followed for the residents reviewed.
Failure to Prevent Oxygen Tubing Contamination
Penalty
Summary
Facility staff failed to implement proper infection control practices for a resident who was receiving continuous oxygen therapy. Multiple observations showed that the resident's oxygen tubing was repeatedly allowed to drag on the floor, become tangled around the wheelchair axle, and rest under the wheelchair in various locations throughout the facility, including the dining room and the resident's room. These observations occurred over two consecutive days and were witnessed by surveyors at different times. Interviews with facility staff, including a licensed nurse, administrative staff, and a CNA, confirmed that the oxygen tubing should not have been dragging on the floor and should have been secured in a designated pouch or pocket on the wheelchair. The facility's policy on oxygen administration did not address the proper storage and management of oxygen-delivering devices to prevent contamination or infection, contributing to the deficiency.
Failure to Post Actual Nursing Staff Hours Worked
Penalty
Summary
A review of the facility's Daily Staffing Sheets for the past 30 days showed that the actual hours worked by nursing personnel were not recorded on the daily staffing sheets. During an interview, an administrative nurse stated she was unaware that the daily staff postings were required to include the actual hours worked. The facility's policy, revised in July 2016, specifies that the actual time worked for each category of nursing personnel must be posted daily for each shift.
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What surveyors actually found near you
We read the 53 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Parsons
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan - Parsons | 1.7 mi | ★★★★★ | 0 | 0 |
| Parsons Presbyterian Manor | 2.1 mi | ★★★★★ | 17 | 0 |
| Prairie Mission Retirement Village | 14.1 mi | ★★★★★ | 0 | 0 |
| Oswego Operator, Llc | 14.1 mi | ★★★★★ | 14 | 0 |
| Advena Living Of Cherryvale | 17.5 mi | ★★★★★ | 0 | 0 |
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