Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Heritage Grove Estates during CMS and state inspections, most recent first.
Missing CNA Competency Reviews and In-Service Training: The facility failed to provide regular in-service education based on nurse aide performance reviews. Record review showed that 2 CNAs lacked competency reviews and in-services tied to performance evaluations, and an Administrative Nurse stated personnel files did not contain current yearly competencies or related in-service documentation. The facility policy required in-service training based on weaknesses identified in performance reviews and facility assessment.
Staff failed to sanitize shared equipment between resident uses, perform hand hygiene consistently, and follow PPE requirements during resident care. Aides used a full-body lift without cleaning it after transfer, a CNA used the same BP cuff on two residents without sanitizing it, wound care was provided without a gown, and staff did not use gown and gloves during care for residents on EBP. The facility also lacked documented water management program records for Legionella prevention.
Missing Annual In-Service Training Documentation for Nurse Aides: The facility failed to verify that two CNAs had completed the required 12 hours of annual in-service training. Personnel files for both aides lacked documentation, and the DON stated the facility could not determine whether the training had been completed. The facility policy required at least 12 hours of annual in-service training based on employment date, with documentation kept in the personnel file.
Missing Criminal Background Check for Maintenance Employee: The facility failed to provide evidence that a criminal background check had been completed for a maintenance employee who had already been working at the facility. Admin staff confirmed the record could not be found, even though facility policy states criminal record checks are completed for all applicable applicants and employees before they work and before they have access to residents.
The facility failed to provide written transfer notices, bed-hold information, and LTCO notifications for three residents who were transferred to the hospital and later returned. Record review showed the residents had hospital discharge and re-entry events, but the facility could not produce documentation that the required notices were given. An admin staff member stated the transfer packet was supposed to be completed by nursing staff, but it had not been done.
CAA Analysis of Findings Not Completed for Triggered MDS Areas: Two residents had comprehensive MDS assessments that triggered multiple CAAs, including areas such as functional abilities, urinary continence and indwelling catheter, nutritional status, pressure ulcer/injury, pain, cognitive loss/dementia, visual function, dehydration/fluid maintenance, and dental care. The CAA worksheets were completed without documenting the required analysis of findings, and an RN stated she was unaware that anything needed to be entered in that section.
Incorrect Dating of Opened Insulin Pens: Staff failed to properly date opened insulin pens for two residents. An LPN observed multiple insulin pens on a med cart that were already in use but had been labeled with the current date after the survey team arrived, even though the actual open dates were unknown. The DON later stated that undated opened pens should not be dated for use and that new pens should be used instead. The facility policy required insulin pens to be clearly labeled with required information, including the date dispensed and expiration date.
Failure to Address PTSD Triggers in Care Planning: A resident with PTSD, depression, anxiety, and severely impaired cognition had care documentation that described memory and mood as great, but the care plan and social services assessment did not address PTSD, trauma history, triggers, or interventions to prevent re-traumatization. Staff stated the facility did not have a trauma-informed care assessment, and the EMR lacked evidence of trigger-specific goals or interventions.
Inaccurate controlled substance reconciliation occurred when staff failed to properly document narcotic counts and did not immediately report a count discrepancy. An e-kit in the medication room contained lorazepam for a resident who had died, and the controlled drug record and narcotic count sheet showed missing signatures and inconsistent remaining amounts. The DON verified the discrepancy and missing documentation, and stated narcotics should be counted each shift and discrepancies reported right away.
Unlabeled insulin flex pens were found for several residents, including a resident’s Novolog pen and another resident’s Humalog pen, along with multiple Lantus and Humalog pens on treatment carts. Nurses verified that insulin pens should be dated when opened and marked with the discard date, but the pens observed were missing the correct open and discard dates or had inaccurate dates.
A facility failed to keep hospice collaboration information current for two residents with severe cognitive impairment and multiple chronic conditions. One resident’s care plan lacked hospice contact details, supplies, DME, and meds, and the hospice binder was missing the current POC and related hospice documentation. A second resident’s binder lacked the most recent recertification and current POC, even though the care plan included hospice services, DNR wishes, and hospice-provided meds, DME, and visits.
Failure to Post Required Nurse Staffing Information: Surveyors observed the Daily Nurse Staffing Report posted with the names of nurses and aides on duty and the hours they worked, but it did not include the required breakdown of RN, LPN, CMA, and NA staffing by shift or the total actual hours worked per shift. Administrative staff verified the report should also show the number of staff for each shift and the facility census, consistent with the facility's staffing posting policy.
A cognitively impaired resident at risk for elopement left a facility unsupervised due to a door not being properly latched and staff failing to check an alarm. The resident was outside in cold weather for over an hour before being found in an Assisted Living building. The incident revealed lapses in supervision and alarm response procedures.
The facility failed to ensure agency staff received required communication training, relying on a contracted agency for education. A CNA and an LN lacked documented communication training, despite having other training. The facility had no policy for required education, risking impaired care and decreased quality of life for residents.
The facility failed to ensure agency staff received required training on resident rights, impacting care quality. Training records for an agency CNA and LN lacked documentation of resident rights training, though they had training in other areas like ANE and dementia. The facility relied on the agency for staff education and lacked a policy for required direct care staff training.
A resident with dementia and other conditions was transferred to a shower room in a manner that compromised their dignity. The resident, unable to sit upright, was pulled backward in a shower chair down the hallway, partially uncovered, contrary to the facility's dignity policy. Staff interviews confirmed this practice was inappropriate and against established guidelines.
A resident with dementia and COPD was at increased risk for respiratory infection due to improper storage of oxygen tubing. Observations showed the tubing was wrapped around a chair and draped over a concentrator instead of being stored in a provided bag. Staff interviews confirmed the expectation for sanitary storage, but the facility lacked a policy to ensure compliance.
A facility failed to maintain consistent communication with a dialysis center for a resident requiring hemodialysis. Despite a care plan for monitoring the resident's arteriovenous access, records showed no consistent communication with the dialysis provider. Staff interviews revealed that communication sheets were not sent with the resident, and the dialysis provider did not always return them, contrary to the facility's policy.
Missing CNA Competency Reviews and In-Service Training
Penalty
Summary
The facility failed to provide regular in-service education based on the outcomes of nurse aide performance reviews. Record review showed that the facility employed nine nurse aides who had worked there for at least one year, but in-service records documented that 2 of the nurse aides reviewed had not completed in-service education tied to performance review findings and competency needs. CNA M, hired 08/28/2014, lacked competency review and in-services based on performance evaluations, and CNA N, hired 06/28/2023, also lacked competency review and in-services based on performance evaluations. On 07/22/2026 at 09:00 AM, Administrative Nurse D stated the facility had recently been bought, had new owners, and that personnel files had been located but did not contain documentation of current yearly competencies and in-services based on performance evaluations. The facility policy stated that in-service training would be based on resident needs and any area of weakness identified in nurse aide performance reviews and facility assessment, and that documentation would be maintained in the employee personnel file.
Infection Control Failures With Shared Equipment, PPE Use, and Water Management Program
Penalty
Summary
The facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff did not sanitize shared equipment between resident uses and did not consistently perform hand hygiene. On 07/20/2026, two CNAs assisted a resident with a full-body lift transfer from a wheelchair to a recliner; one CNA left the room without washing her hands and took the lift machine back to storage without sanitizing it. During catheter care, the resident’s urinary drainage bag was placed on a trash can with the bag touching the floor, a graduated cylinder was placed on the floor without a barrier, urine was drained into the cylinder, and the cylinder was left on the toilet back without being rinsed. Both aides removed PPE and left the room without washing their hands. A CNA later stated the lift should be put in the room and plugged in after use. Additional observations showed repeated failures to sanitize shared equipment and follow infection control practices. A CMA used the same blood pressure cuff on two residents without sanitizing it between uses and popped medications from pill cards without performing hand hygiene before the procedure. An administrative nurse provided wound care for a resident’s left lateral leg wound without wearing a gown. Another CMA entered a resident’s room while the resident was on Enhanced Barrier Precautions and assisted with repositioning in bed without donning a gown or gloves. Later, a CNA and an administrative nurse transferred another resident on Enhanced Barrier Precautions with a full lift machine, removed PPE, and took the lift out of the room without sanitizing it before returning it to storage. The facility also failed to establish a documented water management program to prevent the growth of Legionella and other water-borne pathogens. Record review showed no documentation of such a program, and an administrative staff member verified the lack of documentation. The facility’s policies stated that hand hygiene should be documented according to established procedures, reusable equipment should be cleaned according to current procedures, PPE should be available for Enhanced Barrier Precautions during high-contact care, and a water management team should develop and implement the water management program.
Missing Annual In-Service Training Documentation for Nurse Aides
Penalty
Summary
The facility failed to ensure nurse aides received the required 12 hours of annual in-service training. Review of employee records showed that CNA M, hired on 08/28/2014, had no evidence of the required 12-hour in-service in the personnel file, and the facility could not provide documentation when requested. CNA N, hired on 06/28/2023, also had no evidence of the required 12-hour in-service in the file, and the facility was unable to provide documentation for that employee as well. During interviews on 07/22/2026, Administrative Nurse D stated the facility could not determine whether CNA M and CNA N had completed any of the required 12 in-service hours. Administrative Nurse D also stated the facility had recently been bought and had new owners, that the personnel files had been located but did not contain documentation of the in-service hours, and that the online training program did not show any documented in-service training hours for either employee. The facility policy stated nurse aides would receive at least 12 hours of in-service training annually based on employment date, with documentation maintained in the personnel file.
Missing Criminal Background Check for Maintenance Employee
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after the facility failed to conduct a criminal background check for one employee. Maintenance Staff U had worked at the facility since 06/23/2026, but on 07/22/2026 the facility was unable to provide evidence that a criminal background check had been completed for this employee. The employee was allowed access to residents without confirmation that they had not been found guilty by a court of law of abuse, neglect, exploitation, misappropriation of property, or mistreatment. During the review, Administrative Staff A stated that the facility would obtain criminal background and record checks on all employees prior to the employee working at the facility. Administrative Staff A also verified that a criminal record check for Maintenance Staff U could not be found. The facility’s Background Investigation policy stated that criminal record checks are conducted on all personnel applying for employment, and that the Human Resource department conducts applicable background investigations on each individual making application for employment and on any current employee when appropriate for the position.
Failure to Provide Transfer Notices, Bed-Hold Information, and LTCO Notifications
Penalty
Summary
The facility failed to provide Resident 6, Resident 8, and Resident 44 and/or their representatives with written notification of transfer for facility-initiated transfers and a bed-hold policy when they were transferred to the hospital. The record review showed that Resident 6 had a discharge MDS dated 05/19/2026 documenting a planned discharge to an acute hospital with return anticipated, an entry MDS dated 05/20/2026 documenting re-entry from an acute hospital, another discharge MDS dated 06/15/2026 documenting an unplanned discharge to an acute hospital with return anticipated, and an entry MDS dated 06/19/2026 documenting re-entry from an acute hospital. Resident 8 had a discharge MDS dated 04/27/2026 documenting an unplanned discharge to an acute hospital with return anticipated and an entry MDS dated 05/01/2026 documenting re-entry from an acute hospital. Resident 44 had a discharge MDS dated 11/19/2025 documenting an unplanned discharge to an acute hospital with return anticipated and an entry MDS dated 11/24/2025 documenting re-entry from an acute hospital. On 07/21/2026, the facility was unable to provide the requested bed-hold notices, written transfer notifications, or LTCO notifications for these residents’ hospital transfers. Administrative Staff A stated she could not find any record of the bed holds, written notifications of transfer, or ombudsman notifications for Residents 6, 8, and 44. She stated the facility had a packet that nursing staff was supposed to complete when a resident was transferred to the hospital, but it had not been done, and that the prior administrator and staff had not completed the bed-hold, notice of transfer, and ombudsman notification after the change in ownership in February 2026.
CAA Analysis of Findings Not Completed for Triggered MDS Areas
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for two residents after their comprehensive MDS assessments triggered multiple CAA areas. For one resident, the admission MDS dated 05/05/2026 triggered CAAs for Communication, Functional Abilities, Urinary Continence and Indwelling Catheter, Nutritional Status, Pressure Ulcer/Injury, and Pain, but the CAA worksheet dated 05/13/2026 documented that the triggered areas lacked completion with an analysis of findings. For the second resident, the admission MDS dated 06/29/2026 triggered CAAs for Cognitive Loss/Dementia, Visual Function, Functional Abilities, Urinary Continence and Indwelling Catheter, Nutritional Status, Dehydration/Fluid Maintenance, Dental Care, and Pressure Ulcer/Injury. The second resident’s CAA worksheet dated 06/29/2026 documented that only the Nutritional Status CAA had been completed, and the remaining triggered CAA areas were completed on 07/02/2026 by Administrative Nurse F, but also lacked an analysis of findings. During interview, Administrative Nurse F stated she had completed the MDSs and CAA worksheets and had never documented anything in the analysis of finding area and was unaware that she needed to. Administrative Nurse D stated that the MDS would trigger the CAA area and that the MDS Coordinator, social services, or dietary staff would complete the CAA and document information regarding items checked on the worksheet to assist with development or revision of the care plan. The facility’s MDS 3.0 Completion policy directed that staff document key findings based on the CAA review, including the nature of the condition, complications and risk factors affecting care planning decisions, factors considered in developing interventions, and the need for referrals or evaluation by appropriate health professionals.
Incorrect Dating of Opened Insulin Pens
Penalty
Summary
The facility failed to apply standards of practice when staff recorded incorrect opened dates on insulin pens for two residents, R28 and R73. During observation on 07/20/2026, R28’s Lantus flex pen and R73’s Humalog flex pen, two Lantus Solostar flex pens, and one Lantus flex pen on the North Treatment Cart Hall 2 were labeled with that day’s date even though the pens were not full and some were half empty. The observation showed the pens were already in use, but the dates on them did not reflect when they had actually been opened. During interview, LN G verified that nurses should date insulin pens when they are opened and mark the discard date, and acknowledged the pens had not been dated before. LN G stated that after realizing the survey team was in the facility, she labeled the pens with that day’s date even though she did not know when they had actually been opened. Administrative Nurse D later stated that if the insulin pens did not have a date and were already opened and in use, the nurse should not date them for use; instead, the opened undated pens should be discarded and new pens obtained and dated when first opened and used. The facility’s insulin pen policy required pens to be clearly labeled with the resident’s name, physician’s name, date dispensed, type of insulin, amount to be given, frequency, and expiration date, and stated that if the label is missing, the pen will not be used.
Failure to Address PTSD Triggers in Care Planning
Penalty
Summary
The facility failed to identify trauma-based triggers related to a resident with PTSD and failed to implement individualized interventions to prevent re-traumatization. The resident’s EMR documented diagnoses of encephalopathy, depression, anxiety, and PTSD. The Significant Change MDS documented a BIMS score of six, indicating severely impaired cognition, and noted the resident needed partial to substantial staff assistance with cares. The Psychosocial Well Being CAA and the care plan documented that the resident’s memory and mood appeared great, but neither document addressed the resident’s PTSD. The resident’s care plan lacked a care area for PTSD, any identified triggers that could cause re-traumatization, and interventions if re-traumatization occurred. The Social Services initial assessment and history documented PTSD, but it did not include any goal or interventions related to PTSD. The EMR also lacked evidence of an assessment to identify the resident’s trauma history or triggers, and it lacked goals and interventions to minimize or eliminate the effect of triggers. Social Services stated the facility did not have an assessment specific to trauma-informed care, and Administrative Nurse D stated the resident should have information listing trauma history, possible triggers, and interventions to minimize triggers. The facility’s Trauma-Informed Care policy stated that triggers which may re-traumatize residents with a history of trauma should be identified and added to the care plan.
Inaccurate controlled substance counts and failure to report discrepancy
Penalty
Summary
The facility failed to provide appropriate and adequate narcotic drug reconciliation when staff did not accurately record controlled substance doses on the narcotic count record and did not immediately report a discrepancy in a resident’s controlled substance count. During observation of the south medication room refrigerator, an emergency medication kit was found without an expiration date or documentation of its contents. Inside the kit was 12 mL of lorazepam oral concentrate for a resident who had recently died. The certified medication aide stated that medications are usually returned to the pharmacist when a resident passes away. Record review showed the resident’s controlled drug record documented lorazepam administration on 06/30/2026 with 14.75 mL remaining, but the next entry on 07/05/2026 listed 0 mL administered and 12 mL remaining, creating a discrepancy in the count. The narcotic count sheet also had missing off-going nurse signatures on multiple dates. The administrative nurse verified the missing documentation and the count discrepancy, and stated staff should count narcotics every shift and report discrepancies to administration. The administrative nurse also verified the resident had died on 06/30/2026 and stated the pharmacist should have picked up the medication.
Unlabeled Insulin Pens
Penalty
Summary
The facility failed to label insulin flex pens for Resident 1, Resident 28, Resident 39, and Resident 73 when the pens were initially opened for use. On 07/20/2026, observation of the North Treatment Cart Hall 2 showed Resident 28’s Lantus flex pen was not labeled with the correct date opened or discard date. Resident 73’s Humalog flex pen, two Lantus Solostar flex pens, and one Lantus flex pen were also not labeled with the correct date opened or discard date. License Nurse G later verified that nurses should date insulin pens when opened and mark the discard date, and confirmed the dates on the pens were not the accurate dates they were opened. Later that day, observation of the North Treatment Cart Hall 1 showed Resident 1’s Novolog flex pen and Resident 39’s Humalog insulin flex pen were not labeled with the date opened or the discard date. License Nurse H verified that nurses should date insulin pens when they are opened and indicate the discard date. Administrative Nurse D also verified that the nurse should label and date the insulin flex pens with the date they were opened and the date of discard. The report also cited MedlinePlus guidance that open, unrefrigerated Novolog, Humalog, and Lantus can be used within 28 days and then must be discarded, and the facility’s Medication Storage policy stated medications would be stored according to manufacturer recommendations.
Hospice collaboration and documentation were incomplete for two residents
Penalty
Summary
The facility failed to ensure collaboration of care between hospice providers and the facility for two residents receiving hospice services. One resident had diagnoses including encephalopathy, chronic respiratory failure, and atrial fibrillation, with severely impaired cognition and care needs related to ADLs, oxygen dependence, incontinence, and deconditioning. The resident’s care plan noted hospice services, hospice CNA visits, hospice nurse visits, and expected poor skin integrity at end of life, but it did not include direction for staff on how to contact the hospice provider or identify the supplies, DME, or medications hospice would provide. The resident’s hospice binder at the nurse’s station did not contain the current hospice plan of care. The binder was missing the most recent hospice POC and the related hospice information that should include the most recent patient-specific plan of care, hospice election form, physician certification and recertification, hospice personnel contact information, 24-hour on-call instructions, hospice medication information, and hospice physician and attending physician orders. On observation, the resident was lying in bed resting. A second resident had diagnoses including chronic respiratory failure, CHF, and DM, with severely impaired cognition and hospice services in place. This resident’s care plan included hospice-related directions such as DNR wishes, hospice attendance at family care meetings, medications and DME provided by hospice, and hospice nursing, chaplain, and social service visits. However, the hospice binder contained only past certification and recertification periods and lacked the most recent recertification signed by the hospice medical director as well as the current hospice POC. On observation, the resident was sitting at the dining table eating breakfast. Staff stated that the hospice provider was responsible for keeping the binder current and that the facility care plan should reflect the hospice provider, contact information, supplies, medications, and visit frequency.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the actual scheduled hours worked for nursing staff directly responsible for resident care per shift. On 07/20/2026 at 08:30 AM, surveyors observed a Daily Nurse Staffing Sheet posted across from the North nurse's station that listed the date, the names of nurses and aides on duty, and the hours they worked, but it did not include a breakdown of the RN, LPN, CMA, and NA staff working each shift or the calculated hours worked for each shift. On 07/21/2026 at 07:30 AM and again on 07/22/2026 at 7:20 AM, surveyors observed the Daily Nurse Staffing Report posted with the nurse and aide names on duty and the hours they worked. On 07/22/2026 at 08:10 AM, Administrative Nurse D and Administrative Staff A verified that the Daily Nurse Staffing Report should be posted daily with the RN, LPN, CMA, and NA total hours worked per shift, the number of staff for each shift, and the facility census. The facility's Nursing Staffing Posting policy, dated 2025, stated that the Nurse Staffing Sheet would be posted daily in a readable format and include the facility name, current date, current census, and the total number and actual hours worked by RN, LPN, and CNA staff directly responsible for resident care per shift.
Failure to Supervise Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, who was at risk for elopement and falls, resulting in the resident leaving the facility unsupervised. The resident, who had severe cognitive impairment due to Alzheimer's disease and vascular dementia, was able to self-propel in a wheelchair through a hallway to a locked door with a keypad. The door was not properly latched, allowing the resident to exit the building through a set of double doors, which triggered an alarm at the nurse's station. However, the staff turned off the alarm without checking the door, allowing the resident to remain outside in cold weather for over an hour. The resident was eventually found in the dining room of the Assisted Living building, having traveled across a parking lot and through snow in temperatures ranging from 22 to 23 degrees Fahrenheit. The resident was dressed inadequately for the weather, wearing only a short-sleeved T-shirt, sweatpants, socks, and shoes, and was reported to be cold to the touch upon return to the facility. The resident's vital signs indicated a low body temperature, but no signs of hypothermia were observed. The incident highlighted a failure in the facility's response to door alarms and supervision of residents at risk for elopement. Interviews and investigations revealed that the door the resident exited through had not latched properly, and the nurse on duty deactivated the alarm without verifying the source. The facility's policy required staff to immediately check the source of any door alarm before deactivating it, which was not followed in this case. The facility's failure to adhere to its elopement prevention procedures and ensure the security of exit doors placed the resident in immediate jeopardy.
Removal Plan
- A new elopement risk assessment was completed for the resident.
- The nurse involved received corrective actions for not following elopement procedures and received education.
- Maintenance assessed and adjusted the door and checked door alarms.
- Staff education on policy, elopements, and door alarm response was completed.
- A QAPI meeting related to elopements was completed.
- Signs posted on door alarm mechanism at each nursing station to ensure all alarms are on and reminder that under no circumstances will an alarm be turned off until the source of the activation has been determined completed.
- An all-staff in-service completed.
- Reviewed elopement risk posters to ensure all were up to date and completed.
- The resident's care plan was updated to include interventions and monitoring of wandering completed.
Failure to Ensure Communication Training for Agency Staff
Penalty
Summary
The facility failed to ensure that agency staff received the required communication training, which is essential for providing quality care to residents. The facility had a census of 57 residents and relied on a contracted agency to provide necessary education for agency nursing staff. However, upon review, it was found that the credentialing files for an agency Certified Nurses Aid (CNA) and an agency Licensed Nurse (LN) lacked documentation of completed communication training. While the CNA had training in abuse, neglect, and exploitation (ANE), dementia, and infection control, and the LN had training in ANE and dementia, neither had documented communication training. An interview with the Administrative Nurse revealed that the facility did not ensure that the agency staff had the required education and training for direct care staff. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, which contributed to the deficiency. This oversight placed residents at risk for impaired care and decreased quality of life.
Deficiency in Resident Rights Training for Agency Staff
Penalty
Summary
The facility, with a census of 57 residents, failed to ensure that agency staff received the required training on resident rights, which is essential for providing proper care and maintaining the quality of life for residents. During a review of training records, it was found that the credentialing files for an agency CNA and an agency LN lacked documentation of completed training on resident rights. Although the CNA had received training in abuse, neglect, and exploitation (ANE), dementia, and infection control, and the LN had received training in ANE and dementia, neither had documented training on resident rights. An administrative nurse at the facility stated that the facility relied on the contracted agency to provide the necessary education for agency nursing staff, and admitted that the facility had not ensured that the agency staff had the required education and training for direct care. Additionally, the facility was unable to provide a policy related to the required education for direct care staff, leading to a deficiency in ensuring the completion of necessary resident rights training for staff providing care.
Failure to Maintain Resident Dignity During Transfer
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R41, during a transfer to the shower room. R41, who had diagnoses of dementia, COPD, and anxiety, was dependent on staff for activities of daily living and had severely impaired cognition. The resident's care plan specified a preference for evening showers twice weekly and required staff to break down tasks into manageable segments, maintain a routine, and provide reassurance. On the day of the incident, R41 was transferred from bed to a shower chair using a Hoyer lift by two CNAs. The resident was dressed in a gown open at the back and was unable to sit upright on the shower chair. Due to the unavailability of a bath bed, the CNAs attempted to reposition R41 on the shower chair and pulled him backward down the hallway to the shower room, with one CNA trying to prevent the resident's feet from dragging on the floor. Interviews with staff revealed that pulling a resident backward in a shower chair and transporting them uncovered in the hallway were against the facility's dignity policy. The policy emphasized maintaining residents' dignity by ensuring privacy and covering them during transport outside their rooms. Despite this, the staff did not adhere to the care plan or the dignity policy, resulting in a failure to treat R41 with respect and dignity. This incident placed the resident at risk for negative psychosocial outcomes and decreased dignity.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to ensure the sanitary storage of oxygen tubing for a resident, identified as R41, which increased the risk of respiratory infection and complications. R41's medical history included dementia, chronic obstructive pulmonary disease (COPD), and anxiety, with severely impaired cognition and dependence on staff for activities of daily living. Observations revealed that the oxygen tubing and nasal cannula were improperly stored, being wrapped around a Broda chair and draped over an oxygen concentrator, rather than being placed in a provided black bag for sanitary storage. Interviews with facility staff, including a Certified Nurse Aide (CNA), a Licensed Nurse (LN), and an Administrative Nurse, confirmed that the expectation was for oxygen equipment to be stored in a sanitary manner, using bags or containers provided for this purpose. Despite this, the facility was unable to provide a policy related to the sanitary storage of oxygen equipment when not in use, highlighting a gap in ensuring proper procedures were followed to prevent contamination and potential health risks for the resident.
Failure to Ensure Communication with Dialysis Center
Penalty
Summary
The facility failed to establish a consistent form of communication between the facility and the dialysis center for a resident, identified as R3, who required hemodialysis. R3 had diagnoses of dependence on renal dialysis and end-stage renal disease, necessitating dialysis on Monday, Wednesday, and Friday. Despite having a care plan that required staff to monitor and assess R3's arteriovenous access for signs of infection or impairment, the facility's records from late May to early August lacked evidence of consistent communication with the dialysis provider. This deficiency was highlighted during interviews with facility staff, who acknowledged that communication sheets were not sent with R3 to the dialysis center, and the dialysis provider did not always return them. The facility's undated Hemodialysis Policy required coordination of care, including the transmission of information to and from the dialysis unit. However, the facility had stopped sending communication sheets due to the dialysis provider not returning them. This lack of communication placed R3 at risk of potential adverse outcomes and physical complications related to dialysis, as there was no consistent exchange of information regarding R3's condition before and after dialysis sessions.
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Illustrative
What surveyors actually found near you
We read the 190 citations issued within 25 miles in the last 12 months — including the 4 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 Topeka
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brewster Health Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Tanglewood Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Providence Living Center | 3.7 mi | ★★★★★ | 53 | 2 |
| Lexington Park Nursing & Post Acute Center | 3.7 mi | ★★★★★ | 10 | 0 |
| Excel Healthcare And Rehab Topeka | 3.8 mi | — | 0 | 0 |
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