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 Legacy At College Hill during CMS and state inspections, most recent first.
Failure to supervise a resident during bathing, address fall risks, and use wheelchair foot pedals. A resident who needed help with bathing was left alone in an unlocked shower room after a CNA assisted with shaving; he slipped, struck his chin, later developed nausea and vomiting, and was diagnosed with an SDH, required a ventilator, returned on hospice, and died in the facility. The facility also did not identify fall causes or add fall-prevention interventions for one resident after a fall, and staff were observed pushing another resident in a wheelchair without foot pedals.
Resident council meetings were not held regularly, and no minutes or meetings were found for an extended period. A resident said the council had not met consistently since new ownership, and an admin staff member said she had only arranged one meeting in the past three months and did not know where the minutes were. An admin nurse was unsure whether meetings were occurring, while the facility policy stated it supports residents' rights to participate in a Resident Council.
Unsafe and Unclean Facility Environment: Surveyors observed multiple environmental deficiencies, including an unlocked maintenance storage room with stacked AC units, dirty vents, black substance on windowsills, walls, doors, handrails, and equipment, missing or broken light covers, holes in walls, and debris in hallways and the dining room. Staff interviews showed housekeeping cleaned vents and AC units, but filters were not changed and documentation practices were inconsistent, while the facility policy required a safe, clean, comfortable, and homelike environment.
A resident with COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM had intact cognition but needed extensive ADL assistance and had lower-body impairment. His care plan directed staff to keep his call light within reach, yet during observation it was found at the bottom of the bed and out of reach while he was lying in bed. Staff stated call lights should always be within the resident's reach and that residents should be told where they were placed.
A CMA left a locked med cart unattended with the laptop screen unlocked, allowing A resident's personal medical information and medications to be visible. The CMA said she was not sure whether the screen needed to be locked or hidden when away from the cart, and later interviews confirmed the cart and laptop screen should be locked whenever staff step away.
A resident with anxiety, PTSD, depression, moderately impaired cognition, and documented cognitive deficits with visual hallucinations had a PASARR I that indicated further evaluation was needed, but the clinical record lacked evidence that the PASARR Level II assessment was completed. The facility could not produce documentation that the Level II was requested or provided, and an Administrative Nurse stated social services could not find proof the assessment had been done.
A resident with COPD, major depressive disorder, neuromuscular bladder dysfunction, and DM had a Foley catheter and required staff assistance with toileting and catheter care, but his care plan did not include staff direction for urinary catheter care. The resident’s orders called for catheter irrigation, catheter care, dependent drainage, use of a dignity bag, and output charting, yet during observation the catheter bag was dangling from the bed, the tubing was under his leg, and staff interviews showed uncertainty about who placed catheter care on the care plan.
A resident with COPD, MDD, bladder dysfunction, and DM was dependent on staff for bathing and other ADLs, but bathing was not provided or documented as required. Records showed no bath sheets for an extended period, no refusal documentation, and the resident reported only one shower in two years, few bed baths, and inability to clean his hands or fingernails because his sink was not usable. Staff interviews showed confusion about bathing documentation and refusal handling, while observations found long fingernails with dark brown debris under them.
Failure to Provide Activities for a Resident with Dementia: A resident with dementia, anxiety, severe cognitive impairment, and total ADL dependence was not provided an activities program to support social needs and psychosocial well-being. Records showed only one 1:1 activity over several months, while observations found the resident repeatedly in bed with the TV on. Nurses acknowledged turnover in the activities dept and that there had been no activities in the memory unit for several days, despite care plan directions to invite and encourage participation and provide in-room activities.
A resident with COPD, major depressive disorder, neuromuscular bladder dysfunction, and DM had a Foley catheter that was not secured with an anchor and was observed dangling from the bed or resting on wheelchair foot pedals. The catheter tubing was placed under the resident’s leg, no dignity bag was used, and the care plan lacked catheter-specific direction. Staff interviews confirmed the tubing should be anchored and the bag secured below the bladder in a privacy bag, while the resident stated the facility had not offered a dignity bag and tape on the tubing caused pulling.
A resident with COPD, a respiratory infection, continuous O2, and CPAP therapy had CPAP and nasal cannula tubing observed lying on the bed and the CPAP mask draped over the machine instead of being stored in a sanitary container. Staff interviews showed inconsistent understanding of how to store the respiratory equipment, and the facility did not provide the requested storage of the equipment when not in use.
Dialysis Access Monitoring and Order Documentation Deficiencies: The facility failed to document daily access site assessments for a resident receiving HD, with records showing checks on dialysis days but not on non-dialysis days. The facility also lacked a complete physician order for another resident’s dialysis schedule, clinic location, and chair time, even though staff confirmed the resident went to dialysis on M/W/F and the care plan was not updated to match the current schedule.
Pureed diet food was not prepared according to the facility recipe for two residents. A dietary aide processed smothered pork chops and gravy in a food processor without referring to the available recipe, while stating he knew what to add to thin or thicken food as needed. The dietary manager said she was still educating staff on proper procedures, and the facility policy required puree foods to be smooth, soft, and homogeneous with specific preparation guidelines.
Failure to make survey results available. Observation showed the state agency results book was not available for residents and visitors to view. An Administrative Staff D stated a survey book existed but did not know where it was, and the facility could not provide a policy on past survey results availability.
Failure to post and retain daily nurse staffing information. Observation showed no staffing sheet posted, and an AN stated the staffing information should be easily viewed. The facility also did not keep records of all daily nurse staffing postings for the required 18 months, despite policy stating the information must be readily available to residents, staff, and visitors.
The facility did not maintain an effective pest control program, as evidenced by staff and resident reports of rodents and rodent droppings in rooms and common areas. A resident with intact cognition showed surveyors two dead mice caught in traps she placed under her bed, and housekeeping staff found rodent droppings and a dead rodent during cleaning. The pest control service had been discontinued due to unpaid invoices, and the facility's policy requiring ongoing pest control was not followed.
A resident with intact cognition and a housekeeper reported that a section of flooring at the dining room entrance had been missing and covered with water-saturated blankets for several weeks, creating ongoing safety concerns. Administrative staff confirmed the issue was due to a broken pipe and noted a lack of documentation and unresolved payment issues for repairs, resulting in failure to provide a safe and homelike environment.
A resident with dementia, depression, and traumatic brain injury, who was assessed as at risk for elopement, was able to exit the facility unsupervised due to staff failing to keep the Elopement Risk Book current and accurate. The book, used to alert staff to residents at risk for elopement, contained outdated information, lacked required photos and face sheets, and staff were unclear about which residents were at risk or responsible for updates. This lapse in documentation and supervision led to an increased risk of elopement for affected residents.
The facility failed to implement a water management program for Legionella and did not follow proper infection control practices for storing oxygen equipment. Two residents had unbagged oxygen tubing and nasal cannulas left in their wheelchairs, exposing them to potential contamination. The facility lacked documentation of completed water management processes and did not provide a policy for sanitary storage of medical equipment.
The facility failed to maintain a safe and sanitary environment in the main dining room and 400 hall, with issues such as missing flooring, grayish-black substances on vents and air conditioners, and missing mopboard. These deficiencies were verified by staff, who acknowledged the lack of maintenance personnel, placing residents at risk for health issues and falls.
The facility's kitchen failed to meet professional food safety standards, with uncovered food items improperly stored in the refrigerator, maintenance issues like missing tiles and substances on pipes, and expired sanitizer test strips. These deficiencies placed 65 residents at risk for foodborne illness.
The facility failed to offer or obtain informed declination for the pneumococcal PCV20 vaccination for several residents, as per CDC guidance. A review of medical records showed a lack of consent or informed declination for the vaccine, placing residents at risk. Interviews with staff confirmed the absence of a systematic approach to determine vaccination eligibility, relying instead on external medical directors without a definitive tracking system.
A resident was transferred to the hospital without being provided with written information regarding the facility's bed hold policy. The resident, who had multiple serious medical conditions, was transferred due to a decline in health. The facility failed to obtain a signed acknowledgment from the resident's representative, placing the resident at risk of not being able to return to the facility.
A facility failed to implement a person-centered care plan for a resident with PTSD, major depressive disorder, and traumatic brain injury. The care plan lacked specific interventions for PTSD, despite the resident's diagnosis since 2022. Administrative nurses were unaware of this omission, which violated the facility's policy for comprehensive care plans. This deficiency risked the resident's psychosocial well-being and treatment effectiveness.
A resident with cognitive and physical impairments, requiring supervision while smoking, sustained a cigarette burn due to unsupervised smoking. Despite facility policies and care plans indicating the need for supervision, the resident continued to smoke without oversight, obtaining cigarettes from family or other residents. This failure to enforce smoking policies placed the resident and others at risk for smoke or fire-related hazards.
A resident with end-stage renal disease required dialysis three times a week, but the facility failed to document essential details in the care plan, such as the dialysis schedule and site care. This deficiency was confirmed by an administrative nurse and observed during an interview with the resident, who expressed concerns about meal timing related to dialysis sessions.
A facility failed to provide trauma-informed care for a resident with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan lacked specific interventions to address PTSD triggers, and staff were unaware of this omission. Interviews revealed an expectation for staff to manage PTSD triggers, but no structured guidance was provided. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
A facility failed to ensure the Consultant Pharmacist identified and reported missed insulin administrations and blood sugar readings for a resident with diabetes. The resident's medical records showed numerous undocumented instances of insulin administration and blood sugar readings over several months. Despite the facility's policy, the CP did not report these omissions, placing the resident at risk for unnecessary medication administration and complications.
A resident with diabetes and other medical conditions did not receive physician-ordered insulin and blood sugar checks as required. Over several months, staff failed to sign off on multiple doses of insulin and blood sugar readings, with no documentation explaining the omissions. This placed the resident at risk for unnecessary medication administration and complications.
The facility failed to ensure CMS-approved indications for antipsychotic medications for three residents, leading to the risk of unnecessary medication administration. One resident was prescribed Vraylar without a documented physician response to a pharmacist's request for an appropriate indication. Another resident was prescribed risperidone for an unapproved indication of anxiety, and a third resident's clinical record lacked documentation for the continued use of Seroquel. These deficiencies placed the residents at risk for unnecessary medication use.
The facility failed to label and discard insulin medications properly, risking ineffective doses for residents. Observations showed unlabeled insulin flex pens and vials, with some having incorrect expiration dates. Licensed nurses confirmed the need for proper labeling and discarding per policy, which was not followed, placing residents at risk.
A facility failed to ensure proper collaboration with a hospice provider for a resident, leading to inadequate end-of-life care. The resident's care plan lacked essential information such as contact details for the hospice provider, a list of medical supplies, and a schedule of hospice staff visits. This deficiency was identified through observations, record reviews, and staff interviews, highlighting a lack of communication and coordination between the facility and the hospice provider.
A resident with Alzheimer's and Down's Syndrome, dependent on staff for care, developed a stage four pressure ulcer due to the facility's failure to reposition him every two hours, monitor his skin weekly, and provide timely wound treatments. Despite hospice staff's education efforts, the facility continued to neglect repositioning and peri-care duties, leading to further skin breakdown and additional pressure ulcers.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident with Alzheimer's and muscle weakness had a pressure ulcer worsen to stage four and a urinary catheter inserted, but the care plan was not updated. Another resident with diabetes and hemiplegia developed a foot wound, which was not included in the care plan. A third resident with a urinary catheter had a care plan that did not reflect his ability to manage the catheter independently. These oversights violated the facility's policy requiring care plan updates with changes in residents' conditions.
A resident with a history of diabetes and hemiplegia developed an ulcer on her right foot, but the facility failed to provide the ordered treatments, including pressure-relieving boots and regular dressing changes. Observations showed the resident's boot was often on the floor, and staff did not consistently monitor or document the wound's status. Interviews revealed confusion among staff about the care plan, and the facility's policy lacked clear guidelines for wound assessment frequency.
Two residents in a LTC facility were not provided timely incontinence care, resulting in saturated briefs and urine-soaked linens. One resident with Alzheimer's and Down's Syndrome was frequently found wet despite a care plan for two-hour checks. Another resident with hemiplegia and dementia was not changed for several hours, contrary to the care plan. The facility's policy required scheduled toileting, but it was not followed, leading to inadequate care.
A resident with pain and restless leg syndrome missed multiple doses of Norco and a Fentanyl patch due to the facility's failure to reorder medications timely. Despite experiencing significant pain, the facility did not document attempts to notify the physician or pharmacy. Staff interviews revealed a lack of awareness and communication regarding the medication shortage, and the facility's policy lacked clear instructions for reordering medications.
The facility failed to maintain effective infection control practices, including improper glove removal and hand hygiene during resident care, and incorrect positioning of a urinary catheter drainage bag. Staff did not change gloves between tasks, and a resident's catheter bag was positioned above the bladder, contrary to facility policy.
Failure to Supervise During Bathing, Address Fall Risks, and Use Wheelchair Foot Pedals
Penalty
Summary
The facility failed to provide adequate supervision to prevent accidents for a resident who required assistance with bathing. On 04/27/2026 at about 8:00 PM, the resident self-propelled into an unlocked shower room, came out, and waved down a CNA to request help with shaving. The CNA assisted with shaving and then left the resident alone in the shower to complete his own shower. While staff were out of the shower room, the resident slipped and hit his chin on the shower bar. About two hours later, he became nauseous, vomited, reported a headache, and asked to go to the hospital. The resident went to the emergency department and was diagnosed with a subdural hematoma. He was subsequently placed on a ventilator. The resident returned to the facility on hospice and died in the facility on 05/06/2026. The report states this placed the resident in immediate jeopardy. The facility also failed to identify causative factors for falls and develop and implement interventions to prevent further falls for another resident, and failed to ensure a safe environment when staff propelled a resident in a wheelchair without foot pedals. One resident had diagnoses including difficulty walking, weakness, abnormal posture, lack of coordination, and anxiety, and was documented as moderate to high fall risk, with a care plan that did not address fall risk or fall-prevention interventions. After a fall in the hall that sent the resident to the hospital for shoulder pain, there was no post-fall intervention documented. Another resident, who had diagnoses including pneumonia, sepsis, altered mental status, neuropathy, neuralgia, anxiety, and hypertension, was observed being pushed in a wheelchair without foot pedals, with his legs bent and feet positioned just above the floor. Staff acknowledged that the wheelchair should not have been used that way, and nursing staff stated foot pedals should be used whenever pushing a resident in a wheelchair.
Resident Council Meetings Not Held Regularly
Penalty
Summary
The facility failed to facilitate and ensure the resident council was able to meet regularly. Record review of the Resident Council Meeting showed no minutes or meetings for the months of May 2025 through May 2026. A resident stated the Resident Council had not met on a regular basis since the new owners acquired the facility and reported that Administrative Staff A conducted a meeting in 02/26, though the resident could not remember the exact day. The resident also stated the activities directors previously facilitated the Resident Council meeting, but there had been several turnovers in the activity department and a Resident Council meeting had not occurred. An administrative nurse stated Administrative Staff A had held a meeting with residents and that the facility had turnover in the activity department, but she was unsure whether meetings were happening. Administrative Staff A stated she had arranged and assisted residents with one resident council meeting in the past three months and did not know where the minutes for that meeting could be found. The facility's Resident Council Meeting policy dated 02/01/26 stated the facility supports residents' rights to organize and participate in resident groups, including a Resident Council.
Unsafe and Unclean Facility Environment
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment. During observation on 06/01/2026, surveyors found multiple environmental issues throughout the building, including an unlocked maintenance storage room on the 300 hall with seven air conditioner units stacked inside, a resident room with a black fuzzy substance on the windowsill and areas of missing paint on the walls, and a 200 hall ceiling light with no cover and two springs hanging down. The 200 hall also had a dirty cart with popcorn debris, hallway doors with black substance on the bottoms, walls with white spackle-like substance, and a broken light fixture that was missing a bulb and was dimly lit. On the 500 hall, surveyors observed six holes in the wall above the baseboard, an outside courtyard door not shut, another courtyard door unlocked, handrails with large areas of missing paint and dirt on the brackets, and a storage room with five tall boxes of supplies and one plastic-wrapped mattress sitting directly on the floor. Additional observations showed the 100 hall floor stained with a brown dirt-like substance and a blue popped balloon in the hallway, a Hoyer lift in the hallway with food debris and other black substances on the foot part, and vents near the activity room, respiratory storage room, and 100 hall with a black organic-like substance. On 06/02/2026, the dining room had a dusty floor vent and a vent cover knocked off and lying on the floor. Interviews with housekeeping, maintenance, and administrative nursing staff showed that housekeeping cleaned vents and air conditioner units, but filters were not changed, maintenance did not chart filter changes, and a housekeeping checkoff sheet had just been implemented. The facility policy stated that the environment should be safe, clean, comfortable, and homelike and that the physical layout should not pose a safety risk.
Call Light Left Out of Resident's Reach
Penalty
Summary
The facility failed to ensure Resident 5's call light was within reach so he could call for staff assistance. Resident 5 had diagnoses of COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. His Significant Change MDS documented a BIMS score of 15, indicating intact cognition, and also noted impairment of the extremities on both sides of his lower body. The MDS further documented that he needed setup or cleanup assistance with eating and oral hygiene and was dependent on staff for toileting, bathing, and dressing. Resident 5's Falls CAA documented anxiety, antidepressant drug use, and assistance required for ADLs, placing him at risk for falls. His care plan stated that staff were to keep his call light within his reach so he could notify nursing when he needed to use the toilet or had an incontinence episode, and a later care plan entry stated staff were to keep the call light within his reach as he allowed. During observation, Resident 5 was lying in bed with his eyes shut, and his call light was found at the bottom of the bed on the left-hand side, out of his reach. Staff interviews stated that call lights should be placed within the resident's reach, on the bed rail or on the person, and that residents should be told where the call light was placed.
Failure to Protect Resident Medical Record Privacy
Penalty
Summary
The facility failed to ensure staff secured and protected the privacy and confidentiality of Resident 8's medical record. On 06/02/26 at 07:55 AM, a CMA left a locked medication cart unattended with the laptop screen unlocked, and Resident 8's personal medical information and medications were visible on the screen. When the CMA returned at 07:57 AM, she confirmed she was assigned to that medication cart and stated she was not positive whether the screen needed to be locked or hidden when she was away from the cart. Later interviews confirmed that medication carts and laptop screens should be locked whenever a medication aide or nurse walks away from the cart. The facility's Confidentiality of Personal and Medical Records policy stated that residents have the right to secure and confidential personal and medical records, including confidentiality of all information contained in a resident's records regardless of the form of storage or location.
Failure to Complete PASARR Level II Evaluation
Penalty
Summary
The facility failed to coordinate care for a resident following a Preadmission Screening and Resident Review (PASARR) that indicated a Level II evaluation was needed. The resident had diagnoses of anxiety, PTSD, and depression, and the Quarterly MDS documented a BIMS score of 9, indicating moderately impaired cognition. The resident’s CAA also documented a cognitive deficit and visual hallucinations, and the care plan included interventions for family involvement, activities, social interaction, and in-room activities. The resident’s EMR contained a PASARR I dated 09/11/24 that indicated further evaluation was required, but the clinical record lacked evidence that the PASARR Level II evaluation was completed. When the facility was asked for evidence that the Level II assessment had been requested and provided, it was unable to produce documentation. On observation, the resident was seen sitting in the dining room with a smoker apron on, watching TV, and her hair was oily and stringy. The Administrative Nurse stated the social service department was unable to find documentation that the Level II PASARR assessment had been completed as indicated.
Care plan omitted urinary catheter care
Penalty
Summary
The facility failed to revise Resident 5’s care plan to include care of his urinary catheter within 7 days of the comprehensive assessment. Resident 5’s EMR listed COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. His quarterly MDS documented a BIMS score of 15, impairment of the extremities on both sides of his lower body, dependence on staff for toileting, bathing, and dressing, and use of a Foley catheter during the observation period. The urinary incontinence/indwelling catheter CAA dated 03/09/26 documented that he triggered for alteration in elimination and need for an indwelling catheter due to ADLs, and that he required assistance with toileting, perineal care, use of a bed pan for bowel elimination needs, and indwelling catheter care. Resident 5’s care plan addressed bowel incontinence, impaired skin, rashes, irritation in the peri-area, toileting assistance, call light use, and loose fitting clothing, but it lacked staff direction for urinary catheter care. Physician orders directed indwelling urinary catheter irrigation with 60 mls of normal saline every shift, catheter care, hanging the catheter to dependent drainage, keeping it inside a dignity bag, and charting output every shift. During observation on 06/01/26, Resident 5 was lying in bed with his eyes shut; his catheter bag was three-fourths full of yellow urine, hung from the bed, the tubing was placed under his right leg, the bag was not secured to the bed, and he did not have a dignity bag. Staff interviews showed a CNA stated he would rely on the ADL log at the nurse’s desk for catheter care information, an LN was unsure who placed urinary catheters on residents’ care plans, and an Administrative Nurse stated the urinary catheter should be placed on the resident’s care plan.
Failure to Provide and Document Bathing and Hygiene Assistance
Penalty
Summary
The facility failed to ensure staff assisted R5 with bathing and hygiene as needed. R5’s EMR documented diagnoses of COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. The Quarterly MDS showed a BIMS score of 15, impairment of the extremities on both sides of the lower body, and dependence on staff for toileting, bathing, and dressing, with set-up or clean-up assistance needed for eating and oral hygiene. The CAA documented that R5 triggered for altered functional abilities and self-care/mobility because he required assistance with ADLs, including total care for bathing, toileting, turning, and mobility needs. The care plan stated R5 required assistance with ADLs, was incontinent, and was a two-person assist with bathing and showering, with staff to inspect skin during showers, alert nurses to skin issues, encourage two baths a week, and check and trim nails during baths. Despite this, the care report showed only three baths in early April and no bathing documented for May, and the bath sheets contained no entries from 04/01/26 through 05/31/26. The EMR also lacked documentation of bathing refusals. On observation, R5’s right hand was resting on his electric wheelchair and later on his abdomen, and his fingernails were long with a dark brown substance under them. R5 stated he had only one shower since being at the facility in the last two years, said staff told him he was too big for the shower chair, reported receiving only a few bed baths, and said he was unsure when he should get baths or showers because he did not get them. He also stated he tried to wash his hands and clean his fingernails but could not use his sink, which he said was not cleaned and had urine dumped into it from his catheter bag. A CMA stated she did not chart bathing in the EMR and had just learned she was supposed to chart in TASK, while an LPN stated the bath aide handled showers and refusals were to be taken to the nurse and then to Administrative Nurse D. Administrative Nurse D stated the facility had hired bath aides in 05/26 and that bathing was expected to be performed for each resident and charted in the EMR, with refusals charted in progress notes.
Failure to Provide Activities for a Resident with Dementia
Penalty
Summary
The facility failed to implement an activities program to support a resident’s social needs with involvement in both individual and group activities to support his highest psychosocial well-being when staff failed to offer and provide activities of his choice. The resident had diagnoses of dementia, anxiety, cognitive communication deficit, and senile degeneration of the brain. His quarterly MDS dated 05/15/26 documented a BIMS score of zero, indicating severely impaired cognition, and noted he was rarely or never understood and dependent on staff for all ADLs. His care plan directed staff to invite him to all scheduled activities, encourage participation, provide in-room activities as desired, and offer orientation to the facility’s daily schedule. Review of the resident’s EMR from 03/01/26 through 06/01/26 showed only one documented activity, a 1:1 visit on 05/04/26. Observations on 06/01/26 and 06/02/26 showed the resident repeatedly lying in bed with the TV on, with no documented participation in activities. On 06/03/26, an Administrative Nurse stated the resident liked to watch TV and listen to music and acknowledged there had been a lot of turnover in the activities department, that residents liked to watch TV when activities occurred, and that she was aware there had not been activities in memory care in the last few days. Another Administrative Nurse stated the facility was lacking in activities and was aware there were no activities in the memory unit. The facility’s Dementia Care policy stated residents with dementia were to receive appropriate treatment and services to meet their highest practicable physical, mental, and psychosocial well-being.
Inadequate Foley Catheter Securement and Privacy
Penalty
Summary
Failure to provide adequate catheter care occurred for R5, a resident with COPD, major depressive disorder, neuromuscular dysfunction of the bladder, and DM. R5’s MDS documented intact cognition with a BIMS score of 15, impairment of both lower extremities, dependence on staff for toileting, bathing, and dressing, and use of a Foley catheter during the observation period. The resident’s CAA identified alteration in elimination and the need for an indwelling catheter due to ADL needs, with assistance required for toileting, perineal care, bed pan use, and catheter care. R5’s care plan addressed bowel incontinence and toileting assistance but did not include staff direction for urinary catheter care. Physician orders directed staff to irrigate the indwelling urinary catheter with 60 mls of normal saline every shift, complete catheter care, hang the catheter to dependent drainage, and keep it inside a dignity bag. During observations, R5’s catheter tubing was placed under his right leg, the catheter bag was dangling from the bed without being secured, and no dignity bag was present. Later observations showed the catheter bag lying on the foot pedals of R5’s electric wheelchair, again without a dignity bag. R5 stated the facility had never offered a dignity bag and did not have an anchor for the catheter; he said tape had been used on the tubing and it pulled. Staff interviews confirmed the tubing should be anchored, the bag should be secured and placed below the bladder, and catheter bags should be in a blue privacy bag. An administrative nurse stated anchors were available but may have been misplaced and acknowledged R5 did not have a dignity bag, although she said he did not want staff to mess with the catheter.
Respiratory Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident with COPD, diabetes mellitus, major depressive disorder, and neuromuscular dysfunction of the bladder who also had a respiratory infection and was receiving continuous oxygen and CPAP therapy. The resident’s MDS documented intact cognition, lower-body extremity impairment, and dependence on staff for toileting, bathing, and dressing, with setup or cleanup assistance needed for eating and oral hygiene. The care plan and physician orders directed staff to assist with CPAP application every bedtime, ensure oxygen was connected at 3 L/min, clean the CPAP mask daily, and store the CPAP equipment in a bag or enclosed storage when not in use. During observations, the resident’s CPAP and nasal oxygen tubing were found laid on the bed, and the CPAP mask was observed draped over the CPAP machine on the bedside table, with the respiratory equipment not stored in a sanitary container. A CNA stated the equipment should be stored in a bag and pulled shut, while an LPN stated she was unsure how the equipment should be stored and said respiratory staff handled respiratory issues during the day. An administrative nurse stated all respiratory equipment should be placed in a bag when not in use and that all staff could place the equipment in the bags. The facility did not provide storage of respiratory equipment as requested.
Dialysis Access Monitoring and Order Documentation Deficiencies
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had the dialysis access site assessed within the standards of practice. The resident had diagnoses of dependence on dialysis and diabetes mellitus, and the record showed intact cognition with a BIMS score of 15. The care plan directed staff to complete a dialysis flow sheet daily, observe the shunt access site for complications, report abnormalities to the physician, and avoid blood pressure checks and needle sticks in the right arm. Although dialysis communication sheets showed access site assessments on dialysis days, the resident’s EMR lacked evidence that staff monitored and assessed the access site on non-dialysis days. During observation on 06/03/26, the resident was seen in the dining room before leaving for dialysis. A licensed nurse stated that nursing staff obtained vital signs and weights pre- and post-dialysis and that the resident attended dialysis every day except Thursday, Saturday, and Sunday. The nurse also stated staff checked the access site on the days the resident went out for dialysis and could not find documentation of access site checks on Thursday, Saturday, and Sunday. An administrative nurse later stated the access site should be accessed and documented daily on the MAR or TAR. The facility also failed to ensure that another resident had an active physician’s order that included the dialysis clinic, location, chair time, and days of treatment. That resident had diagnoses of CKD stage 4 and type 2 diabetes mellitus, with records showing hemodialysis during the observation period and a BIMS score of 15 on one assessment and 7 on another. The care plan listed dialysis days and chair time, but it had not been updated to reflect the resident’s current Monday, Wednesday, and Friday schedule at 05:15 AM or the current transportation provider. The EMR contained orders for access monitoring, pressure dressing removal, and pre- and post-dialysis assessments, but it lacked a physician’s order specifying the dialysis clinic, clinic location, chair time, or days of dialysis. Staff interviews confirmed the resident went to dialysis on Monday, Wednesday, and Friday and that the physician’s order should include when, where, and what days dialysis occurred.
Pureed Diet Preparation Not Followed
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and at a safe and appetizing temperature when pureed food was prepared for two residents on a pureed diet. On 06/02/26 at 10:29 AM, Dietary CC prepared pureed smothered pork chops by placing three pork chops from a warmer oven into a Robot Coupe food processor, then adding gravy from a separate container with a ladle. During the process, he did not refer to the recipe for the smothered pork chops that was available for him to follow. He also used a plastic spatula to scrape the food from the processor and continued processing after adding more gravy, then transferred the pureed pork chops into a clean metal container and covered and labeled it. At 10:35 AM, Dietary CC stated the facility had weekly menus each month that included recipes for each food and how they should be prepared, including pureed foods, but he had been preparing pureed food for a little while and knew what to add to thin or thicken food when needed. At 10:36 AM, Dietary BB stated she had been the dietary manager for only two weeks and was still educating staff on proper procedures. She stated she would re-educate Dietary CC to ensure he followed the recipes provided for the purees. The facility's Puree Food Preparation policy dated 02/01/26 stated puree foods should be prepared to prevent lumps or chunks and should have a smooth, soft, homogeneous consistency similar to soft mashed potatoes, with specific guidelines for additives by food type.
Failure to Make Survey Results Available
Penalty
Summary
The facility failed to post the previous state inspection information in a location accessible to residents and visitors. On 06/01/2026 at 07:37 AM, observation showed that the state agency results book was not available. During an interview on 06/03/2026 at 01:40 PM, Administrative Staff D stated that there is a survey book for the facility, but she did not know where it was. The facility was unable to provide a policy related to the availability of past survey results.
Failure to Post and Retain Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing sheet was posted and failed to retain the required 18 months of daily nurse staffing postings. On 06/01/2026 at 07:37 AM, observation showed that no nurse staffing sheet was posted. During an interview on 06/03/2026 at 01:40 PM, Administrative Nurse D stated that staffing should be posted where it could easily be viewed and that the facility did not keep documents of all daily posted nurse staffing from the last 18 months due to high turnover. The facility policy, Nurse Staffing Posted Information dated 02/01/2026, stated that nurse staffing information was to be made readily available in a readable format to residents, staff, and visitors at any given time.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations and staff interviews confirming the presence of rodents and rodent droppings in resident rooms and common areas. Pest control vendor reports documented a captured rodent and staff sightings of mice, with recommendations to keep doors closed. Despite these findings, the last documented visit from the pest control vendor was in March, and the service was discontinued due to unpaid invoices. Housekeeping staff reported finding rodent droppings, dried urine, and a dead rodent during deep cleaning of resident rooms, and these findings were reported to supervisors. A resident with intact cognition showed surveyors two dead mice in spring-loaded traps she had placed under her bed, stating this was not the first occurrence and that she needed more traps. Other staff, including a CNA and the maintenance supervisor, confirmed recent sightings of rodent droppings and evidence of rodents in the facility. The maintenance supervisor was unaware that residents were using their own traps and expressed surprise at the findings. The facility's policy requires an ongoing pest control program to ensure the building is free of rodents, but this was not maintained due to the cancellation of the pest control service.
Failure to Maintain Safe and Sanitary Environment Due to Prolonged Flooring Issue
Penalty
Summary
Surveyors observed that the facility failed to maintain a safe, clean, and homelike environment for its residents. During an initial tour, it was noted that flooring was missing at the entrance of the dining room on the 300 hallway, with an area approximately four feet long by one foot wide covered by water-saturated blankets and surrounded by wet floor caution signs. This condition had persisted for at least two to three weeks, as confirmed by both a resident and a housekeeper. The resident, who was cognitively intact, expressed concerns about safety due to the persistent wet floor. Administrative staff confirmed that the flooring issue was due to a broken pipe under the floor, which had been assessed by a local plumber. However, there was no documentation or estimate available to verify the plumber's visit. The administrator also reported concerns about the facility's ability to pay for repairs, as invoices had not been paid by the corporate office since March 2025. The facility's policy required providing a safe, clean, and homelike environment, which was not met in this instance.
Failure to Maintain Accurate Elopement Risk Documentation and Supervision
Penalty
Summary
The facility failed to implement and maintain up-to-date interventions to mitigate the risk of elopement for a resident with significant cognitive impairment. The resident in question had diagnoses of dementia, depression, and traumatic brain injury, and was assessed as being at risk for elopement based on a recent increase in their elopement risk assessment score. The resident's care plan included the use of a WanderGuard bracelet, 15-minute visual checks, and specific monitoring instructions. Despite these interventions, the resident was able to exit the facility when a transportation company opened the door, indicating a lapse in supervision and monitoring. Staff relied on an Elopement Risk Book at the nurse's stations to identify residents at risk for elopement, but the book was not kept current. Observations and interviews revealed that the Elopement Risk Book contained outdated information, lacked resident photos and face sheets, and had discrepancies regarding which residents were currently at risk or had active WanderGuard devices. Staff members were unclear about which residents were at risk and who was responsible for updating the book, with some staff unaware of recent elopement incidents and the current status of the elopement risk documentation. The facility's policy required that each resident's risk for elopement be assessed upon admission and that a photo and face sheet be placed in the Elopement Risk Book. However, these requirements were not consistently followed, as evidenced by missing photos and outdated lists in the risk books at both nurse stations. This failure to maintain accurate and current elopement risk documentation contributed to the increased risk of elopement for residents identified as at risk.
Failure to Implement Water Management and Infection Control Practices
Penalty
Summary
The facility failed to implement a water management program for Legionella disease, which is a bacterium spread through mist and can cause pneumonia, particularly in adults over 50 and those with weakened immune systems. The facility was unable to provide documentation of any completed water management processes or testing results, as the last maintenance supervisor had left and the information could not be retrieved. Although the facility had materials for a water management process, there was no evidence that the process was completed, and no policy was provided related to the sanitary storage of oxygen or catheter tubing. Additionally, the facility did not adhere to acceptable infection control practices regarding the storage of oxygen tubing and nasal cannulas for two residents. Observations revealed that the oxygen tubing and nasal cannulas for these residents were left unbagged and placed in the seat of their wheelchairs, exposing them to potential contamination as staff and residents moved through the area. Administrative staff acknowledged that the oxygen equipment should have been stored in a bag when not in use, but this practice was not followed, placing residents at risk for infectious diseases.
Environmental Deficiencies in Dining Room and 400 Hall
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for its residents, particularly in the main dining room and the 400 hall. Observations revealed several issues, including a section of missing flooring in front of the shower room on the 400 hall, which was approximately 18 inches wide by five feet long and half an inch deep, exposing the concrete beneath. In the main dining room, there were four floor vents and two window air conditioners covered with a grayish-black fuzzy substance. Additionally, the windows around the dining room had numerous streaks of grayish-black areas. Further issues in the dining room included missing mopboard below the window air conditioner and around the floor air vents, as well as a section of mopboard sticking out from the wall below the shelf where iced tea was kept. These environmental deficiencies were verified by Administrating Staff A, who acknowledged the lack of maintenance staff and stated that he was responsible for addressing these issues. The facility's Quality of Life-Homelike Environment Policy, revised in May 2017, emphasized the importance of maintaining a clean, sanitary, and orderly environment, which the facility failed to uphold, placing residents at risk for impaired health and well-being and falls.
Deficient Food Safety Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by several observations in the kitchen. During an inspection, it was noted that the walk-in refrigerator contained a box of uncovered bacon and a box of roasted turkey breast stored above a box of bulk pork sausage, which violates proper food storage protocols. The Dietary Manager confirmed these findings and acknowledged that staff should cover food items before refrigeration and store thawing meat on the bottom shelf. Additionally, the outside of the ice machine had streaks of a whitish substance, and the drainage pipe from the dishwasher was improperly positioned, touching the floor drainage area. Further inspection revealed multiple maintenance issues in the kitchen area, including missing tiles under the sinks and dishwasher, grayish-black substances on pipes, peeling sheetrock in a storage closet, and expired sanitizer test strips. The ceiling vent and lights were also found to have grayish and black substances, respectively, and the window above the steam table had streaks of a grayish substance. These deficiencies in food storage, preparation, and kitchen maintenance placed the 65 residents who received meals from the facility's kitchen at risk for foodborne illness.
Failure to Offer Pneumococcal Vaccination
Penalty
Summary
The facility failed to offer or obtain informed declination or physician-documented contraindication for the pneumococcal PCV20 vaccination for several residents, as per the latest CDC guidance. The review of clinical medical records for five residents revealed a lack of evidence that the facility or the resident representative received or signed a consent or informed declination for the pneumococcal vaccine PCV20. This oversight placed the residents at risk for pneumococcal infection and related complications. Interviews with facility staff, including Administrative Nurses E and D, confirmed the absence of a systematic approach to determine residents' eligibility for the PCV20 vaccination. The facility relied on the medical director or clinic physician's office to determine eligibility but lacked a definitive system to track who was eligible, when they were eligible, and whether they had been offered or declined the vaccinations. The facility's existing policy required assessment of pneumococcal vaccination status within five working days of admission, but this was not effectively implemented, leading to the deficiency.
Failure to Provide Bed Hold Policy Documentation
Penalty
Summary
The facility failed to provide Resident 18 with written information regarding the bed hold policy when she was transferred to the hospital. Resident 18, who had a range of serious medical conditions including Influenza A, acute respiratory failure, hypoxia, cerebrovascular accident, dementia, and diabetes mellitus, was transferred to the hospital due to a significant decline in her health. The nurse's notes indicated that the resident was unresponsive, had a high temperature, and low oxygen saturation levels, prompting the nurse practitioner to order her transfer to the hospital. However, the facility did not provide the resident or her representative with a signed copy of the bed hold policy, which is required to ensure the resident's right to return to the facility. The facility's bed hold policy mandates that residents and their representatives be informed in writing about the facility and state bed hold policies, both in advance of any transfer and at the time of transfer. In this case, the facility's records showed that the bed hold policy document was signed by an administrative nurse rather than the resident's representative, and there was no evidence of a signed acknowledgment by the representative. The administrative nurse confirmed that the representative had not signed the document and that the facility could not provide written evidence of the representative's acknowledgment of the bed hold policy. This deficiency placed Resident 18 at risk of not being permitted to return and resume residence in the nursing facility. The facility's failure to provide the necessary documentation and obtain the representative's acknowledgment of the bed hold policy violated the established procedures and policies, which are designed to protect residents' rights during hospital transfers.
Failure to Implement Person-Centered Care Plan for PTSD
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's care plan, last revised on 10/23/24, did not include a specific care area to address PTSD, its triggers, or interventions to prevent re-traumatization. Despite the resident's documented diagnosis of PTSD since 09/09/22, the care plan lacked individualized interventions to manage the condition effectively. This oversight was identified during a survey, where it was noted that the resident had a severely impaired cognition with a BIMS score of six and had displayed behaviors such as rejecting care. Interviews with administrative nurses revealed a lack of awareness regarding the absence of a PTSD care area in the resident's care plan. The facility's policy, revised in March 2022, mandates that care plans should be comprehensive and person-centered, including measurable objectives and timeframes. However, the facility did not adhere to this policy, as the resident's PTSD was not addressed at admission or upon diagnosis. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment.
Failure to Supervise Resident Smoking Leads to Injury
Penalty
Summary
The facility failed to maintain a safe environment for a resident, identified as R21, who was assessed to require supervision while smoking due to cognitive and physical impairments. Despite being educated on the need for supervision and the use of a protective smoking apron, R21 continued to smoke unsupervised, which led to a cigarette burn on her left iliac crest. The resident's medical history included conditions such as cerebral infarction, major depressive disorder, acute respiratory failure with hypoxia, and pneumonia, which necessitated staff assistance for activities of daily living and supervision for safety. R21's care plan and smoking policy indicated that she was a supervised smoker due to her impaired dexterity and history of smoking inside the facility. The facility's smoking assessment documented that R21 had no cognitive loss but had visual defects and dexterity problems, which increased her risk of injury from smoking. Despite these assessments, R21 was able to obtain cigarettes from family or other residents and smoked without supervision, leading to the burn injury. The facility's smoking policy required that all residents be informed of smoking limitations and that those requiring supervision be directly monitored by staff, family, or volunteers. However, the facility did not enforce these policies effectively, allowing R21 to smoke unsupervised, which placed her and other residents at risk for smoke or fire-related hazards.
Inadequate Dialysis Care Plan Documentation for Resident
Penalty
Summary
The facility failed to provide ongoing care plan communication and documentation for a resident, identified as R70, who required dialysis treatment. R70 had a diagnosis of end-stage renal disease and was admitted to the facility with a physician's order for dialysis three times a week. However, the care plan for R70 lacked essential documentation regarding the dialysis treatment, including the dialysis center, the schedule for dialysis sessions, and the care required for the dialysis site. This lack of documentation was confirmed by Administrative Nurse D, who acknowledged that the care plans were completed by a corporate nurse off-site and updated in-house as needed. The facility's policy on the care of residents with end-stage renal disease outlined the need for staff training and comprehensive care plans reflecting the resident's needs related to dialysis care. Despite this policy, the facility did not ensure that R70's care plan included necessary information about his dialysis treatment, placing him at risk for inadequate care and potential health decline. The deficiency was observed during an interview with R70, who expressed concerns about the timing of his meals in relation to his dialysis schedule, and was further verified by the administrative nurse.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care for a resident diagnosed with PTSD, major depressive disorder, and traumatic brain injury. The resident's electronic medical record documented these diagnoses, and the resident exhibited behaviors such as rejecting care and had a severely impaired cognition score. Despite these indicators, the resident's care plan lacked specific interventions to address PTSD triggers or prevent re-traumatization. The facility's failure to include a PTSD care area in the resident's care plan was noted, and staff were unaware of this omission. Interviews with administrative nurses revealed that there was an expectation for staff to have directions on managing PTSD triggers and interventions, but this was not implemented for the resident. The facility did not provide a policy regarding PTSD care when requested, indicating a lack of structured guidance for managing such cases. This deficiency placed the resident at risk for decreased psychosocial well-being and ineffective treatment, as the facility did not identify trauma-based triggers or implement individualized interventions to prevent re-traumatization.
Failure to Identify and Report Missed Insulin Administration
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported missed insulin administrations and blood sugar readings for Resident 25. The resident had multiple diagnoses, including diabetes mellitus, and was prescribed both fast-acting and long-acting insulin. However, there were numerous instances where the administration of these medications and the required blood sugar readings were not documented in the resident's medical records over several months. Resident 25's medical records revealed a lack of staff sign-off on insulin administration and blood sugar readings across multiple months. Specifically, there were missing sign-offs for Lantus and Humalog insulin administrations and blood sugar readings in November and December 2024, as well as January and February 2025. Despite the facility's policy requiring the CP to perform monthly medication regimen reviews, these omissions were not identified or reported by the CP. Interviews with facility staff indicated an expectation that the CP would identify and report missed medication administrations. However, the CP did not fulfill this responsibility, and there was no documentation explaining why the insulin was not administered as ordered. This oversight placed Resident 25 at risk for unnecessary medication administration and related complications.
Failure to Administer and Document Insulin for Resident
Penalty
Summary
The facility failed to ensure that Resident 25's physician-ordered insulin and finger stick blood sugars were administered and documented as required. The resident, who had a range of medical conditions including diabetes mellitus, hypertension, and major depressive disorder, was prescribed both fast-acting and long-acting insulin. However, there were multiple instances over several months where the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked staff sign-off for the administration of these medications and the completion of blood sugar readings. Specifically, the MAR and TAR for November 2024 through February 2025 showed numerous missed sign-offs for both Lantus and Humalog insulin, as well as for blood sugar readings. Despite the facility's policy requiring documentation when medications are not administered, there was no documentation in the resident's progress notes explaining why the insulin doses were missed. This lack of documentation and adherence to physician orders placed the resident at risk for unnecessary medication administration and related complications. Interviews with administrative nurses confirmed the expectation that nursing staff should administer insulin as ordered and document any reasons for not doing so. The facility's policy, revised in April 2019, emphasized the importance of administering medications safely and timely, and documenting any deviations. The failure to follow these protocols resulted in a deficiency related to the administration and documentation of medications for Resident 25.
Inadequate Indication for Antipsychotic Use in Residents
Penalty
Summary
The facility failed to ensure that three residents had a CMS-approved indication for the use of antipsychotic medications, leading to the risk of unnecessary medication administration and related complications. Resident 25, who had multiple diagnoses including hallucinations and major depressive disorder, was prescribed Vraylar for hallucinations without a documented physician response to a pharmacist's request for an appropriate indication. Despite a recommendation for a gradual dose reduction, the physician maintained the current dosage, citing a history of hallucinations and potential increased symptoms with a decrease. Resident 38, diagnosed with Alzheimer's disease and dementia, was prescribed risperidone for dementia with psychotic disturbances. However, a pharmacist noted that risperidone was listed for anxiety, which is not an approved indication. Although a gradual dose reduction was attempted, the facility did not ensure a CMS-approved indication for the medication, placing the resident at risk for unnecessary use. Resident 22, with severe cognitive impairment and a diagnosis of dementia, was prescribed Seroquel for major neurocognitive disorder. The clinical record lacked physician documentation of the rationale and risks versus benefits for the continued use of Seroquel. The facility's failure to ensure an appropriate indication for the use of Seroquel placed the resident at risk for unnecessary psychotropic medication administration.
Failure to Properly Label and Discard Insulin Medications
Penalty
Summary
The facility failed to properly label and discard insulin medications, which placed residents at risk for receiving ineffective medications. Observations revealed that several insulin flex pens and vials were not labeled with the date they were opened or their expiration dates. Specifically, a Glargine flex pen and a Levemir vial were found without these labels, and two other flex pens had incorrect expiration dates. Licensed nurses verified that the insulin should have been labeled and discarded according to the facility's policy and professional guidelines. Additionally, another resident's lispro insulin pen was found without an open date, which was confirmed by a licensed nurse. The facility's policy requires that insulin pens be labeled with the resident's name and the date opened. The failure to adhere to these labeling and storage policies resulted in a risk of administering ineffective insulin doses to the residents involved.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure proper collaboration of care between a resident's hospice provider and the facility, which placed the resident at risk of inadequate end-of-life care. The resident, who had been recently admitted to hospice services, had a significant medical history including Alzheimer's disease, dementia, hemiplegia, heart failure, and cerebral infarction. The resident's care plan was lacking in specific directions for staff on how to contact the hospice provider, details of the medical supplies and equipment provided by hospice, and a schedule of hospice staff visits. The resident's electronic medical record and hospice provider book were missing critical information, such as the hospice plan of care, a list of medications, and other services provided by hospice. Interviews with facility staff revealed that there was an expectation for the hospice plan of care to be included in the hospice book, and for the care plan to reflect all necessary hospice information. However, this information was not present, indicating a lack of coordination and communication between the facility and the hospice provider. The facility's Hospice Program policy outlined the responsibilities of both the hospice and the facility in managing the resident's care, emphasizing the need for coordinated care plans. Despite this policy, the facility did not ensure that the hospice plan of care was integrated into the resident's care plan, nor did it provide staff with the necessary information to effectively coordinate care with the hospice provider. This oversight resulted in a deficiency that compromised the resident's end-of-life care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and adequate care for a resident, R1, who was at high risk for pressure ulcers due to his medical conditions, including Alzheimer's disease, Down's Syndrome, and muscle weakness. R1 was totally dependent on staff for mobility, transfers, and toileting, and was always incontinent of bowel and bladder. Despite these needs, the facility did not implement a turning/repositioning program and failed to monitor R1's skin weekly, conduct weekly wound assessments, and provide wound treatments as ordered. As a result, R1 developed an unstageable pressure ulcer on his upper medial buttocks, which was not identified by the facility until two weeks after its onset, and it progressed to a stage four pressure ulcer. The facility's inaction and lack of communication contributed to the deterioration of R1's condition. Hospice staff repeatedly found R1 in saturated briefs and linens, indicating a failure to change and reposition him every two hours as required. Despite hospice staff educating facility staff on the importance of repositioning and providing peri-care, the facility continued to fail in these duties. The facility also failed to document wound characteristics and did not have treatment orders in place for R1's pressure area until 15 days after its onset. Additionally, the facility did not notify the dietary staff of R1's pressure area, which could have impacted his nutritional interventions for skin healing. The facility's documentation was inconsistent and incomplete, with missing entries for wound care and repositioning checks. The facility failed to perform weekly skin assessments as ordered and did not document current wound characteristics. R1's condition worsened with the development of additional skin issues, including new pressure ulcers on his left outer ankle, left ear, upper right abdomen, and fingers. The facility's lack of timely intervention and inadequate care led to the progression of R1's pressure ulcers and further skin breakdown.
Failure to Update Care Plans for Residents with Pressure Ulcers and Catheter Management
Penalty
Summary
The facility failed to revise the care plans for three residents, leading to deficiencies in their care. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, had a significant decline in his pressure ulcer from stage two to stage four, and a urinary catheter was inserted to assist with wound healing. Despite these changes, the care plan was not updated to reflect the new stage of the pressure ulcer or the presence of the urinary catheter, which was a requirement according to the facility's policy. Resident 2, who had diabetes mellitus with neuropathy, hemiplegia, and dementia, developed an arterial wound on her right foot. The care plan did not include this wound or provide guidance for its care, despite multiple assessments and treatments being documented. The facility's failure to update the care plan with the presence of the wound and the necessary care instructions was a clear oversight. Resident 5, who required assistance with personal care and had an indwelling urinary catheter, had a care plan that did not reflect his ability to empty his catheter bag independently. Observations showed improper management of the catheter tubing and drainage bag, which was not addressed in the care plan. The facility's policy required care plans to be revised as residents' conditions changed, but this was not done for Resident 5, leading to a deficiency in his care management.
Failure to Provide Ordered Wound Care and Pressure Relief
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident, identified as R2, who had an ulcer on her right foot. R2 had a medical history that included diabetes mellitus with neuropathy, hemiplegia affecting the right side, dementia, muscle weakness, and osteoarthritis. Despite being at risk for pressure ulcers, the facility did not ensure that R2 received the necessary treatments as ordered, including the use of pressure-relieving boots while in bed. Observations revealed that R2's pressure-relieving boot was often found on the floor rather than on her foot, and staff failed to change her dressing as scheduled. The facility's records showed inconsistencies and omissions in the documentation of R2's wound care. The Treatment Administration Record for June 2024 lacked any treatment interventions for R2's right foot, and there was a significant delay in implementing treatment orders for the wound. The Weekly Non-Pressure Wound assessments were incomplete, lacking measurements and descriptions of the wound area. Additionally, the facility's staff did not consistently monitor R2's wound status weekly, as required. Interviews with staff members revealed a lack of clarity and adherence to the care plan for R2. Licensed nurses and certified nurse aides were unsure about the specific requirements for R2's wound care and the use of pressure-relieving boots. The facility's policy on pressure ulcers and skin breakdown did not specify the frequency of assessments, contributing to the inadequate monitoring and treatment of R2's condition. These deficiencies highlight the facility's failure to ensure that R2 received the necessary care and treatment for her ulcer, as ordered by her physician.
Inadequate Incontinence Care for Residents
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, resulting in saturated briefs and urine-soaked linens. Resident 1, diagnosed with Alzheimer's disease, Down's Syndrome, and muscle weakness, was always incontinent of bowel and bladder and dependent on staff for toileting. Despite a care plan requiring staff to check and change his brief every two hours, multiple hospice visit notes documented that Resident 1 was frequently found saturated with urine, indicating neglect in providing necessary care. Resident 2, diagnosed with hemiplegia, dementia, muscle weakness, and osteoarthritis, was also always incontinent of bowel and bladder and dependent on staff for toileting. Observations revealed that Resident 2 was not checked or changed for several hours, despite the care plan instructing staff to do so every two hours. The resident reported feeling wet and not being changed since early morning, and staff confirmed the delay in providing care. The facility's policy on urinary continence and incontinence management required scheduled toileting and interventions to manage incontinence. However, the facility's failure to adhere to these policies resulted in inadequate care for both residents, as evidenced by the repeated findings of saturated briefs and soiled linens.
Failure to Timely Reorder Pain Medications
Penalty
Summary
The facility failed to ensure timely reordering of medications for a resident, identified as R4, resulting in missed doses of critical pain management medications. R4, who had diagnoses of pain and restless leg syndrome, was assessed with intact cognition and required scheduled pain medication. The resident missed eight doses of Norco and one dose of a Fentanyl patch over a period from July 27 to July 29, 2024. The facility's Medication Administration Record (MAR) indicated that the medications were unavailable, and there was no documentation of attempts to notify the physician or pharmacy to obtain the medications. R4 reported experiencing significant pain, which affected her sleep and daily activities, with pain levels reaching up to eight or nine on a scale of ten. Despite the administration of PRN acetaminophen, which was sometimes ineffective, the facility did not document the use of other available pain management options, such as Voltaren gel. The resident expressed that the facility had run out of her medication in the past and noted that the medication aides did not reorder in a timely manner, leading to a delay in obtaining a new prescription over the weekend. Interviews with facility staff revealed a lack of awareness and communication regarding the medication shortage. Certified Medication Aide R and Administrative Nurse D described the process for reordering medications, which involved using the electronic system or faxing a request to the pharmacy. However, there was a failure to follow these procedures effectively, as evidenced by the lack of documentation and follow-up. The facility's policy on medication administration did not provide clear instructions for reordering medications, contributing to the oversight that led to R4's missed doses.
Infection Control Deficiencies in Glove Use and Catheter Positioning
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several observations involving improper glove removal and hand hygiene practices. On one occasion, a Certified Nurse Aide (CNA) removed a resident's wet disposable brief with gloved hands and then handled a new brief without changing gloves. Additionally, a Licensed Nurse (LN) performed wound care on a resident's pressure ulcer without performing hand hygiene between glove changes, despite acknowledging the importance of doing so. The LN also used scissors to cut a foam piece and applied it to the resident's wound without proper hand hygiene, and the CNA assisted with the same gloves used to handle the wet brief and trash can. Another incident involved a CNA providing peri-care to a resident after incontinence and then placing clean bedding and a brief on the resident without changing gloves. The CNA later acknowledged the need to change gloves between tasks. Furthermore, a resident's pressure-reducing boot was stored directly on the floor, which is not in line with proper infection control practices. The facility also failed to ensure proper positioning of a resident's urinary catheter drainage bag. The catheter tubing was observed exiting from the bottom of the resident's pant leg and crossing a lap tray before reaching the drainage bag, which was positioned above the bladder. This improper positioning was noted on two separate occasions, and staff acknowledged that the drainage bag should be positioned lower than the bladder to prevent complications. The facility's policies on hand hygiene and catheter care were not adhered to, contributing to these deficiencies.
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 347 citations issued within 25 miles in the last 12 months — including the 8 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 Wichita
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Great Plains Post Acute | 1.3 mi | ★★★★★ | 17 | 0 |
| Larksfield Place | 1.5 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Wichita | 2 mi | ★★★★★ | 0 | 0 |
| Catholic Care Center, Inc | 3.2 mi | ★★★★★ | 3 | 1 |
| Center At Waterfront Llc | 3.3 mi | ★★★★★ | 19 | 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.