Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Nortonville Health Care Center during CMS and state inspections, most recent first.
Failure to Manage Resident Substance Use and Contraband: A resident with a history of alcohol and stimulant abuse had repeated incidents of drug paraphernalia, a knife, lighters, and suspected methamphetamine use in his room. Staff documented pinpoint pupils, a red face, and a crack pipe with methamphetamine still in the bowl, but the care plan lacked substance-use interventions and the record did not show monitoring after the resident refused hospital transport. Notes also described self-harm behaviors, out-of-facility meds on the resident’s table, and no clear follow-up on the contraband or intoxication.
Controlled medication records were not maintained in a way that allowed accurate reconciliation, and the narcotic destruction cabinet key could not be accounted for. Surveyors found the locked cabinet full of old narcotic meds, including medications dating back to 2024, and the facility could not account for dozens of narcotic prescriptions affecting current and discharged residents. Staff interviews and record review also showed discrepancies between narcotic count sheets and the eMAR, missing destruction documentation, and confusion over pharmacy involvement in controlled substance destruction.
The facility failed to maintain an effective infection prevention and control program. Surveyors observed dirty mechanical lifts moved between residents without cleaning, laundry and trash transported through halls, clothing piled in rooms, and PPE for EBP scattered or missing outside resident rooms. Records showed residents with wounds, catheters, MRSA, ESBL, sepsis, and IV antibiotics lacked an effective EBP program, while infection surveillance and water management documentation were incomplete or absent.
A resident with PVD, DM, impaired cognition, cellulitis, and prior pressure injuries had a change in condition while on antibiotics, including altered mental status, coughing, and refusal of hospital transfer and labs, but staff did not document continued monitoring, reapproach, education, or follow-up. The resident later developed extensive LLE infection with MRSA, required a below-the-knee amputation, and returned with further infection, while the record lacked evidence of timely monitoring, care planning, or wound care documentation tied to the change in condition.
A resident with incontinence, impaired mobility, PVD, edema, pain, and moderate cognitive impairment developed a facility-acquired sacral/coccyx pressure injury that was repeatedly documented with inconsistent staging, missing wound descriptions, and no wound images. Nursing notes often said the skin issue had not been evaluated, physician notes did not mention the wound, and the wound was variously charted as stage 2 and stage 3 while measurements changed and the wound later required hospitalization for wound care and sepsis.
A resident with left hip pain after a fall had ongoing pain documented, but the ordered opioid pain medication was not obtained for nearly two weeks and the MAR showed no evidence it was given during the ordered period. The resident also had no care plan interventions for pain or falls, and the pain CAA lacked further development. In a separate issue, a resident refused a dental visit and the record lacked evidence of follow-up attempts; later the resident developed left lower molar pain, swelling, infection, and difficulty chewing.
A resident admission agreement included a broad waiver stating the facility was not liable for loss or damage to valuables, personal property, or money brought into the facility. An admin staff member stated the regional office prepared the packets, staff completed and updated inventory lists at admission, and missing items were handled through the grievance process, but also acknowledged the agreement did not protect residents from misappropriation. The facility policy stated an admission agreement shall not include a general waiver of liability for residents’ health and safety.
Resident-Centered Activities Program Not Provided: The facility failed to provide an activities program tailored to residents’ interests, hobbies, and cultural preferences. The calendar listed repeated group activities, but some scheduled events were cut off, some activities did not occur as planned, and staff substituted other activities when residents did not want the scheduled ones or when supplies were unavailable. A resident stated the activities did not match his interests, and a consultant nurse stated activities should be resident-specific and age-appropriate.
The facility failed to show evidence that staff competency evaluations were completed for certified staff and Administrative Staff A. Surveyors requested the records twice, and a consultant later stated there was no proof the facility had performed competency evaluations. The facility policy stated staff would have the appropriate competencies and skill sets to assure resident safety and resident well-being.
Missing CNA Annual In-Service and Competency Documentation: The facility failed to provide evidence of at least 12 hours of annual in-service education for CNAs based on individual performance reviews. Administrative staff could not locate competency evaluations or training records after repeated requests, and a consultant stated there was no proof that competency evaluations had been completed with certified staff.
Failure of Administrative Oversight Across Resident Safety, Controlled Medications, and Infection Control: Administration failed to oversee a resident with SUD who was found with drug paraphernalia, knives, and methamphetamine in the facility, and staff did not have a clear system for monitoring intoxication or investigating the incidents. The facility also lacked a reliable controlled-substance accounting and destruction process, with missing narcotic records, an unsecured destruction cabinet, and unexplained medication discrepancies. In addition, infection control practices were deficient, with soiled clothing left in resident areas, urine odors throughout the building, and no effective system for tracking infections or documenting the IP role.
The facility failed to complete an effective facility-wide assessment for resident care needs and staffing resources. The assessment was completed by the admin team and select dept heads, but lacked input from direct care staff, residents, resident reps, and family members, and it did not include a plan to recruit and retain direct care staff. It also lacked acuity detail, meaningful staff competency evaluation for listed trainings such as CPR, CNA care, med admin, dementia care, and infection control, and it did not evaluate the infection prevention and control program despite identifying multiple common infections and residents in isolation/quarantine.
QAPI Program Lacked Effective Leadership Involvement and Failed to Identify Quality Concerns: The facility failed to maintain an effective QAPI program with consistent leadership participation. Survey review showed the DON did not attend multiple QAPI meetings and the Medical Director’s attendance was inconsistent. Staff could not produce prior agendas and described the same monthly topics being reviewed online. The facility also could not show that QAPI identified or addressed the Immediate Jeopardy and SQC findings involving accident hazards/supervision, pharmacy services, infection control, immunizations, and activities.
QAPI lacked evidence of effective monitoring and follow-through on repeated survey deficiencies. Prior citations included multiple areas such as F580, F623, F689, F755, F880, and F883, and the current survey again found issues including F689, F755, F880, F883, and F679, with IJ cited for F689, F755, and F880. QAPI sign-in sheets showed the DON missed multiple monthly meetings and the Medical Director did not attend quarterly, while staff described a repetitive monthly online process and could not provide prior agendas or evidence that systemic concerns were being tracked and addressed.
QAPI meetings did not have the required quarterly attendance by key disciplines, including the DON, Medical Director, Pharmacy, Therapy, and other department representatives. Review of sign-in sheets showed monthly QAPI meetings with inconsistent participation, and several meetings lacked evidence that required members attended. Administrative staff stated QAPI was done online, the agenda was the same each month, and sign-in sheets were not always sent to the Medical Director for signature. The facility policy stated QAPI was to be held monthly and that all disciplines should have a representative at least quarterly.
Failure to Monitor Antibiotic Use and Infection Control: The facility failed to implement an antibiotic stewardship program and did not maintain a system to track antibiotics, infectious organisms, or infection follow-up. Records showed multiple antibiotic orders for residents with cellulitis, wound infections, UTI, and MRSA, but the infection surveillance and binder lacked organism details, infection source tracking, and review of antibiotic effectiveness. Individual residents also had incomplete monitoring after catheter-related infection, cellulitis with mental status change and refusal of care, and a worsening sacral pressure injury that progressed to sepsis.
Qualified Infection Preventionist Not Designated and Infection Control Program Lacked Oversight. The facility identified an Administrative Nurse as the IP but could not show she was qualified by education, training, experience, or certification, and could not locate documentation of specialized infection prevention and control training. The facility assessment and infection surveillance records lacked meaningful evaluation, tracking, and trending of infections or antibiotic stewardship, while observations showed laundry, lifts, and soiled briefs being moved through resident areas with limited infection control practices and delayed EBP signage for residents with wounds, catheters, and MDROs.
Failure to document and offer flu and pneumococcal immunizations. The facility had no evidence that residents were offered the 2025 flu vaccine when it became available, and EHR immunization records showed only prior-year dates or undated refusals. For several residents, the facility could not produce signed consents, declinations, or administration records for flu, pneumococcal, or COVID-19 vaccines. A consultant nurse stated the DON or Social Services completed the consent/declination forms, while an administrative nursing staff member was responsible for overseeing immunizations and documentation.
Failure to conduct mandatory QAPI training for all staff and to verify staff competencies. The facility did not provide evidence of competency evaluations for certified staff, and a consultant stated there was no proof these evaluations had been completed. The facility policy stated staff would have the competencies and skill sets needed to assure resident safety and support the highest practicable physical, mental, and psychosocial well-being.
The facility failed to show evidence of CNA competency evaluations to support staff training and resident care needs. Surveyors requested the records from Administrative Staff A, but no proof was provided, and Consultant Staff X stated there was no documentation that competency evaluations had been completed for certified staff. The facility policy stated staff would have appropriate competencies and skill sets to support resident safety and well-being.
Failure to maintain and respond to monthly pharmacy reviews: The facility could not produce complete MRRs or physician responses for several residents receiving psychotropic and other medications. Residents had diagnoses including dementia, bipolar disorder, TBI, seizures, schizoaffective disorder, anxiety, and cognitive impairment, and records showed routine antipsychotic use with missing GDR documentation and pharmacy review follow-up. Staff and the CP reported that review documents were blank, unavailable, or not responded to, despite repeated emailed MRRs and recommendations.
Controlled meds awaiting destruction were not properly secured or accounted for. Staff did not know who had the key to the locked narcotic destruction cabinet, and maintenance had to cut off the lock after the cabinet was found full of narcotic meds that had not been destroyed for months. The facility audit also identified at least 55 narcotic Rx that could not be accounted for, and the cabinet contained medication cards with count sheets, including some dating back to 2024.
The facility failed to show that it offered the COVID-19 vaccine to residents and could not produce signed consents, declinations, or vaccination records for several residents. A consultant nurse said the DON or Social Services completed immunization consents/declinations, while Administrative Nursing Staff B was responsible for overseeing immunizations and documentation in the EHR. The facility policy stated the COVID-19 vaccine would be made available to all residents and staff and that they would be educated about it.
Failure to provide SNF ABN forms to two residents when Medicare Part A skilled services ended and the facility initiated discharge with remaining benefit days. The facility issued NOMNCs for both residents, but no ABNs were provided; staff documented they were unaware the ABN needed to be completed. Interviews showed the SSD and BOM described using NOMNCs and ABNs when residents were discharging from skilled services.
The facility failed to document required physician rationale, nonpharmacologic attempts, GDRs, and PRN limits for psychotropic medications for multiple residents. One resident with dementia and bipolar disorder received routine antipsychotics without a documented risk-versus-benefit statement or GDR rationale, another resident had a PRN lorazepam order without a 14-day stop date or supporting physician documentation, and a third resident’s psychotropic regimen lacked evidence of a physician response to pharmacy review or GDR documentation.
A resident with an indwelling catheter, MRSA, CKD, and bladder dysfunction did not receive timely catheter-related care planning or consistent catheter care. The record lacked catheter interventions and EBP until later in the stay, despite orders for catheter care every shift and monitoring for UTI. The resident was hospitalized multiple times for UTI and IV abx, reported staff did not clean the catheter or provide peri-care, and said the catheter was not secured with an anchor. A nurse also stated staff had seen the resident picking at the catheter with a knife, but this was not documented or care planned.
A resident with DM and CKD stage 4 who was receiving dialysis had incomplete dialysis communication records and missing post-dialysis assessments. The chart lacked signed dialysis communication sheets, several sheets were missing or incomplete, and staff interviews confirmed that pre- and post-dialysis vitals, weights, and assessments were not consistently documented in the EMR/TAR or fully completed on the dialysis forms.
A resident with dementia, bipolar disorder, and PTSD had a documented history of childhood sexual assault and other trauma-related behaviors, including accusations about money and increased emotional distress after her roommate died. Although staff noted her grief, emotional upset, and behavioral concerns, the care plan addressed general cognitive and psychosocial needs but did not include trauma-specific triggers or individualized interventions tied to her past trauma.
Failure to Individualize Dementia Care and Behavior Interventions A resident with dementia and bipolar disorder had repeated episodes of yelling, cursing, refusal of care, and accusations that staff had her money, but the care plan and CAA did not identify her specific behaviors, triggers, or individualized interventions. The record also showed limited analysis of dementia care needs and activity preferences, while staff interviews confirmed the resident’s money-related concerns and behavior patterns were known but not captured in the care plan.
A resident with moderate cognitive impairment and a history of sepsis refused a dental visit, but the record lacked evidence of follow-up attempts to obtain dental care. Weeks later, the resident developed left lower molar pain with redness, swelling, inflamed gums, and difficulty chewing, and was treated with antibiotics for a dental infection. Staff interviews indicated the resident had been reporting tooth pain and that Social Services was to contact the dental group, but no further dental appointment documentation was found.
CAA analysis of findings was not completed for three residents after comprehensive MDS assessments triggered CAAs for issues including cognitive loss/dementia, urinary incontinence/indwelling catheter, psychotropic drug use, ADL functional/rehabilitation potential, and behavioral symptoms. The consultant nurse stated she reviewed resident needs and updated the care plan, but did not complete the CAA analysis because she had been told it was not required, despite facility policy stating the CAA summary was part of a comprehensive assessment.
A facility failed to develop individualized care plans for a resident with dementia and bipolar disorder and another resident with changing ADL needs. The first resident had documented yelling, cursing, refusal of care, and other behaviors, but the care plan did not list specific behaviors, triggers, or interventions. The second resident used a wheelchair and walker and required varying levels of help with standing and transfers, but the care plan did not address ADL status, transfers, or mobility needs.
A resident with TBI, severe cognitive impairment, and unsafe mobility had multiple falls, including an unwitnessed bedroom fall and a bathroom fall with a forehead abrasion. The care plan listed him as at risk for falls but did not document new interventions after the falls, and the fall investigation reports lacked root cause analyses. Staff interviews showed inconsistent communication about fall interventions, and the facility’s policies required care plan review and revision after falls and with comprehensive and quarterly MDS assessments.
Nurse Staffing Information Not Posted: The facility failed to post daily nurse staffing numbers and actual hours worked during the survey, and staffing sheets were not available after September 2025. Observations showed the required staffing information was missing, and an admin staff member stated the facility had switched to timesheets, had only started posting staffing sheets the day prior, and did not know where the earlier sheets were. The facility policy required the Nurse Staffing Sheet to be posted at the beginning of each shift and maintained for at least 18 months.
Failure to Protect Resident from Resident-to-Resident Abuse: A cognitively impaired resident with a history of aggression entered a dining area and, without provocation, punched another resident multiple times, causing both residents to fall from their wheelchairs. The aggressive resident had diagnoses including TBI, depression, anxiety, and severe cognitive impairment, and his record documented repeated verbal and physical aggression toward staff and other residents. Staff were present in the area, but the assault occurred before intervention, and interviews confirmed there was no provocation.
A resident with multiple comorbidities developed a worsening left heel pressure ulcer after staff failed to implement a physician's order for suspension boots and did not document or apply the intervention. The order was not entered into the EMR, and the care plan did not address the required preventative measures. The wound deteriorated, and there was no evidence of timely physician notification or communication with the resident's representative, despite facility policies requiring these actions.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, resulting in unsafe conditions for residents.
The facility did not ensure RN coverage for eight consecutive hours daily, as required, with schedule reviews revealing multiple days without an RN on duty. Staff could only verify RN coverage through a staffing program, and the facility was unable to provide an RN coverage policy when asked.
The facility did not complete annual performance reviews for five staff members, including LNs, CMAs, and CNAs, who had been employed for over a year. Personnel records lacked documentation of these evaluations, and the administrative nurse could not verify their completion. The facility also failed to provide a policy for employee annual performance reviews when requested.
The facility did not maintain a system to accurately account for controlled medications in its emergency kit, with the kit being stored in an office that was found unlocked and unattended on several occasions. The emergency kit was received with one drawer unlocked and lacking an inventory list, containing Schedule 2 narcotics such as fentanyl, morphine, and tramadol. The facility also lacked a policy for narcotic storage and did not require receipts for kit deliveries, resulting in an inability to reconcile and safeguard controlled substances.
The facility did not ensure a licensed pharmacist performed required monthly drug regimen reviews for all residents, with missing documentation and reports for several months. A resident with multiple complex conditions and at risk for medication side effects did not have their medication regimen reviewed as required by policy.
Surveyors identified multiple sanitation and food safety issues in the kitchen, including unverified use of pasteurized eggs, dirty equipment and surfaces, expired chemical testing strips, dead insects above food prep areas, and structural problems such as missing baseboards and a back door gap. Dietary staff confirmed the need for cleaning and repair, and the facility's policies for cleaning and sanitizing were not followed.
The facility did not prioritize quality improvement, failed to develop and implement action plans, and did not conduct or document any Performance Improvement Projects (PIPs) for two consecutive years. Administrative staff confirmed the absence of PIPs and noted frequent changes in facility leadership. The facility also did not provide evidence of QAPI committee activities or regular data review as required by policy.
The facility did not maintain a QAA committee with the required members or meet at least quarterly, as sign-in sheets lacked key personnel and there was no documentation for meetings in the previous year. No Performance Improvement Projects were started or documented, contrary to the facility's QAPI policy.
The facility did not implement a water management program for Legionella prevention, despite staff training and an existing policy requiring routine cleaning and disinfection of potable water systems. Both maintenance and administrative staff confirmed that a surveillance system for Legionella was not in place.
The facility did not have a certified Infection Preventionist (IP) responsible for the infection prevention and control program, and could not provide documentation of a current certified IP. An administrative nurse confirmed the absence of a certified IP and was unsure if an infection tracking system had been in place previously, despite facility policy requiring the IP to oversee infection control activities and reporting.
A review of CNA records showed that several aides employed for over a year did not complete the required 12-hour in-service training, and facility leadership could not provide documentation to verify compliance.
Surveyors found that expired medications, including multivitamins, zinc tablets, Milk of Magnesia, and nicotine patches, were not removed from the medication room. An LN confirmed the medications were expired and should have been removed, and the facility could not provide a policy for medication storage or expired medications.
A facility serving 30 residents did not employ a full-time Certified Dietary Manager to oversee its food and nutrition services. The staff member acting as manager was not certified and had not begun certification training. The facility also could not provide a policy for employing a Certified Dietary Manager, relying instead on monthly visits and phone consultations from a Registered Dietitian.
Two residents were not assessed for eligibility to receive the pneumococcal PCV20 vaccine, and there was no documentation of the vaccine being offered, declined, or contraindicated. Medical records lacked evidence of consent or informed declination, and staff confirmed there was no system in place to check vaccine eligibility.
Failure to Manage Resident Substance Use and Contraband
Penalty
Summary
The facility failed to prevent, identify, and intervene in a resident’s substance use disorder after multiple incidents involving drug paraphernalia and suspected methamphetamine use in the resident’s room. The resident had diagnoses including alcoholic liver disease, psychoactive substance abuse in remission, and other stimulant abuse, and the admission record noted a history of chronic alcohol abuse and drug abuse. The resident’s MDS showed behavioral symptoms and the care area assessments for functional abilities, behavioral symptoms, psychotropic drug use, mood state, and psychosocial well-being triggered for review but were not further assessed for care planning decisions. The resident’s care plan did not include interventions for psychoactive substance abuse, stimulant use, signs and symptoms of illegal substance use, or triggers for possible illegal substance use. Staff documented a green tackle box and red basket in the resident’s room containing pill bottles, lighters, a torch, a large knife, and a black pouch with a drug pipe, but the note did not show follow-up on the unidentified pill bottles, knife, torch, lighter, or pipe. A later incident note documented the resident with pinpoint pupils and a severely red face, and staff found a crack pipe with methamphetamine still in the bowl and a lighter hidden in an eyeglass case. The resident refused hospital transport, law enforcement declined to transport him because of his medical conditions, and the record lacked evidence of monitoring for adverse outcomes after the methamphetamine use was identified. The resident’s record also showed self-harming and unsafe behaviors that were not addressed in the care plan or progress notes. Documentation noted the resident cutting scabs off his skin with a buck knife and applying alcohol to the areas, out-of-facility medications on his table, self-isolation in his room, and wound care for self-picking behaviors without evidence that the underlying cause was addressed. Staff interviews reflected concern that the resident was intoxicated, that he had access to knives and other items in his room, and that there were no clear interventions in place after the incidents. The Administrator and/or Regional Nurse were notified of the incidents, but the record did not show that the resident’s substance use disorder, paraphernalia, or intoxication were effectively managed.
Controlled Medication Accounting and Destruction Failures
Penalty
Summary
The facility failed to provide pharmaceutical services with a system for records of receipt through disposition of controlled medications that was detailed enough to allow accurate reconciliation. Surveyors found that the facility did not maintain and periodically reconcile controlled medication records, and the pharmacy did not have an onsite presence to assist with destruction of controlled narcotic substances for an extended period. A locked narcotic destruction cabinet in the medication room was used for medications awaiting destruction, but the administrator did not know who had the key, and maintenance staff had to cut the lock off the cabinet to access it. When the cabinet was opened, it was found to contain numerous narcotic controlled medications dating back to 2024. The facility could not account for 49 separate narcotic prescriptions of unknown quantity affecting 22 current and discharged residents. The facility’s own investigation identified multiple controlled medication prescriptions that could not be reconciled, including fentanyl, hydrocodone-acetaminophen, tramadol, hydromorphone, lorazepam, clonazepam, morphine, oxycodone, pregabalin, and Ativan injection. The facility also lacked records showing destruction sheets, delivery sheets, or documentation for several medications that were supposed to have been destroyed or sent with residents. Surveyors also identified discrepancies between narcotic count sheets and the eMAR, including administrations documented on count sheets but not on the eMAR and inconsistencies in liquid narcotic counts. One resident’s morphine count sheet showed a discrepancy in the amount on hand and amount remaining, and another resident’s lorazepam liquid records included handwritten changes, a notation of a spill, and no associated progress note. Staff interviews showed confusion about who held the key to the destruction cabinet and how narcotic destruction records were maintained. The facility’s policy required controlled substances awaiting destruction to be placed in a locked narcotic destruction box and destroyed by the licensed pharmacist in the presence of a licensed nurse, with records maintained for inventory and destruction.
Infection Prevention and Control Program Failure
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program in accordance with its facility assessment, regulatory requirements, and professional standards of practice. On entrance to the building, surveyors observed a strong urine odor throughout the common areas and multiple resident rooms with clothing piled on side tables and floors, full trash cans, and dust and debris on mechanical lifts. Staff were observed transporting laundry, trash, and multi-resident use equipment without cleaning the equipment between uses, including mechanical lifts moved throughout the facility with visible dust and debris on the bases. Surveyors also observed inconsistent use of enhanced barrier precautions (EBP). One resident room had a precaution sign and a plastic drawer set intended for PPE, but the PPE was scattered on top of and around the drawers, with an open box of masks and a bag of gowns on the floor. Additional rooms later had EBP signs and PPE drawers placed outside them, but staff interviews indicated the facility had only recently begun using these signs and PPE placements. Staff were observed carrying soiled laundry and trash through the hallways and touching handrails while transporting a visibly soiled bag, and clothing was observed hanging over handrails in the hallways. Record review showed residents with wounds, catheters, and MDROs did not have an effective EBP program in place. One resident had a long history of MRSA, a urinary catheter order, and multiple infections including UTI and blood culture growth; another resident received antibiotics for cellulitis and later developed extensive foot and ankle infection with MRSA bacteremia and below-the-knee amputation; a third resident had chronic wounds, ESBL E. coli carrier status, sepsis, ICU admission, and IV antibiotics. The facility’s infection surveillance records lacked tracking of infection locations, organisms, and follow-up actions, and the infection control binder lacked evidence of infection tracking, antibiotic review, or organism identification. The facility also lacked evidence of a water maintenance program assessment and did not have documentation of legionella testing or consistent water temperature monitoring. The Administrator was notified that the Immediate Jeopardy was ongoing.
Failure to Monitor and Document Change in Condition and Infection Treatment
Penalty
Summary
The facility failed to monitor, document, and follow up on a resident’s change in condition related to cellulitis and later severe left lower extremity infection. The resident had peripheral vascular disease, type 2 diabetes mellitus, impaired cognition, prior pressure injuries, and later an amputation of the left lower extremity. While the resident was receiving antibiotics for cellulitis, staff documented altered mental status, coughing, disorientation, and refusal of hospital transfer, but the record lacked evidence of continued monitoring, reapproach after refusal, or education about the seriousness of the situation. The record also lacked evidence that ordered labs were obtained after the resident refused them or that staff attempted further follow-up after the refusal. The resident’s care plan did not include direction for refusal of care, refusal of skin or wound assessments, or cellulitis-related monitoring. The care plan also lacked interventions tied to the cellulitis identified during the infection episode and did not reflect the resident’s later amputation or associated changes in ADL status in the CAA. The record showed antibiotic orders for cellulitis, but there was no evidence the facility monitored the effectiveness of the antibiotics or the resident’s skin for signs or symptoms of cellulitis, and the skin check documented during the change in condition did not show monitoring for cellulitis or other significant changes. Later, the resident requested transport to the hospital because of severe left lower extremity pain and was found to have extensive infection involving the bones and soft tissues of the foot and ankle, including osteomyelitis, septic tenosynovitis, and possible septic arthritis, with MRSA detected in blood cultures. The resident ultimately required a below-the-knee amputation and later returned to the hospital with MRSA bacteremia and infection of the residual stump. The record lacked evidence the facility assessed, documented, or placed interventions related to the amputation when the resident returned, and wound care for the incision was not documented until several days after treatments resumed.
Incomplete Pressure Injury Assessment and Monitoring
Penalty
Summary
The facility failed to ensure effective interventions, accurate assessments, and consistent monitoring to prevent a facility-acquired pressure injury from worsening for a dependent, incontinent resident with impaired mobility, peripheral vascular disease, edema, generalized weakness, pain, and moderate cognitive impairment. The resident’s care plan identified skin impairment risk related to incontinence and impaired mobility and included weekly skin checks, moisture barrier ointment, Braden scoring, a pressure reduction mattress and wheelchair cushion, and use of incontinence pads. However, the wound tracking documentation repeatedly lacked wound descriptions, staging details, images, and resident pain/condition/tolerance information, and several entries identified the wound as “not evaluated.” The resident’s sacral/coccyx wound was first documented as a facility-acquired stage 2 pressure injury and then followed through multiple pressure ulcer evaluations that showed inconsistent staging and incomplete documentation. The wound was variously described as an open lesion, stage 2, and later stage 3, with one evaluation incorrectly lowering the stage from stage 3 back to stage 2. Several assessments documented granulation tissue and slough in a wound still staged as stage 2, despite pressure injury staging guidance that stage 2 wounds do not have granulation or slough. The wound measurements fluctuated and increased over time, while progress notes repeatedly described the wound as stable, stalled, or improving, and many evaluations lacked photographs and detailed wound characteristics. The resident’s records also showed gaps in clinical recognition and communication. Monthly and skin check notes identified skin issues but often stated they had not been evaluated and did not include wound measurements, staging, or condition details. Physician monthly notes and the new admit H&P did not mention the pressure injury despite the ongoing wound. The resident later required hospitalization for wound care and sepsis, and hospital paperwork documented severe sepsis, a chronic sacrococcygeal ulcer described as stage 3-4 on clinical evaluation, and diagnoses including pressure injuries of the coccygeal and sacral regions. The hospital discharge instructions included wound packing and barrier care for the coccyx and sacrum/perianal area, and the resident returned to the facility with IV antibiotics and later required another transfer after becoming cold, clammy, diaphoretic, and hypotensive.
Pain Management and Dental Care Failures
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident with left hip pain after a reported fall. The resident complained of left hip pain on 07/19/25, limped, and was unable to bear full weight on the left foot. The record showed the resident had a diagnosis of pain in the left hip, had a BIMS score of 11 on the admission MDS, and later a BIMS score of 14 on the quarterly MDS. The pain CAA did not trigger for further review, the functional abilities CAA lacked further development, and the care plan initiated 07/03/25 lacked interventions related to pain, falls, or the resident’s subsequent left hip pain. The resident’s pain was treated with lidocaine patches and Tylenol, but these were not effective. A physician order for hydrocodone-acetaminophen 5-325 mg was entered on 08/12/25, yet the medication was not obtained until 08/25/25, and the MAR showed blank slots with no documentation that the medication was provided during the period it was ordered. The resident reported pain almost daily from 08/12/25 through 08/21/25, ranging from 1 to 8 on the pain scale. The record also showed the resident was on tramadol for moderate to severe left hip pain and stated it was not working. The MAR/TAR did not reflect the later signed order indicating the medication could be given every 4 hours as needed, and the resident’s pain management documentation showed no non-medication interventions during the observation period. The facility also failed to ensure a resident received needed dental care and services. The resident refused a dental visit on 10/30/25, and the record lacked evidence of staff attempts to get the resident to a dentist after that refusal. About two months later, the resident began complaining of tooth pain. Records showed redness and swelling to the left lower molar, an infection treated with penicillin, and later documentation of mouth and facial pain with difficulty chewing. The resident stated the bottom left tooth had been hurting for two weeks and that it hurt to eat, while staff noted the resident had a hard time eating, held her mouth, and complained that the tooth hurt. The facility’s dental services policy stated emergency dental services included treatment for acute pain in teeth or gums and that delays related to obtaining dental services would be documented, but the record contained no further progress notes regarding dental follow-up after the refusal.
Admission Agreement Included Improper Waiver of Liability for Personal Property
Penalty
Summary
The facility failed to establish and implement an admissions agreement that protected residents’ right to personal property. The Skilled Nursing Facility Resident Agreement stated under part four, page 14, section D Personal Possessions that the resident, under no circumstances, held the facility responsible for or liable of any nature whatsoever for the loss or damage to valuables, personal property, or money brought into the facility. Administrative Staff D stated the regional level completed the admission agreement packets and sent them out, and that staff completed an inventory list with the resident at admission and updated it with anything new brought in. She also stated that if a resident reported an item missing, staff followed the grievance process, investigated to find the item, and took ownership after the facility verified the item went missing in the facility. She stated the admission agreement statement did not protect residents from misappropriation. The facility’s admission policy, last revised 09/26/25, directed that an admission agreement shall not include a general waiver of liability for the health and safety of residents.
Resident-Centered Activities Program Not Provided
Penalty
Summary
The facility failed to provide a resident-centered activities program that incorporated resident interests, hobbies, and cultural preferences for a meaningful life. The activity calendar for January 2026 listed repeated group activities such as bingo, exercise group, coloring creations, movie and popcorn, mani time, trivia, balloon toss, happy hour, and free hour, but some scheduled times were cut off on the calendar. On 01/13/26, several residents sat in the dining room waiting to play scheduled bingo. On 01/14/26, residents were observed in the dining room and day area during scheduled activities, including residents coloring while others watched television, and one resident had coloring supplies in front of her but did not participate. The report also documented that a scheduled cooking activity did not occur because the Activities Director did not have chocolate chips, and exercise group did not occur because nobody wanted to do it, so coloring pages were used instead. The Activities Director stated she followed an activity book for ideas, interviewed residents about what they liked, and tried to switch activities when residents did not want the scheduled one. A resident stated the activities did not meet his interests because of the age and preferences of the other residents, and he said he mainly enjoyed watching a movie. Consultant Nurse C stated activities should be resident specific for age and demographic, and expected the activity calendar to be followed or changed to something equally engaging and enjoyable when needed. The facility policy stated residents should receive an ongoing program of activities designed to meet their interests and physical, mental, and psychosocial well-being.
Missing Staff Competency Evidence
Penalty
Summary
The facility failed to ensure staff had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident as determined by resident assessments, plans of care, and the facility assessment. The census was 34 with 14 residents in the sample. During the survey, the facility did not provide evidence of competency evaluations for Administrative Staff A when requested on 01/11/26 and again on 01/12/26. In an interview on 01/26/25, Consultant Staff X stated she did not have any proof that the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 showed the facility stated it would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident.
Missing CNA Annual In-Service and Competency Documentation
Penalty
Summary
The facility failed to provide evidence of at least 12 hours of annual in-service education for Certified Nurse Aides, and the education was not shown to be based on individual performance reviews. The facility census was 34 residents, and the deficiency was identified through interview and record review. Administrative Staff A was asked on 01/11/26 and again on 01/12/26 to provide evidence of CNA competencies and annual in-service education, but the facility could not locate the documentation. During an interview on 01/13/26 at 03:10 PM, Administrative Staff A stated they were still looking and had reviewed Administrative Nurse B's office without finding any documentation related to annual CNA training based on performance reviews. During an interview on 01/26/25 at 03:51 PM, Consultant Staff X stated she did not have proof that the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 stated the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being for each resident.
Failure of Administrative Oversight Across Resident Safety, Controlled Medications, and Infection Control
Penalty
Summary
The facility failed to provide effective administration for all 34 residents, with survey findings tied to multiple immediate jeopardy deficiencies involving accident hazards, pharmacy services, and infection control. The report states that administrative oversight was lacking during an extended recertification and complaint survey, and that staff reported fear of retaliation when raising concerns to administration. Administrative Staff A and Administrative Nurse B were repeatedly identified as failing to ensure oversight, documentation, and follow-up for resident care issues and facility systems. Regarding accident hazards, a resident with a history of alcohol and drug use and current drug use at admission was not managed with adequate oversight after entering the facility. The resident had blisters on both hands, but the record lacked follow-up or investigation into the cause. The resident was later found cutting scabs off himself with a knife and using non-facility managed medication, yet the record did not show investigation or follow-up. Staff later found four pill bottles, a torch, a red lighter, a large knife, and a black pouch containing a drug pipe in the resident’s room, and administration did not know what happened to the items. On another occasion, staff reported the resident appeared intoxicated with pinpoint eyes and a very red face, and a search of the room found a crack pipe containing methamphetamine. Methamphetamine spilled onto the medication cart during the event, and administration stated it was unaware whether smoking methamphetamine in the facility was reportable or required an investigation. Regarding pharmacy services, the facility lacked a system to account for controlled medications from receipt through disposition. The pharmacy had not been onsite to assist with destruction of controlled narcotics for months, and the administrator did not know who had the key to the locked narcotic destruction cabinet until maintenance cut the lock off. The cabinet contained stacks of medication cards with count sheets, boxes of medications, and a metal sharps-style bin with what appeared to be empty bottles of morphine and lorazepam. The facility could not account for 49 separate narcotic prescriptions affecting 22 current and discharged residents, and it lacked count sheets for a resident’s oxycodone. The administrator stated she had never seen narcotic destruction occur, could not find destruction records, and acknowledged that all count sheets had gone to one nurse, creating a single point of failure. Regarding infection control, the facility was observed with multiple resident rooms containing clothing strung across the floor and bedside tables, along with a strong smell of urine throughout the building. The facility lacked a system to store soiled resident clothing to prevent spread of infectious organisms. The administrator walked through the facility but did not address the observed conditions. The facility also lacked a complete infection prevention and control program, including tracking and trending infections, identifying organisms present, implementing enhanced barrier precautions for residents at risk due to wounds, catheter use, or other devices, and maintaining documentation that the designated infection preventionist had the education, experience, or certification for the role. The facility also failed to maintain a water management program, despite the issue having been cited on the prior annual survey.
Facility Assessment Lacked Required Input, Acuity Detail, and Competency Evaluation
Penalty
Summary
The facility failed to conduct an effective facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations. Review of the facility’s assessment tool showed 45 licensed beds and an average of 32 occupied beds in the last quarter, but the assessment was completed by the administrator, DON, social services director, medical director, and physical therapy without evidence of input from other required members of the community, including direct care staff, residents, resident representatives, and family members. The assessment also lacked a plan to maximize recruitment and retention of direct care staff. The acuity section of the assessment did not include a number or range of residents who required extensive services, special care high services, special care low services, clinically complex care, behavioral symptoms and cognitive performance, or reduced physical function. The facility’s description of staff training and competencies was limited to general statements such as annual competencies, monthly in-services, and education as needed, without describing how competency or effectiveness would be evaluated. The assessment listed CPR, life enrichment directors, culture change/person-centered care, infection control stewardship, CNA training, dementia management, disaster planning, medication administration, resident assessments, measurements for vital signs, urine, I&O, glucose, catheter care, care for residents with Alzheimer’s, dementia, and mental illness, specialized care, and unit care including nonpharmacological interventions, but provided no further detail on competency evaluation. The facility also failed to provide evidence of any staff competencies performed since the last annual survey. In the infection control section, the assessment identified common diagnoses such as skin and soft tissue infections, respiratory infections, tuberculosis, UTIs, MDROs, septicemia, viral hepatitis, C. difficile, influenza, and scabies, and noted an average of one to three residents in isolation or quarantine with active infection. Although the assessment included a section for evaluating the infection prevention and control program, it lacked any evaluation, review, or development of that program.
QAPI Program Lacked Effective Leadership Involvement and Failed to Identify Quality Concerns
Penalty
Summary
The facility failed to implement and maintain a comprehensive QAPI program and plan through effective involvement by governance and leadership. The facility reported a census of 34 residents, and survey findings identified Immediate Jeopardy and Substandard Quality of Care while the facility could not provide evidence that its QAPI program was effective in identifying quality concerns. Administrative staff stated the facility completed QAPI online on the computer and discussed the same topics each month, but could not produce prior agendas and pointed to a blank form as the monthly agenda. Review of QAPI sign-in sheets showed the DON did not attend the July 2025 through January 2026 meetings, and the Medical Director had not attended quarterly. Administrative staff stated quarterly meetings were held because QAPI was monthly, but attendance by the Medical Director was inconsistent and depended on his schedule. The facility’s blank QAPI form included sections for meeting purpose, IDT member attendance, and multiple audit topics such as physician visits, vaccines, wound reports, infection log review, incident review, therapy requests, psychotropic medication review, catheter review, discharge services, MDS review, care plans, equipment needs, DNR review, physician order signatures, and weight changes. The facility assessment tool revised 11/2025 stated the QAPI meeting would be held monthly and attended by the DON, Administrator, BOM, Activities Director, Medical Director, Therapy Director, Maintenance Director, and Environmental Services Lead, and that all staff were aware of and welcome to attend. The facility’s QAPI policy stated the committee would review resident concerns, grievances, and resident council input, and would use data such as infection logs, wound reports, antibiotic utilization, CMS quality measures, incident logs, weight loss reports, and medication audits. During the survey, the facility could not provide evidence that the QAPI program identified or addressed concerns related to the Immediate Jeopardy and Substandard Quality of Care findings involving accident hazards/supervision, pharmacy services, infection control, influenza and pneumococcal immunizations, and activities meeting resident interests and needs.
QAPI Program Lacked Evidence of Monitoring and Corrective Action
Penalty
Summary
The facility failed to show evidence that its QAPI program developed and implemented action plans to correct quality deficiencies cited on prior and current surveys. Review of the prior recertification survey dated 04/16/25 showed citations for multiple deficient practices, including F580, F623, F625, F689, F727, F730, F744, F755, F756, F760, F761, F801, F812, F867, F868, F880, F882, F883, and F947. During the current survey, the facility was again cited for several of these areas, including F689, F755, F880, F883, and F679, with Immediate Jeopardy identified for F689, F755, and F880 and Substandard Quality of Care identified for F689, F883, and F679. On 01/13/26, Administrative Staff A brought QAPI sign-in sheets to the surveyor. The sign-in sheets showed the DON did not attend the July 2025 through January 2026 meetings and the Medical Director had not attended quarterly. Administrative Staff A stated the facility did QAPI online on the computer and talked about the same thing every month, but she did not know how to print prior agendas and said the blank form was used each month. She also stated the facility had quarterly meetings because QAPI was monthly, but attendance by the Medical Director was hit and miss depending on his schedule. Review of the QAPI monthly blank answer form showed a general template with sections for resident care topics, incident review, infection control, medication review, wound reports, and other audits. The facility’s revised 11/2025 Facility Assessment Tool stated QAPI meetings would be held monthly and attended by the DON, Administrator, BOM, Activities Director, Medical Director, Therapy Director, Maintenance Director, and Environmental Services Lead, and that the meetings would be used to determine what was working and what needed improvement. The facility could not provide evidence that the QAPI program monitored systemic concerns cited on prior surveys to correct and mitigate the findings of Immediate Jeopardy and Substandard Quality of Care identified on the current survey.
QAPI Meetings Lacked Required Quarterly Attendance
Penalty
Summary
The facility failed to ensure the required members attended the Quality Assurance Performance Improvement (QAPI) meetings at least quarterly. The facility census was 34 residents, and survey review of the QAPI sign-in sheets showed monthly meetings from 04/10/25 through 01/09/26 with handwritten attendance records. The records showed attendance by various administrative and department staff, but several meetings lacked evidence that required disciplines such as the Administrator, DON, Medical Director, Pharmacy, Therapy, Social Services, or other disciplines attended as required. The 04/10/25 meeting lacked evidence the Administrator, Pharmacy, or Medical Director attended. The 07/08/25, 08/07/25, and 09/09/25 meetings lacked evidence the DON, Social Services, Therapy, Dietary, Pharmacy, or Medical Director attended. The 10/07/25 meeting lacked evidence the DON, Therapy, or Medical Director attended. The 11/06/25 meeting lacked evidence the DON, Therapy, or Medical Director attended, and the 12/09/25 meeting also lacked evidence the DON, Therapy, or Medical Director attended. The 01/09/26 meeting lacked evidence the DON, Therapy, Pharmacy, or Medical Director attended. From 04/10/25 through 01/09/26, the Medical Director attended only one meeting, on 06/11/25, over a ten-month period. The DON attended three meetings, on 04/10/25, 05/09/25, and 06/11/25, during the same period. On 01/13/26, Administrative Staff A stated the facility did QAPI online on the computer and that it was the same agenda every month, but she did not know how to print prior agendas and said she would forget to send the sign-in sheet to the Medical Director to sign. The facility policy stated QAPI meetings would be held monthly and that at least quarterly all disciplines should have a representative at the QAPI meetings.
Failure to Monitor Antibiotic Use and Infection Control
Penalty
Summary
The facility failed to develop and implement an antibiotic stewardship program and failed to maintain a system to monitor antibiotic use, infectious organisms, and infection follow-up for residents receiving antibiotics. The facility assessment identified common infectious conditions including skin and soft tissue infections, respiratory infections, urinary tract infections, multi-drug-resistant organisms, septicemia, C. difficile, influenza, and scabies, but the infection prevention and control section lacked any evaluation, review, or development of the infection control program. The Infection Surveillance Monthly Report showed 25 total infections over the reporting period, but the report listed no infections for later months and left several infection categories blank, including blood/systemic, bone/joint, cardiovascular, and ear/nose/mouth/throat. Record review showed 48 separate physician-ordered antibiotics and/or infection-related treatments for 18 residents, including treatment for cellulitis, upper respiratory infections, wound infections, and MRSA of unknown location. The facility’s infection control binder lacked tracking of infections, antibiotic review, and identification of the infectious agent or organism involved. Consultant Nurse C stated the infection surveillance report appeared to track and trend infections, but it lacked specific infection locations, infectious organisms, notation of catheter-associated urinary tract infection, and a system for recording infection control incidents with follow-up or the source of infection. The facility also failed to ensure appropriate monitoring and treatment for individual residents receiving antibiotics and infection-related care. One resident admitted with a urinary catheter had infected wounds to both inner thighs without an anchor for the catheter, was hospitalized multiple times, received IV antibiotics, had MRSA, and returned without monitoring or intervention to prevent further infection. Another resident treated for cellulitis had no documented evidence that the antibiotics were effective, no ongoing monitoring of signs or symptoms, and no documented response after a change in mental status and refusal of hospital transport and labs. A third resident developed a facility-acquired stage 3 sacral pressure injury, was hospitalized for wound care and IV antibiotics for sepsis, and the record showed ineffective assessments and inconsistent monitoring before the wound worsened.
Qualified Infection Preventionist Not Designated and Infection Control Program Lacked Oversight
Penalty
Summary
The facility failed to designate one infection preventionist who was qualified by education, training, experience, and/or certification and who worked at least part time on the infection control program. The facility identified Administrative Nurse B as the Infection Preventionist, but did not provide evidence that this staff member was qualified for the role or that specialized infection prevention and control training had been completed. The facility policy dated 05/14/24 stated the IP would be sufficiently trained, obtain specialized training before assuming the role, and provide evidence of training, but the facility was unable to locate documentation showing Administrative Nurse B completed such training. The facility assessment dated 11/18/25 identified common infectious disease concerns including skin and soft tissue infections, respiratory infections, tuberculosis, UTIs, multidrug-resistant organisms, septicemia, viral hepatitis, C. difficile, influenza, and scabies. The assessment also stated the facility would need to provide identification and containment of infections and prevention of infections, but it lacked any evaluation, review, or development of the infection control program. Review of infection surveillance records showed 25 total infections between 07/01/25 and 01/12/26, while the summary by infection category contained blank sections for blood/systemic, bone/joint, cardiovascular, and ear/nose/mouth/throat infections. The facility also lacked formal tracking and trending of resident infections and lacked documentation of an antibiotic stewardship program. Observations on 01/11/26 and 01/12/26 showed laundry being transported down resident hallways, mechanical lifts moved from room to room without cleaning in between residents, dusty footprints along the bases of the lifts, and staff carrying visibly soiled briefs in clear bags through hallways and into resident rooms while dragging the bags along handrails. Only one room initially had Enhanced Barrier Precautions signage and PPE outside the room, but additional rooms were later noted to have signage and PPE placed outside after the initial tour; residents without EBP signage had wounds, indwelling catheters, and known MDRO infections. Interviews also revealed the facility had no documentation of legionella testing despite its prior water management plan, and staff reported missing care when the facility was short staffed. Review of resident records showed multiple physician-ordered antibiotics and infection-related treatments for cellulitis, upper respiratory infections, wound infections, and MRSA.
Failure to Document and Offer Flu and Pneumonia Immunizations
Penalty
Summary
The facility failed to provide evidence that residents were offered influenza immunizations for the 2025 influenza season when the vaccines became available and/or beginning approximately October 1, 2025. Review of the resident electronic health records under the immunizations tab on 01/12/26 showed no evidence that residents were offered and/or received influenza immunizations at the facility during the 2025 season, and the charts either reflected 2024 dates or noted refusals without dates. Upon request on 01/14/26, the facility was unable to provide signed consents, declinations, or documentation of vaccination administration for influenza, pneumococcal, and Covid-19 vaccines for R2, R6, R7, R11, and R16. Consultant Nurse C stated she could not find the requested immunization documentation and reported that the DON or Social Services would complete the influenza immunization consent/declinations, while Administrative Nursing Staff B was responsible for overseeing immunizations and ensuring they were administered and documented in the EHR. The facility policy stated residents were to be offered influenza and pneumococcal immunizations yearly between 10/01 and 03/31 unless medically contraindicated, already immunized, or refused.
Failure to Train Staff on QAPI Program
Penalty
Summary
The facility failed to conduct mandatory training for all staff on its Quality Assurance and Performance Improvement (QAPI) program and failed to ensure staff had the appropriate competencies and skill sets related to the program. Based on interview and record review, the facility did not provide evidence of staff competency evaluations from Administrative Staff A when requested on 01/11/26 and again on 01/12/26. During an interview on 01/26/25, Consultant Staff X stated she did not have any proof that the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 showed the facility would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident.
Failure to Verify CNA Competency Evaluations
Penalty
Summary
The facility failed to ensure the adequacy of in-service training provided to staff by not evaluating the competencies and skill sets of Certified Nurse Aides (CNAs) to support the implementation of interventions needed to meet residents' needs and as identified in the facility assessment. The census was 34 with 14 residents in the sample. Surveyors found that the facility did not provide evidence of competency evaluations for CNAs when requested from Administrative Staff A on 01/11/26 and again on 01/12/26. During an interview on 01/26/25, Consultant Staff X stated she did not have proof that the facility performed competency evaluations with certified staff. Review of the Sufficient Staff Policy dated 05/15/24 showed the facility stated it would provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being for each resident.
Failure to Maintain and Respond to Monthly Pharmacy Reviews
Penalty
Summary
The facility failed to respond to and maintain monthly medication regimen reviews (MRRs) completed by the consultant pharmacist for multiple residents, including R1, R32, R3, and R24. The facility’s policy required the licensed pharmacist to review each resident’s drug regimen at least monthly, include the medical chart, document any irregularities, communicate those irregularities in writing to the attending physician, medical director, and DON, and make the written communication a permanent part of the medical record. Surveyors found that the facility could not produce complete MRRs or physician responses for several months for these residents. For R1, the record showed diagnoses of dementia and bipolar disorder, severe to moderate cognitive impairment on MDS assessments, and use of multiple psychotropic and other medications including olanzapine, quetiapine, lorazepam, and later Remeron. The chart showed antipsychotic use on a routine basis and no gradual dose reduction attempt. The pharmacy review notes included a recommendation to consider dose reduction for trazodone, but the facility could not provide the MRRs or physician responses for March, July, August, November, or December 2025. Staff also stated they could not locate completed pharmacy reviews, GDRs, or rationales, and the consultant pharmacist stated she emailed the facility multiple times and never received a response. For R32, the record documented diffuse traumatic brain injury, failure to thrive, seizure disorder, major depressive disorder, generalized anxiety disorder, severe cognitive impairment, and use of antipsychotic, antianxiety, antidepressant, and anticonvulsant medications. The pharmacy review notes referenced MRRs in September and December 2025, but the facility could not provide the MRRs or physician responses for those months. For R3, the record documented multiple chronic conditions including stroke, epilepsy, Parkinson’s disease, schizoaffective disorder, anxiety, and diabetes, with psychotropic medication use and prior care plan references to pharmacy review and a contraindicated GDR. The pharmacy review notes referenced MRRs in May 2025, December 2025, and January 2026, but the facility could not produce the MRRs or physician responses. For R24, the record documented anxiety, mild cognitive impairment, and psychotropic medication use; pharmacy review notes referenced MRRs in November and December 2025, but the facility could not provide the MRRs or physician responses. Staff interviews indicated the DON was expected to handle pharmacy reviews, but the facility could not locate the completed reviews, and the consultant pharmacist stated she had never been to the facility for an onsite visit.
Controlled Medications Not Secured or Accounted For
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted professional principles because schedule II-V controlled narcotic medications were not kept in a manner that limited access to authorized staff and the quantity stored was not minimal. The facility had one locked cabinet inside the medication room that was used for narcotic medications awaiting destruction, but staff did not know who had the key to that cabinet. The administrator and nursing staff reported uncertainty about the key, and maintenance staff was asked to cut the lock off the cabinet. When the cabinet was opened, it was found to be full of narcotic controlled medications that had not been destroyed since at least February 2025. Staff interviews showed conflicting understanding about who controlled access to the narcotic destruction cabinet, with some staff assuming Administrative Nurse B had the key and others stating only Administrative Nurse B could access it. Administrative Nurse B stated she was supposed to have the key, did not know what happened to it, and said she asked maintenance to cut off the lock because she did not know what was in the cabinet. The facility audit identified at least 55 narcotic medication prescriptions, of unknown quantity for each, that the facility could not account for. The medication destruction cabinet contained stacks of medication cards with count sheets attached, including one dated back to 2024. The facility policy stated controlled substances awaiting destruction must be placed in the locked narcotic destruction box and that keys or access controls must be accounted for at all times, but the cabinet key was not accounted for and the cabinet had remained locked with accumulated narcotic medications inside.
Missing COVID-19 Immunization Documentation
Penalty
Summary
The facility failed to provide evidence that it offered COVID-19 immunizations to residents who lived at the facility and failed to provide signed consents, declinations, or evidence of vaccination administration for Residents 2, 6, 7, 11, and 16. On request, the facility could not produce COVID-19 vaccination signed consents, declinations, or documentation of vaccination administrations for influenza, pneumococcal, and/or COVID-19 vaccinations for those residents. Consultant Nurse C stated she was unable to find the requested immunization documentation and reported that the DON or Social Services would complete the immunization consent/declinations. She also stated that Administrative Nursing Staff B was responsible for overseeing immunizations and ensuring they were administered, and that after resident consent was obtained, staff were expected to administer the immunization and document it in the EHR. The facility policy stated it would make the COVID-19 vaccine available to all residents and staff and would educate residents and staff about the vaccine.
Failure to Provide SNF ABN When Medicare Skilled Services Ended
Penalty
Summary
The facility failed to provide Form CMS 10055, Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN), to two residents when Medicare Part A skilled services were ending and the facility initiated discharge from Medicare Part A services while the residents still had remaining benefit days. For one resident, the facility provided a Notice of Medicare Non-Coverage (NOMNC) showing physical therapy ended because goals were met, and the resident signed it, but no SNF ABN was provided. For the second resident, the facility provided a NOMNC showing Medicare therapy services ended because the resident reached maximum functional level, and the resident signed it, but no SNF ABN was provided. The facility's SNF Beneficiary Notification Review forms for both residents documented that the facility initiated discharge from Medicare Part A services with remaining benefit days, and also documented that a SNF ABN was not provided because staff were unaware the form needed to be completed. During interviews, the Social Services Designee stated she received notification from nursing or therapy when a resident was discharging from skilled services and used a facility policy to determine whether an ABN was needed. The Business Office Manager stated therapy sent notices when residents were discharging from skilled services and that she gave both a NOMNC and ABN to residents because the ABN informed them they could pay for services themselves if they wanted.
Psychotropic Medication Documentation Deficiencies
Penalty
Summary
The facility failed to prevent unnecessary psychotropic medication use for multiple residents by not documenting required physician rationale, nonpharmacological attempts, gradual dose reduction (GDR) efforts, or appropriate PRN limits. Surveyors identified that the facility had a census of 34 residents and reviewed records for residents receiving psychotropic medications. The findings involved residents with diagnoses including dementia, bipolar disorder, traumatic brain injury, anxiety disorder, depression, schizoaffective disorder, Parkinson’s disease, epilepsy, and severe cognitive impairment. For one resident with dementia and bipolar disorder, the record showed routine antipsychotic use, including olanzapine and quetiapine, along with lorazepam and later Remeron. The resident’s MDS assessments documented cognitive impairment and no behaviors, yet the facility could not provide a physician-documented risk-versus-benefit statement or documentation of nonpharmacological attempts before starting the antipsychotics. The facility also could not provide evidence of GDR attempts or a rationale against GDR for the resident’s psychotropic medications. The resident’s care plan referenced psychotropic use and monitoring, but the record lacked the required supporting documentation. For another resident with diffuse TBI, failure to thrive, seizures, major depressive disorder, and generalized anxiety disorder, the record showed routine use of quetiapine and lorazepam, including a PRN lorazepam order for anxiety/agitation that did not have a 14-day stop date. The facility could not provide physician documentation supporting extended PRN use beyond 14 days or evidence of GDR attempts or rationale against GDR for the resident’s psychotropic medications. For a third resident with anxiety disorder, stroke, epilepsy, Parkinson’s disease, and schizoaffective disorder, the record showed routine quetiapine and clonazepam use, and a pharmacy review recommended a medication decrease, but the record lacked evidence of a physician response, risk-versus-benefit evaluation, or GDR documentation. Staff interviews confirmed they could not locate the GDRs, rationales, or pharmacy review responses, and they stated that such documentation should exist when psychotropic medications are continued or adjusted.
Inadequate catheter care and UTI monitoring
Penalty
Summary
The facility failed to ensure a resident with an indwelling urinary catheter received appropriate catheter care and services to help prevent urinary tract infections and catheter-related complications. The resident had diagnoses including MRSA infection, diabetic chronic kidney disease, neuromuscular dysfunction of the bladder, and chronic kidney disease. The admission MDS showed the resident required substantial to maximal assistance with transfers and toileting, was frequently incontinent of bowel, and required an indwelling catheter. The care area assessments triggered for several areas, but were not further assessed for potential problems to guide care planning decisions and interventions. The resident’s care plan did not include catheter-related interventions until after the resident had already been in the facility for months, even though the resident had required an indwelling catheter since admission. The record showed orders for catheter output monitoring and catheter care every shift, catheter changes every 30 days and as needed, and later orders for antibiotic treatment for UTI. The care plan also lacked enhanced barrier precautions for the indwelling device until later in the stay. The catheter care plan included monitoring for signs and symptoms of UTI and catheter discomfort, but the intervention for checking tubing for kinks did not specify the actual number of times staff were to check. The resident was hospitalized multiple times for UTI and related issues. Hospital records noted UTI, low blood pressure, intravenous antibiotics, yeast in the urine, and extensive wounds to both inner thighs and the left lateral legs. The resident reported that the facility had not done specific wound care beyond replacing bandages and stated staff did not provide catheter care, did not clean the tubing or insertion area, and did not provide peri-care. He also reported the catheter became clogged and that he learned he had UTIs when he went to the hospital. During interview, a nurse stated staff had seen the resident picking at his catheter with a knife, but the record lacked documentation of that behavior or related care-planned interventions. The catheter was observed hanging on the bedside commode rather than being secured with an anchor, and the resident stated he had requested a Velcro anchor but had not received one.
Incomplete Dialysis Communication and Post-Treatment Assessments
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility and failed to complete post-dialysis assessments for a resident with DM and CKD stage 4 who had a history of dialysis care. The resident’s record documented a BIMS score of 15 and need for assistance with transfers, toileting, and bathing. The care plan and physician orders showed the resident was to receive dialysis three times weekly, with pre-dialysis vital signs, weight, and assessment in the morning and post-dialysis vital signs, weight, and assessment in the evening, along with fistula checks for bruit and thrill each shift. Review of the resident’s dialysis communication sheets showed missing, incomplete, or absent documentation across multiple dialysis dates. The EMR lacked signed dialysis communication sheets scanned into the clinical record after a specified date, and the facility was unable to provide several sheets for review. Some communication sheets lacked documentation from the dialysis center, and others lacked post-dialysis documentation from the facility. The resident’s care plan also lacked direction to staff related to dialysis communication sheets. During interview, an LN stated staff were supposed to complete a dialysis communication sheet before the resident left for dialysis, obtain post-return weights, vitals, and assessment information, and document the assessment in the EMR and TAR. The LN stated the assessment should not be limited to vitals alone. A consultant nurse stated the dialysis sheets should be completed fully, sent with the resident, returned from dialysis, and then uploaded into the resident’s profile. The facility’s dialysis policy required ongoing assessment before and after dialysis and ongoing communication and collaboration with the dialysis clinic.
Failure to Provide Trauma-Informed, Individualized Care
Penalty
Summary
The facility failed to provide trauma-informed, individualized care for a resident with dementia and bipolar disorder by not implementing a resident-specific care plan that identified triggers and interventions related to past trauma. The resident’s EMR documented a diagnosis of PTSD, and a trauma-informed care screen/assessment documented that she reported a childhood sexual assault and did not want to discuss it. Despite this history, the resident’s care plans addressed impaired cognition, accusations about money, and psychosocial well-being concerns, but did not address her past trauma or include trauma-specific triggers and interventions. The resident’s records also showed behavioral and emotional concerns that were linked in the report to prior trauma and recent events. One care plan documented that she accused people of taking her money even though she had the card in her possession, and the report stated this behavior was due to a past experience of her family taking her money. Another note documented that she had been hospitalized for psychiatric reasons and had seen psychiatry in the past. Staff observations and interviews described her as upset, talking to herself, grieving her roommate’s death, and becoming more emotional after the roommate passed away. Staff interviews showed the facility recognized trauma screening and care planning as part of the process, but the resident’s trauma history was not incorporated into her care plan. The SSD stated she completed trauma assessments on admission and would place trauma-related findings into the care plan if triggered, but she did not complete another trauma assessment or add anything to the care plan after the roommate died. The consultant nurse stated that if a resident triggered for trauma, the resident needed an individualized care plan for trauma and a safety plan. The CNA and LN also described the resident’s upset behavior, money-related fixation, and increased emotionality, while noting the facility did not have a place that listed residents’ behaviors for new aides.
Failure to Individualize Dementia Care and Behavior Interventions
Penalty
Summary
The facility failed to provide dementia care and services for a resident with diagnoses of dementia without behavioral disturbance and bipolar disorder. The resident’s admission MDS documented severe cognitive impairment with no behaviors, and later quarterly MDS documentation showed moderate cognitive impairment with no behaviors. The resident’s CAA for cognitive loss/dementia lacked an analysis of findings, and the care plan documented impaired cognitive function and impaired thought processes related to dementia, but it did not address individualized behaviors, triggers, or interventions tied to the resident’s dementia diagnosis and related behaviors. The resident’s record showed repeated behavior-related events involving accusations that staff or others had taken her money, yelling, cursing, refusal of care, and agitation. Notes documented the resident stating she would not check her blood sugar until the person in the office gave her money, refusing vital signs and blood glucose checks while saying she was mad about her money, yelling profanities in the lobby and hallway, refusing a shower, and refusing medication while yelling at staff. Additional notes documented the resident yelling that the facility had her money and threatening to “watch her” harm others, with staff attempting redirection without success. The record also showed that the resident had activity preferences and periods of engagement, including enjoying activities depending on how she felt, attending smoke times, bingo, and nail time, and having interests such as reading, music, animals, group activities, favorite activities, and time outdoors. Despite these documented preferences and behavior episodes, the care plans did not identify the resident’s specific triggers, such as money-related concerns or family visits, and did not include individualized interventions for her behaviors. Staff interviews confirmed that the resident had yelling and aggressive behaviors, became upset about money, and that individualized behaviors, triggers, and interventions should have been included in the care plan.
Failure to Obtain Dental Services for Resident With Tooth Pain
Penalty
Summary
The facility failed to provide or obtain dental services for a resident with a history of sepsis who later developed dental pain and an infection in the left lower molar. The resident had moderate cognitive impairment, no documented rejection of care in the MDS, and a care plan that addressed oral hygiene by having staff set up supplies for tooth brushing twice daily. The record showed the resident refused a dental visit on 10/30/25, but there was no evidence of staff attempts to get the resident to a dentist after that refusal. About two months later, the resident began complaining of tooth pain. The record documented redness and some swelling to the left lower molar, and an order was written for Penicillin V Potassium for dental infection. A skilled evaluation later noted pain and discomfort to the lower left jaw, inflamed gums surrounding a single tooth, and difficulty chewing. During observation, the resident stated the bottom left tooth in the back was hurting and that it hurt to eat for the last two weeks. Staff interviews reflected that dental concerns were to be reported to Social Services and that the facility had a dentist who visited every three months and could come out for emergency visits. A CNA stated the resident had been having a hard time eating, was holding her mouth, and said her tooth hurt, with swollen and red gums, and that Social Services said they would contact the dental group. The facility’s dental services policy stated emergency dental services included treatment for acute pain in teeth, gums, or palate and that all actions and delays related to obtaining dental services would be documented in the medical record.
CAA Analysis Not Completed for Triggered MDS Assessments
Penalty
Summary
The facility failed to complete the Care Area Assessment (CAA) analysis of findings for three residents after their comprehensive MDS assessments triggered CAAs. Resident 1’s admission MDS triggered CAAs for cognitive loss/dementia, urinary incontinence/indwelling catheter, and psychotropic drug use, but the triggered CAAs did not include completed analysis of findings. Resident 16’s admission MDS triggered CAAs for cognitive loss/dementia and ADL functional/rehabilitation potential, and Resident 32’s admission MDS triggered CAAs for cognitive loss/dementia and behavioral symptoms; both residents also had triggered CAAs that lacked completed analysis of findings. During interview, the consultant nurse stated she completed the MDSs for the facilities and reviewed what assistance each resident needed, then updated the care plan, but she did not complete the CAA analysis of findings because she had always been told she did not have to. The facility policy, MDS 3.0, Care Assessment Summary and Individualized Care Plans, stated the interdisciplinary team completed the CAAs and that the MDS was not a comprehensive assessment without the CAA summary being completed.
Failure to Individualize Care Plans for Dementia Behaviors and ADL Assistance
Penalty
Summary
The facility failed to develop and implement comprehensive, individualized care plans for two residents. For one resident with diagnoses of dementia and bipolar disorder, the record showed severe to moderate cognitive impairment on MDS assessments and no behaviors on the assessments, but the chart also contained multiple behavior notes documenting yelling, cursing, refusal of care, and statements about money. The resident’s care plans addressed impaired cognition and psychosocial well-being in general terms, but they did not identify the resident’s specific behaviors, triggers, or individualized interventions related to the dementia diagnosis and related behaviors. The resident’s record included examples of behaviors and staff responses, including refusal of blood sugar checks and vital signs, refusal of a shower, yelling in the front room about money, and continued screaming and cursing at staff. Additional observations documented the resident appearing upset, talking to herself, sitting in the day area without engaging in an activity, and appearing upset with an unidentified staff member. Staff interviews confirmed that the resident had yelling and aggressive behaviors, that behaviors could increase when family visited, and that individualized behaviors, triggers, and interventions should have been included in the care plan. For a second resident, the facility did not develop a comprehensive care plan addressing ADL status, including transfers and mobility. The resident had diagnoses of bipolar disorder and left hip pain, used a wheelchair and later a walker, and had MDS findings showing changing levels of assistance needed for standing and transfers, including substantial to maximal assistance on the later assessment. The resident’s care plan addressed a fall and related interventions, but it did not address the resident’s ADL status or how staff should assist with transfers and mobility. During observation, two staff members assisted the resident to stand by placing their arms under her armpits before walking her into the dining room with her walker. Staff interviews indicated that care needs were known through the EMR and care plans, but the resident’s care plan did not contain the individualized ADL guidance reflected in the resident’s assessed needs.
Failure to Update Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to review and revise Resident 32’s comprehensive care plan to include fall prevention interventions after multiple falls. Resident 32 was admitted with diagnoses including diffuse traumatic brain injury with loss of consciousness, adult failure to thrive, and other seizure, and his admission MDS documented a BIMS score of zero, indicating severe cognitive impairment. His quarterly MDS later noted that a BIMS was not conducted because he was rarely or never understood. The Cognitive Loss/Dementia CAA dated 08/24/25 lacked an analysis of findings, and the care plan dated 09/19/25, revised on 01/12/26, identified him as at risk for falls and injury related to unsafe mobility and impaired safety awareness. Resident 32 had several falls documented in the record. On 09/08/25, staff heard him yelling and found him lying on his right side near the exit door after he stated he fell while trying to pull up his pants; the nurse completed an assessment, obtained vital signs, and started neurological checks. Another note documented an unwitnessed fall on 09/14/25 in his bedroom with no injuries reported. On 11/01/25, staff documented that he fell in a bathroom between two rooms, sustained a small abrasion to his left forehead, and stated he fell while self-transferring and hit his forehead on a heater vent on the floor. On 11/19/25, the facility initiated one-on-one safety supervision for continuous visual contact. The care plan documented only one intervention, dated 09/19/25, stating that staff provided a mattress on Resident 32’s floor for safety, comfort, and injury prevention. It did not document interventions after the falls on 09/08/25 and 11/01/25. The facility’s fall investigation reports for the 09/08/25 and 09/14/25 falls lacked root cause analyses, and no report was provided for the 11/01/25 fall. Staff interviews indicated that interventions were expected after each fall and that the care plan should be updated, but CNA N stated she did not receive notification of new interventions and relied on word of mouth, while LN S stated she expected a fall intervention on the care plan after each fall. The facility’s Fall Prevention Program policy directed that the care plan be reviewed and updated after a fall, and the Comprehensive Care Plans policy directed the interdisciplinary team to review and revise the comprehensive care plan with each comprehensive and quarterly MDS assessment.
Nurse Staffing Information Not Posted
Penalty
Summary
The facility failed to ensure that the number of nursing staff, including licensed and unlicensed staff, and the actual hours worked were posted each day during the onsite survey. On 01/11/26 at 1:45 PM and again on 01/12/26 at 12:31 PM, observations showed that the daily nursing staff numbers and hours were not posted in the facility. Review of the daily posted staffing records showed that the facility did not have daily posted staffing sheets after 09/30/25. During interview on 01/12/26 at 4:03 PM, Administrative Staff A stated the facility did not have the daily staffing posted and said it normally went on the wall where she was standing, but it was not there. On 01/13/26 at 2:13 PM, Administrative Staff A stated the facility only had daily posted staffing until September 2025, then switched to timesheets to show staffing, and started posting staffing sheets the day prior. She stated she knew there were more staffing sheets but did not know where they were. She also stated the MDS staff had previously posted the staffing sheets, but after the MDS budget was lost, that responsibility transferred to the DON, and the night nurse would now be responsible to fill them out and post them. The facility policy stated nurse staffing information was to be readily available in a readable format at any given time, with the Nurse Staffing Sheet posted at the beginning of each shift and staffing records maintained for at least 18 months.
Failure to Protect Resident from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from resident-to-resident abuse when one cognitively impaired resident with a history of aggressive and disruptive behaviors entered the dining area and, without provocation, punched another resident with a closed fist. The assaulted resident was seated calmly in the dining room when the other resident wheeled directly toward him and struck him two to three times in the left shoulder. The second resident tried to block the punches, and both residents fell from their wheelchairs to the floor while several other residents were present and reacted by shouting. The resident who initiated the assault had diagnoses including traumatic brain injury with loss of consciousness, major depressive disorder, anxiety disorder, and generalized anxiety disorder. His assessment documented severely impaired cognition and use of antipsychotic, anti-anxiety, antidepressant, and seizure-control medications. His care plan and progress notes documented repeated aggressive, verbally and physically disruptive behaviors, including aggression toward staff and other residents, wandering into rooms, non-redirectable behavior, and episodes of violence when agitated. The care plan also noted one-on-one monitoring for safety and direction for staff to monitor him in common areas, but the plan lacked further interventions related to his documented aggressive behaviors. At the time of the incident, activity staff were present in the dining area, but the resident was able to approach the other resident and strike him before staff intervened. Interviews after the event confirmed that the assaulted resident said he had been sitting there when the other resident rolled in and hit him, and staff stated there was no provocation. The facility also acknowledged that the resident who initiated the assault was no longer on one-on-one monitoring despite the care plan noting that monitoring, and the incident was identified by surveyors as an Immediate Jeopardy involving failure to prevent and protect a resident from abuse.
Failure to Implement Physician-Ordered Wound Interventions and Notify Provider
Penalty
Summary
The facility failed to follow physician orders and implement preventative wound interventions for a resident with a left heel ulcer. After a consultant assessed the resident and ordered suspension boots and daily wound cleaning, the facility did not enter the order for suspension boots into the electronic medical record (EMR), nor did they apply the boots as directed. The resident's care plan and EMR lacked documentation of the suspension boots order, and there was no evidence that the intervention was implemented. Additionally, the facility did not notify the physician when the resident's left heel wound opened, as required by the order. The resident had multiple diagnoses, including congestive heart failure, diabetes mellitus, and dementia with agitation, and was at risk for skin issues due to impaired mobility and incontinence. Over time, the resident's wound worsened, progressing from a deep tissue injury to an unstageable pressure ulcer, and eventually required advanced wound care interventions such as a wound vac. The EMR showed gaps in documentation of wound assessments, notifications to the physician and the resident's representative, and implementation of ordered interventions. The care plan also failed to address the physician's order for heel protectors and did not include all necessary interventions related to the resident's left heel wound. Interviews with staff revealed confusion and lack of clarity regarding the implementation and documentation of physician orders for wound care and preventative devices. Staff were unsure if the suspension boots were ever ordered or applied, and the EMR did not reflect the order or its implementation. The facility's policies required prompt transcription and implementation of physician orders, as well as systematic pressure injury prevention and management, but these were not followed in this case, resulting in a decline in the resident's wound status and the development of additional complications.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility, with a census of 30 residents, failed to provide Registered Nurse (RN) coverage for eight consecutive hours a day, seven days a week. Review of nursing schedules for June 2024 and March 2025 showed that no RN was on duty on three specific dates. Consulting staff confirmed RN coverage could only be verified through a staffing program, which had recently changed companies. Additionally, when requested, the facility was unable to provide a policy regarding RN coverage.
Failure to Complete Annual Staff Performance Reviews
Penalty
Summary
The facility failed to complete the required annual performance reviews for five staff members, including licensed nurses, certified medication aides, and certified nurse aides, all of whom had been employed for over a year. A review of personnel records showed that these employees did not have documented annual evaluations. When asked, the administrative nurse was unable to locate or verify the existence of these performance reviews. Additionally, the facility could not provide an Employee Annual Performance Review policy upon request.
Failure to Account for and Secure Controlled Medications in Emergency Kit
Penalty
Summary
The facility failed to maintain a system for accounting for controlled medications, specifically regarding the receipt and disposition of narcotics in the emergency kit. On multiple occasions, the door to the Administrative Nurse's office, where the emergency kit was stored, was found unlocked and unattended. The emergency kit itself was received with one of its drawers unlocked, containing Schedule 2 controlled substances such as fentanyl patches, morphine, and tramadol, among others. The kit did not include an inventory list of the narcotic medications, and staff were unable to access two of the three drawers. The facility did not have a policy related to the storage of narcotic medications and did not require a receipt upon delivery of the emergency kit. The pharmacy was notified of the issue with the emergency kit, but did not promptly resolve the problem. When a replacement kit was brought, it also lacked an inventory and contact information for unlocking, leading the facility to refuse it and return the damaged kit. The consultant pharmacist confirmed that the emergency kit should not have been accepted if it was damaged or unlocked, and that proper documentation and inventory should have been provided. The lack of a detailed system for tracking controlled substances and the absence of a storage policy contributed to the facility's inability to accurately reconcile and safeguard narcotic medications.
Failure to Provide Monthly Consultant Pharmacist Drug Regimen Review
Penalty
Summary
The facility failed to provide the services of a Consultant Pharmacist to review and identify irregularities in the drug regimens of all 30 residents during December 2024. Record review showed that monthly medication regimen reviews (MRRs) were documented for August, September, October, and November 2024, but there was no documentation of an MRR for December 2024. Additionally, when requested, the facility was unable to provide the Consultant Pharmacist reports for August through December 2024. Administrative staff reported a change in pharmacy providers in November 2024 and were unable to locate the pharmacist's recommendations for the relevant months. One resident in the sample, who had multiple diagnoses including major depressive disorder, anxiety, pain, diabetes, muscle spasms, repeated falls, and intervertebral disc degeneration, was identified as being at risk for adverse side effects from medications with black box warnings. The resident's care plan required regular pharmacy review and recommendations, but the lack of a December 2024 MRR and missing reports indicated that this oversight did not occur as required by facility policy. Facility policies stated that the consultant pharmacist would review each resident's medication regimen at least monthly to identify any irregularities.
Widespread Kitchen Sanitation and Food Safety Deficiencies
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen during meal preparation and service for all residents. Dietary staff reported cooking eggs to order, including over-easy and sunny-side-up, but could not verify that the eggs used were pasteurized as required. The kitchen's back door had a gap allowing outside light to enter, and the window above the microwave, where bread was stored, had a layer of brown dust. The handwashing sink and eyewash station were dirty, and two wheeled carts had greasy, linty material on the wheels and shelves. Additional observations included brown stains on ceiling tiles, food debris on oven surfaces, dried food remnants in stove drip pans, and lint on shelving used for cutting boards. Dead insects were found in a fluorescent light above food prep areas, and a container holding thermometers and chemical testing strips was covered in brown dust, with the strips found to be expired. Further issues included an ice machine floor drain lacking the required two-inch air gap and baseboards throughout the kitchen that were missing or coming unattached from the walls. Dietary staff confirmed the need for cleaning and repair in these areas and acknowledged that undercooked eggs should be pasteurized. The facility's own Nutritional Service policy requires adherence to federal and state food codes for cleaning and sanitizing equipment, but these standards were not met as evidenced by the observations.
Failure to Implement and Document QAPI Activities
Penalty
Summary
The facility failed to prioritize quality improvement, develop and implement action plans, conduct at least one Performance Improvement Project (PIP) annually, and regularly review, analyze, and act on collected data. During the survey, the facility was unable to provide documentation of any PIPs for the years 2024 and 2025. Administrative staff confirmed that no PIPs had been started or documented in the previous year, and noted that the facility had experienced turnover with seven administrators in the past two years. The facility's QAPI policy required the development and maintenance of a comprehensive, data-driven QAPI program, including systematic identification, reporting, investigation, analysis, and prevention of adverse events. The policy also specified the composition of the QAPI committee and the frequency of meetings. Despite these requirements, the facility did not provide evidence of QAPI committee activities or action plans addressing quality deficiencies, placing all 30 residents at risk for a lack of quality improvement activities.
Failure to Maintain Required QAA Committee Membership and Meetings
Penalty
Summary
The facility failed to maintain a Quality Assessment and Assurance (QAA) committee with the required membership and meeting frequency. Specifically, the QAA committee did not have documented attendance from the medical director or their representative, the administrator or governance leadership, or the consultant pharmacist. Sign-in sheets were only available for two meetings in 2025, with no documentation for meetings in 2024. Administrative staff confirmed the absence of these records and were unable to locate them within the facility. Additionally, the facility did not initiate any Performance Improvement Projects (PIPs) during the current year and had no documentation of PIPs from the previous year. The facility's QAPI policy required a comprehensive, data-driven program with systematic identification and prevention of adverse events, and specified the required committee members and quarterly meetings. The lack of proper QAA committee function and documentation placed all 30 residents at risk for impaired care and services.
Failure to Implement Legionella Water Management Program
Penalty
Summary
The facility failed to implement a water management program for Legionella disease prevention, as required by its own policy. Maintenance staff reported attending training on Legionella prevention but had not yet developed a surveillance system. Administrative staff confirmed the absence of a surveillance system for Legionella prevention. The facility's policy stated that potable water systems should be routinely cleaned and disinfected, but this was not being carried out. This deficiency was identified during a review of records and staff interviews, with a facility census of 30 residents at the time.
Lack of Certified Infection Preventionist for Infection Control Program
Penalty
Summary
The facility failed to ensure that the staff member designated as the Infection Preventionist (IP), who was responsible for the Infection Prevention and Control Program, had completed the required specialized training in infection prevention and control. Upon request, the facility was unable to provide documentation of a current certified IP employed at the facility. An administrative nurse confirmed that there was no current certified IP and stated she had only been employed for four weeks, expressing uncertainty about the existence of an infection tracking system prior to her employment. The facility's policy indicated that the IP was responsible for oversight of the infection prevention and control program, including surveillance activities, documentation, and reporting to the Quality Assessment and Assurance committee.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to maintain an appropriate and effective in-service training program for nurse aides, as required by regulations. Specifically, a review of the records for three randomly selected Certified Nurse Aides (CNAs) who had been employed for more than a year revealed that they did not complete the required 12-hour in-service training. When asked, the Administrative Nurse was unable to verify that these CNAs had received the mandated training, and the facility could not provide documentation of the required in-service hours. This deficiency was identified through observation, record review, and staff interview, and affected a facility with a census of 30 residents.
Expired Medications Not Removed from Medication Room
Penalty
Summary
Surveyors observed that the facility failed to remove expired medications from the medication room, as evidenced by the presence of multiple expired stock medications including multivitamins with iron, zinc tablets, Milk of Magnesia, and nicotine patches. These medications were found to have expiration dates ranging from 04/2024 to 03/2025. A licensed nurse confirmed that these medications were expired and should have been removed from possible use. Additionally, when requested, the facility was unable to provide a policy regarding medication storage or the handling of expired medications. The facility had a census of 30 residents, with a sample of 12 residents included in the review. The failure to remove expired medications was identified through observation, interview, and record review during the survey.
Lack of Certified Dietary Manager in Food and Nutrition Services
Penalty
Summary
The facility, with a census of 30 residents, failed to employ a full-time Certified Dietary Manager to oversee the food and nutrition service. During an observation, kitchen staff were seen completing the morning meal and preparing for the midday meal. The staff member identified as the manager confirmed she was not a Certified Dietary Manager and had not enrolled in a certification course. She also stated that a Registered Dietitian visited monthly and was available by phone for consultation. When requested, the facility was unable to provide a policy regarding the employment of a Certified Dietary Manager.
Failure to Assess and Document Pneumococcal Vaccination Eligibility and Consent
Penalty
Summary
The facility failed to assess two residents for eligibility to receive the pneumococcal PCV20 vaccination and did not offer, obtain informed declination, or secure a physician-documented contraindication for the vaccine as required by CDC guidelines. Review of the clinical medical records for these residents showed no evidence that the facility, the residents, or their representatives received or signed a consent to receive or an informed declination for the pneumococcal vaccine. The records also indicated that no pneumococcal vaccination had been given historically, offered, or declined. An administrative nurse confirmed that there was no system in place to check residents' eligibility status for pneumococcal vaccines at the time of the survey.
What surveyors are citing around you — mapped
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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 122 citations issued within 25 miles in the last 12 months — 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 Nortonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| F W Huston Medical Center | 6.8 mi | ★★★★★ | 24 | 0 |
| Valley Health Care Center | 9.1 mi | ★★★★★ | 0 | 0 |
| Easton Health Care Center | 11.6 mi | ★★★★★ | 14 | 0 |
| Heritage Gardens Health And Rehabilitation Center | 14 mi | ★★★★★ | 0 | 0 |
| Dooley Center | 14.1 mi | ★★★★★ | 9 | 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.