Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Paramount Community Living And Rehab Inc during CMS and state inspections, most recent first.
Food Storage and Temperature Monitoring Deficiencies: Staff failed to maintain safe food handling practices in multiple kitchenettes. Opened food items were left undated, required temperature and sanitation logs were incomplete, and hot foods were served without proper temperature checks or with inconsistent reheating. In one case, a CNA served a resident pureed food that was first too cold, then overheated, and in another, a CNA II used an unsanitized thermometer while checking and reheating entrees.
A resident with dementia, anxiety, and depression had severely impaired cognition and was receiving multiple psychotropic medications, including an antipsychotic, an antianxiety medication, and an antidepressant. The EMR showed informed consent for some psychotropics, but not for trazodone. Staff stated consent was obtained for antipsychotics and that the facility should obtain consent for all psychotropic medications, but no policy for psychotropic consents was provided.
A resident with dementia, anxiety, and severe cognitive impairment was found to have two PRN lorazepam orders that lacked the required 14-day stop date or a specified duration with supporting physician rationale. The resident’s record also documented antipsychotic, antidepressant, and antianxiety use, along with behaviors such as verbal and physical aggression, yelling obscenities, and hitting. An RN verified the PRN orders did not include the required stop date or duration.
A resident with intact cognition and routine anticoagulant use was transferred to the hospital for a critical potassium lab value, but the EMR lacked evidence that a written bed hold policy was provided at the time of transfer. Staff stated the policy was not given because the resident returned within 24 hours, although another staff member stated a bed hold policy should be sent any time a resident transfers to the hospital.
A resident with dementia, anxiety, and depression had an MDS that did not accurately reflect the resident’s falls history and injuries. The record showed multiple falls, including one with a laceration and pain requiring x-rays and another fall followed by x-ray findings of nondisplaced rib fractures, yet the quarterly MDS incorrectly coded only non-injury falls and no major or other injuries. An Administrative Nurse acknowledged the MDS was coded incorrectly.
Failure to Provide Consistent Activities: A cognitively intact resident with cerebral palsy, paralysis of the vocal cords and larynx, tracheostomy status, and depression was dependent on staff for all ADLs and preferred in-room independent activities such as bingo, animals, baking, family time, and TV. The EHR lacked documentation that activities were offered or participated in, and the resident repeatedly stated staff did not offer activities. A CNA said residents staying in their rooms were not offered in-room activities, while an LN said activity offers depended on time; an Activity staff member said offers were always made, but refusals were not charted.
Failure to follow fall prevention interventions for a resident with dementia, anxiety, depression, and severely impaired cognition. The resident had a history of falls and a care plan that included Dycem in the recliner and a weighted blanket when anxious or restless, but staff observed the resident yelling out and using a non-weighted blanket instead. When the resident was moved from the recliner to the wheelchair, Dycem was not in place as documented, and staff stated they were not aware of the specific fall interventions.
Emergency tracheostomy equipment was not readily available for a resident with a trach, cerebral palsy, and paralysis of the vocal cords and larynx. Staff observed no visible trach kit, replacement cannula, or Ambu bag in the room, and an LN said the Ambu bag was stored elsewhere and no extra trach tube was available because the resident used a special metal tube. An admin nurse later found the kit after searching and then placed the kit and Ambu bag in the room.
A facility failed to maintain required dialysis communication and post-treatment documentation for two residents receiving HD. One resident with CKD stage 5 and another with ESRD had orders for pre- and post-dialysis forms and post-dialysis VS, but the forms and VS were not completed as ordered, and the dialysis communication form was left blank for extended periods. Staff and the resident confirmed the post-dialysis assessments were not being done or documented after dialysis.
Failure to obtain informed consent for bed rails for two residents. One resident had severe cognitive impairment after CVA with impaired communication and understanding, while the other had intact cognition but significant mobility limitations related to morbid obesity and OA. Both care plans documented use of quarter bed rails for bed mobility and repositioning, yet their records lacked orders and signed informed consent, and both were observed with upper side rails on each side of the bed. Staff stated consent was not required or that the rails were considered mobility assist rails.
The facility failed to maintain sanitary conditions in various kitchen areas, including heavy build-up of crumbs, dried-on food debris, undated and unlabeled food items, and dirty kitchen equipment, leading to potential foodborne bacteria contamination.
The facility failed to ensure proper infection control techniques for several residents, including improper storage of oxygen tubing, inadequate hand hygiene and glove usage during catheter and perineal care, and placing soiled items near personal care items. These actions led to potential risks of infection.
The facility failed to maintain resident dignity in several instances, including not honoring a resident's preference for support hose, entering a room without knocking during personal care, standing over a resident while feeding, and not using a dignity bag for a catheter bag.
The facility failed to provide unstained towels and washcloths to residents in one of the Green Houses. A resident reported that staff often supply stained, rough, and worn towels. Observations confirmed the presence of such linens, and staff interviews revealed that stained linens should be discarded and replaced, but this was not consistently done, violating the facility's policy on Resident Rights.
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in meeting their individual needs. These included not including preferences for support hose, specific music and TV shows, religious services, facial shaving, and fluid restrictions in the care plans. Staff were unaware of these preferences and needs, resulting in inadequate care.
The facility failed to ensure appropriate activities for five residents, leading to a deficiency in providing meaningful and engaging activities. Despite residents expressing interest in various activities, observations showed that many scheduled activities were not conducted, and staff reported a lack of time and resources to facilitate these activities. This resulted in residents spending most of their time in their rooms with minimal engagement, contributing to their decreased sense of well-being.
The facility failed to complete accurate MDS and CAAs for two residents, leading to deficiencies in their care plans. One resident with Parkinson's disease and dementia had significant weight loss and an unhealed stage III pressure ulcer, while another resident with heart failure and major depressive disorder was on multiple medications without proper CAAs for psychotropic drug use, pain, and mood state.
The facility failed to revise care plans for two residents, one with a fractured toe requiring a walking boot and another with a pressure ulcer on the right heel. Despite observations and staff interviews confirming the residents' conditions, the care plans were not updated to include necessary interventions, leading to inadequate guidance for staff.
The facility failed to provide appropriate facial shaving for a dependent resident with severe cognitive impairment and Parkinson's disease. Despite the care plan and staff expectations, the resident was observed unshaven over multiple days, indicating a deficiency in adhering to the facility's ADL policy.
A resident with multiple health conditions, including DVT and dementia, developed a worsening deep tissue injury on her right heel due to ineffective offloading interventions. Despite being on hospice care and having a care plan, the facility failed to consistently elevate the resident's heels, leading to the deterioration of the pressure ulcer. The facility lacked a specific policy for pressure ulcers and did not update the care plan to address the resident's changing needs.
The facility failed to provide appropriate ROM services for a resident with multiple sclerosis and quadriplegia. Staff did not perform the required ROM exercises due to the absence of a restorative aide, leading to further decrease in the resident's range of motion and hand contractures.
The facility failed to properly secure a resident's catheter tubing, leading to potential injury, and did not ensure another resident's catheter tubing was kept off the floor. Both residents had severe cognitive impairments and were dependent on staff for all activities of daily living. Staff admitted to not following facility policies regarding catheter care.
The facility failed to monitor a resident's physician-ordered fluid restriction. The resident, with multiple diagnoses including hypertension and chronic kidney disease, was on a 2000 ml daily fluid restriction. Staff interviews revealed a lack of awareness and proper monitoring procedures, with no intake sheets or clear guidelines in place. The care plan lacked guidance, and the facility had no policy related to fluid restrictions.
The facility failed to monitor a resident's vital signs weekly and did not follow physician-ordered blood pressure parameters for another resident. One resident experienced a lack of bowel movements for 10 days, and another was given hypertension medication despite blood pressure readings below the prescribed threshold.
Food Storage and Temperature Monitoring Deficiencies
Penalty
Summary
The facility failed to prepare and serve food in accordance with food safety requirements related to food temperatures and sanitary storage. In one kitchenette, opened food items were found undated, including a mustard bottle, cocktail sauce jars, a bag of ground oatmeal labeled pureed, an opened canister of oats, and an open bag of potato chips. In the same kitchenette, temperature logs were incomplete for multiple meal periods and shifts, and sanitation checks and sanitizer bucket tests were documented as not working or not completed for several dates. Refrigerator/freezer temperatures were also not documented on several shifts. Food was also served at improper temperatures and handled inconsistently during meal service. In one instance, a CNA brought pureed sausage and gravy to a resident at 65 degrees F, then microwaved it to 165 degrees F before serving; the resident stated it was too hot to eat. In another kitchenette, staff served spaghetti, sauce, vegetables, and a breadstick without measuring the cooked food temperatures before service. A plated pureed meal was also observed uncovered and unattended on the counter while staff ate with residents. During another meal delivery, a CNA II attempted to check the temperature of a chicken pot pie entree and pureed entree, used a thermometer without sanitizing it between uses, and wiped it with a kitchen towel previously used on the counter and a serving spoon. The pureed entree was observed dry, crusty, and dark on top while its temperature was measured at 161 degrees F after repeated heating. Interviews confirmed staff expectations that opened foods should be dated, temperatures should be documented each shift, and hot entrees should be held at or above 135 degrees F before serving.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to inform a resident or the resident’s representative about the risks and benefits of taking a psychotropic medication. The resident had diagnoses of dementia with behavioral disturbances, anxiety, and depression, and a BIMS score of 4 on a significant change MDS, indicating severely impaired cognition. The resident’s record showed routine use of antipsychotic, antianxiety, and antidepressant medications, and later quarterly MDS documentation noted the resident could not participate in the BIMS assessment, had memory problems, and had severely impaired decision-making skills. The resident’s physician orders included hydroxyzine for anxiety, Seroquel for agitation related to dementia with behavioral disturbances, and trazodone for insomnia. The EMR contained informed consent for Seroquel and hydroxyzine, but there was no evidence of informed consent for trazodone. During observation, the resident was seen yelling for help while handwritten notes from the resident’s daughter were placed in front of her directing her not to yell and to ask staff for what she wanted. Staff were observed responding to the resident at times. A nurse stated that when an antipsychotic was ordered, the nurse informed the DON and staff obtained family consent before starting new medications, and an administrative nurse stated the facility should obtain consent for all psychotropic medications prior to starting them. The facility did not provide a policy for psychotropic consents.
PRN Lorazepam Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to ensure Resident 8 was free from unnecessary psychotropic medications and/or chemical restraints when both PRN lorazepam orders lacked a 14-day stop date or a specified duration with a supporting physician rationale. Resident 8’s EMR documented diagnoses of dementia and anxiety disorder, and the Significant Change MDS dated 02/13/26 recorded a BIMS score of two, indicating severe cognitive impairment. The MDS also noted the resident received an antipsychotic, an antidepressant, and an antianxiety medication. Resident 8’s care plan documented behaviors including verbal and physical aggression, yelling obscenities, and hitting, and directed staff to have the resident seen by the provider for mental health medication management services. The EMR showed physician orders for lorazepam 0.5 mg at bedtime for anxiety, lorazepam 0.5 mg PRN every six hours for anxiety, and Ativan 0.5 mg PRN every four hours for restlessness/anxiety. The two PRN lorazepam orders lacked a stop date or specified duration with a rationale. In interview, Administrative Nurse D stated the resident had two PRN lorazepam orders because of recent hospice orders added to existing orders and verified that neither PRN order had the required 14-day stop date or specific duration.
Failure to Provide Written Bed Hold Policy at Hospital Transfer
Penalty
Summary
The facility failed to provide a written bed hold policy at the time of transfer for a resident who had a Significant Change MDS documenting a BIMS score of 15, indicating intact cognition, and routine use of an anticoagulant. Nurse's progress notes documented that the resident was transferred to the hospital for a critical potassium lab value. The resident's EMR lacked evidence that the written bed hold policy was provided at the time of transfer. During interview, Concierge GG stated the facility did not provide the written bed hold policy because the resident returned within 24 hours, while Administrative Staff A stated that any time a resident transfers out of the facility to the hospital, a bed hold policy should be sent out with them. The facility's Bed Hold Prior to Transfer policy stated that prior to transferring a resident to the hospital or therapeutic leave, the facility will provide written information to the resident and/or resident representative regarding bed hold.
Inaccurate MDS Coding of Falls and Fall-Related Injuries
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) for Resident 59 to reflect the resident’s falls history and fall-related injuries. Resident 59 had diagnoses of dementia with behavioral disturbances, anxiety, and depression, and the 11/13/25 Significant Change MDS documented a BIMS score of 4, indicating severely impaired cognition. That assessment documented one fall, and the Falls CAA noted a history of falls. However, the 02/10/26 Quarterly MDS inaccurately documented that the resident had two or more non-injury falls, no falls with major injury, and no falls with injury except major, despite the record showing otherwise. The resident’s record included multiple fall events and related findings. On 11/17/25, an event note documented a fall with a laceration to the left eyebrow and complaints of pain in the left hand and wrist, with x-rays ordered of the left shoulder, hand, and wrist. On 12/22/25, a fall was documented as having no injuries, but subsequent nursing documentation on 12/23/25 reported x-ray results showing a nondisplaced fracture of the right fourth and fifth rib, and a physician/practitioner progress note on 12/24/25 documented that an x-ray was obtained due to pain in the right ribs and showed fractures. Additional fall notes on 02/05/26 and 02/10/26 documented falls with no injuries, and on 02/05/26 the resident complained of shoulder pain and decreased range of motion, prompting a shoulder x-ray that showed no fractures. On 02/18/26, an Administrative Nurse stated the MDS was coded incorrectly and would be modified, and another Administrative Nurse stated the MDS was expected to be completed in a timely and accurate manner.
Failure to Provide Consistent Activities
Penalty
Summary
The facility failed to provide consistent activities for a resident with cerebral palsy, paralysis of the vocal cords and larynx, tracheostomy status, and depression. The resident’s annual MDS documented a BIMS score of 13, indicating she was cognitively intact, and the assessment showed she used a wheelchair and was dependent on staff for all ADLs. Her care plan documented preferences for independent activities in her room, including bingo, being around animals, baking, being around family, and watching TV. The resident’s EHR lacked documentation that activities were offered to her or that she participated in any activities. During observations, she was in her room watching TV and stated she had not been offered any activities that day. She also reported on another occasion that staff did not offer her activities and that she stayed in her room and had to determine her own activities. A CNA stated residents who stayed in their rooms were not offered activities in their rooms, and an LN stated she would offer some type of activity if time permitted. An Activity staff member stated activities were always offered to residents in their rooms, but the resident’s activity preference was only charted quarterly and not at other times, and that the resident frequently refused activities; however, it was not charted whether an activity was offered or refused. The facility policy required an ongoing program of facility-sponsored group, individual, and independent activities based on each resident’s assessment and preferences.
Failure to Follow Fall Prevention Care Plan
Penalty
Summary
The facility failed to follow fall prevention interventions for a resident with dementia, behavioral disturbances, anxiety, and depression who had severely impaired cognition and poor decision-making skills. The resident’s MDS and care plan documented a history of falls and identified her as at risk for falls related to weakness and poor safety awareness due to dementia. The care plan included interventions such as Dycem in the recliner, initiated on 02/11/26, and offering a weighted blanket when the resident appeared anxious or restless, initiated on 12/10/25. During observation, the resident was repeatedly seen yelling out, appearing restless, and being covered with a non-weighted blanket instead of the weighted blanket documented in the care plan. Staff were observed responding intermittently to her needs, and one CNA stated the facility did not have weighted blankets in the houses, only in the main building. On 02/17/26, when the resident was assisted from the recliner to the wheelchair, there was no Dycem in either location as care planned. Staff interviewed stated they were not aware of the specific fall interventions, although they could look them up in the tablet, and a nurse stated she did not know the interventions until she reviewed the care plan. An administrative nurse stated staff were expected to follow all interventions in the care plans, and the facility policy required the interdisciplinary team to implement interventions based on individual needs and communicate them to caregiving teams.
Emergency tracheostomy equipment not readily available
Penalty
Summary
The facility failed to ensure emergency equipment was readily available for a resident with a tracheostomy if the tracheostomy cannula became accidentally removed. The resident had diagnoses including cerebral palsy, paralysis of the vocal cords and larynx, tracheostomy status, and depression. The resident's annual MDS documented a BIMS score of 13, indicating the resident was cognitively intact, and also noted the resident used a wheelchair, was dependent on staff for all ADLs, and had shortness of breath or trouble breathing when lying flat. The care plan directed staff to monitor and document the resident's level of consciousness, mental status, lethargy, restlessness, agitation, confusion, increased heart rate, and bradycardia. During observations, no emergency tracheostomy kit, replacement cannula, or Ambu bag was visible in the resident's room. A CNA stated she would immediately get the nurse if the resident had respiratory distress or if the tracheostomy tube came out. An LN stated the two things that should be readily available for a tracheostomy resident were suction and oxygen, and said the Ambu bag was in the oxygen storage room and there was no other tracheostomy tube available because the resident's tracheostomy tube was a special metal one and only one was ordered. Later, an Administrative Nurse confirmed there was no Ambu bag in the room, then found the emergency tracheostomy kit after several minutes of searching in a plastic shelving unit on the windowsill. She then stated the kit had been taped to the wall next to the bed and the Ambu bag had been placed in the room.
Dialysis communication and post-treatment documentation not completed
Penalty
Summary
The facility failed to ensure ongoing communication and collaboration with the dialysis facility regarding dialysis care and services for two residents who received renal dialysis. One resident had chronic kidney disease stage 5, dependence on renal dialysis, intact cognition, and impairment to one side of the body with upper and lower extremity involvement. Her care plan directed dialysis on Monday, Wednesday, and Friday and included an intervention for the facility to establish a means of communication with the dialysis facility. Although physician orders required pre-dialysis and post-dialysis documentation and a dialysis communication form, the post-dialysis form was not completed after dialysis on 02/13/26, and the pre-dialysis and post-dialysis forms were not completed on 02/16/26. The dialysis binder also did not contain the completed post-dialysis observation form for those dates. She was observed receiving her lunch tray at 12:16 AM on 02/17/26. The second resident had ESRD, dependence on renal dialysis, intact cognition, and required some assistance with ADLs. His care plan documented dialysis three times weekly, and physician orders required post-dialysis observation forms and post-dialysis vital signs. The resident stated staff checked vital signs before dialysis but did not check them or do anything after dialysis. The post-dialysis form did not show new vital signs, the ordered post-dialysis vital signs were not completed on 02/11/26 or 02/13/26, and the resident-specific post-dialysis information was not entered on the dialysis communication form for any day from 12/01/25 through 02/18/26. A nurse confirmed the post-dialysis form was not completed and the pre- and post-dialysis assessment was not in the EMR, and an administrative nurse stated the pre- and post-dialysis observation assessment form was the key communication tool and must be completed.
Failure to Obtain Informed Consent for Bed Rails
Penalty
Summary
The facility failed to obtain informed consent before installing bed rails for two residents. One resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, visuospatial deficit and spatial neglect following cerebral infarction, and a BIMS score of 4 indicating severe cognitive impairment. Her assessments documented impaired ability to make herself understood and to understand others, partial to moderate assistance with ADLs, and a care plan stating she chose to use one to two quarter bed rails for bed mobility and repositioning. Her record lacked evidence of an order for bed rails and lacked a signed informed consent, yet she was observed with upper side rails on each side of the bed. The second resident had diagnoses including morbid obesity and unilateral primary osteoarthritis of the left knee, a BIMS score of 15 indicating intact cognition, impairment in both lower extremities, and use of a wheelchair for mobility. Her assessments documented she required set-up or clean-up assistance for personal and oral hygiene and was dependent on staff for toileting and lower body dressing, and her care plan stated she chose to use one to two quarter bed rails for bed mobility and repositioning. Her record also lacked evidence of an order for bed rails and lacked a signed informed consent, while she was observed with upper side rails on each side of the bed. Staff stated that no formal consent was required or that consents were not required because the facility did not use bed rails, calling them mobility assist rails, and confirmed there were no informed consents for bed rails.
Unsanitary Food Preparation and Storage Conditions
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions, as evidenced by multiple observations of unsanitary practices and conditions in various kitchen areas. During an initial tour of the resident kitchenette, several issues were noted, including a heavy build-up of crumbs inside the toaster, dried-on food debris on the stove, an uncovered container of corn chips with chips on the floor, food debris in the deep freeze, wet silverware with food debris in the silverware drawer, and greasy fingerprints on the range hood. Similar unsanitary conditions were observed in the kitchenette on the first floor, where an opened, unlabeled, and undated energy drink was found in the refrigerator, a brownish substance was present on the sink's back rim, and the trash can had dried-on food debris and lacked a lid. Further inspection of the main kitchen revealed additional concerns, such as a heavy build-up of a black substance on the refrigerator racks, dust on the ice machine and oven, ground-in dirt and debris on a four-tiered cart used for drying clean dishes, and deeply grooved, dirty knife handles. Food debris was also found in containers holding kitchen utensils, and the microwave had dried-on food debris. The steam table's cutting shelf had deep cuts, making it uncleanable, and the cold cart's doors had ground-in food debris in the rubber seals. In another greenhouse kitchen, undated and partially used cans of nutritional formula, a mug of undated milky substance, slimy cucumbers, and undated pitchers of juice were found. Dietary staff confirmed that they were responsible for maintaining cleanliness and dating opened foods, but these standards were not met, leading to the potential for foodborne bacteria contamination.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure proper infection control techniques for several residents, leading to potential risks of infection. For Resident 9, the staff did not store the oxygen tubing and nasal cannula in a sanitary manner. Observations revealed that the oxygen cannula was placed directly on the bed and the walker without a storage container. Staff members were unaware of the proper storage procedures, and the oxygen cart was found hidden in a closet, covered with clothing and blankets. The facility's policy for oxygen care lacked specific guidelines for the care of tubing and cannulas. For Resident 60, the staff failed to maintain proper hand hygiene and glove usage during catheter care and perineal care. Observations showed that the CNA did not cleanse the catheter spigot before and after emptying the catheter bag and did not change gloves between dirty and clean tasks. The facility's policy required standard precautions during urinary catheter care, but the staff did not adhere to these guidelines. The administrative nurse confirmed that proper hand hygiene and glove changes were expected but not followed. Resident 78 experienced similar issues with improper glove usage during perineal care. The staff did not change gloves after performing peri-care and before dressing the resident. Additionally, Resident 242's catheter care was compromised when the staff placed a soiled graduate next to personal care items like a toothbrush and toothpaste. The facility's policy for urinary catheter care required standard precautions, but the staff did not follow these procedures, leading to potential contamination of personal care items.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence and self-determination in several instances. Resident 37, diagnosed with Alzheimer's disease and severe cognitive impairment, preferred to wear support hose. Despite having multiple pairs in her drawers, staff failed to ensure she wore them, as observed during an interaction with a Certified Medication Aide. The care plan did not reflect this preference, and the facility policy emphasized individual dignity and self-determination, which was not upheld in this case. Resident 60, with diagnoses including diabetes mellitus type two and neurogenic bladder, experienced a breach of dignity when a Certified Nursing Aide entered the room without knocking during personal care, exposing the resident. The aide stayed to collect pizza orders from staff, further compromising the resident's dignity. The facility's policy required staff to knock and wait for permission before entering a resident's room, which was not followed. Resident 31, diagnosed with Parkinson's disease and severe cognitive impairment, was fed by a Certified Nurse Aide who stood over him, contrary to the facility's expectation for staff to sit while assisting residents with meals. Additionally, Resident 78, with severe cognitive impairment and an indwelling urinary catheter, did not have a dignity bag for the catheter bag, as required by the facility's policy. These actions and inactions by the staff failed to respect and maintain the dignity of the residents involved.
Failure to Provide Unstained Towels and Washcloths
Penalty
Summary
The facility failed to provide unstained towels and washcloths to the residents in one of the Green Houses. A resident reported that certified staff, who handle the laundry, often supply towels that are stained, rough, and worn. Observations confirmed the presence of stained and coarse-textured towels and washcloths. Interviews with staff revealed that stained linens should be discarded and replaced when supplies are low, but this was not consistently done. The facility's policy on Resident Rights, which mandates a safe, clean, comfortable, and homelike environment, was not adhered to, resulting in the deficiency.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for four residents, leading to deficiencies in meeting their individual needs. Resident 37, diagnosed with Alzheimer's disease and other conditions, had a care plan that did not include her preference for wearing support hose. Despite having multiple pairs of support hose in her drawer, staff were unaware and did not ensure she wore them, as confirmed by observations and interviews with staff and a family member. The facility's policy required care plans to reflect resident-centered items, which was not adhered to in this case. Resident 78, with severe cognitive impairment due to multiple sclerosis, had a care plan that lacked specific details about her preferences for music, TV shows, and religious services. Despite her expressed importance of these activities, staff were unaware of her preferences, and observations showed she was not engaged in her preferred activities. The facility's policy mandated that care plans should be resident-centered, but this was not followed, resulting in the resident's preferences being overlooked. Resident 242, diagnosed with Parkinson's disease, had a care plan that did not include instructions for facial shaving, despite being dependent on staff for all ADLs. Observations over several days showed the resident remained unshaven, and staff interviews revealed inconsistencies in understanding the shaving schedule. Similarly, Resident 35, with multiple diagnoses including chronic kidney disease and fluid overload, had a care plan that lacked guidance on fluid restriction. Staff were unaware of the specific fluid restriction amounts and did not monitor the resident's fluid intake, contrary to the physician's orders. The facility's failure to include these critical details in the care plans led to deficiencies in providing appropriate care for these residents.
Deficiency in Providing Appropriate Activities
Penalty
Summary
The facility failed to ensure appropriate activities for five residents, leading to a deficiency in providing meaningful and engaging activities. Resident 7, diagnosed with Parkinson's disease, anxiety, and major depressive disorder, was observed to have minimal participation in activities despite expressing interest in books, music, animals, and group activities. The activity calendar listed various activities, but observations revealed that many scheduled activities were not conducted. Interviews with staff indicated a lack of time and resources to facilitate these activities, and the resident reported spending most of her time watching TV in her room, with only occasional participation in bingo once a week. Resident 20, with diagnoses including deep vein thrombosis, heart disease, diabetes, dementia, and an unstageable pressure ulcer, also experienced a lack of appropriate activities. Despite expressing interest in reading, music, and embroidery, observations showed that her preferred activities were not facilitated. The resident's TV was often on a shopping channel without her preference being considered, and her embroidery supplies were out of reach. Interviews with staff revealed a general lack of structured activities and a belief that residents were not interested in participating. Resident 33, with heart failure, vascular dementia, and major depressive disorder, expressed a desire for more frequent bingo games and card playing. However, observations showed that scheduled activities like UNO, Noodle Ball, and Chair Yoga were not conducted. Interviews with staff confirmed that activities were not being provided as planned, and there was a general issue with activity provision in the facility. Similar deficiencies were noted for Residents 37 and 78, who had severe cognitive impairments and required assistance with activities. Despite their interest in music, religious services, and other activities, observations and interviews revealed a lack of engagement and facilitation of their preferred activities, contributing to their decreased sense of well-being.
Failure to Complete Accurate MDS and CAAs
Penalty
Summary
The facility failed to complete accurate Minimum Data Sets (MDS) for two residents, leading to deficiencies in their care plans. Resident 31, diagnosed with Parkinson's disease and dementia, experienced significant weight loss and had an unhealed stage III pressure ulcer upon admission. The facility did not complete the Care Area Assessments (CAA) for nutrition and pressure ulcers, and the care plan for pressure ulcers was not adequately developed. Administrative staff acknowledged that the MDSs were not being completed properly due to a new MDS coordinator still learning the process. Resident 33, diagnosed with heart failure, vascular dementia, and major depressive disorder, was assessed with normal cognitive function but was on multiple medications, including psychotropic drugs, anticoagulants, diuretics, opioids, and antibiotics. The facility failed to develop the CAAs for psychotropic drug use, pain, and mood state, which are essential for creating a comprehensive care plan. Administrative staff confirmed the incompleteness of the MDS and CAAs for some residents, indicating a systemic issue in the facility's assessment process.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for two residents, leading to deficiencies in their care. Resident 9, who had diagnoses including diabetes mellitus and a fractured right great toe, experienced a fall that resulted in a fractured toe and required the use of a walking boot. Despite this incident, the care plan was not updated to include the fall and the necessary interventions. Observations and interviews confirmed that the resident was wearing the walking boot, but the care plan did not reflect this requirement, indicating a failure to guide staff appropriately in the resident's care needs. Resident 20, who had multiple diagnoses including deep vein thrombosis, heart disease, diabetes, and dementia, developed a pressure ulcer on the right heel that was not included in the care plan. The resident was dependent on staff for activities of daily living and had a history of pressure ulcers. Despite weekly observations and the development of a new deep tissue injury on the right heel, the care plan was not updated to include this new injury or the necessary interventions for off-loading the heels. Observations revealed that the resident's heels were not consistently off-loaded, and the care plan lacked updated interventions to address the new pressure ulcer. Interviews with staff confirmed that the care plans for both residents were not revised to include the necessary interventions for their respective conditions. The facility's policy on care planning emphasized the need for resident-centered care plans specific to each resident's unique needs, but this was not followed in these cases. The failure to update the care plans resulted in inadequate guidance for staff in providing appropriate care for the residents' conditions.
Failure to Provide Appropriate Facial Shaving for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate care to a dependent resident regarding facial shaving. The resident, diagnosed with Parkinson's disease and severely impaired cognition, was dependent on staff for all activities of daily living (ADLs), including personal hygiene. Despite the care plan and electronic medical record indicating the resident's dependence on staff for shaving, observations over three consecutive days revealed the resident remained unshaven with scraggly overgrowth of facial hair. Interviews with staff, including a Certified Medication Aide, Certified Nurse Aide, Licensed Nurse, and an Administrative Nurse, confirmed that residents were to be shaved on their shower days and as needed. However, the resident was not shaved as required, indicating a failure to adhere to the facility's policy for ADLs, which mandates necessary services for residents unable to carry out ADLs independently. The Physician's Order Sheet and multiple assessments documented the resident's severe cognitive impairment and dependence on staff for all ADLs. Despite this, the resident was observed unshaven on multiple occasions, and staff interviews confirmed the expectation to shave residents on shower days and as needed. The facility's policy, revised in January 2024, emphasized the necessity of providing services to maintain good nutrition and personal hygiene for residents unable to perform ADLs. The failure to shave the resident as required highlights a deficiency in the facility's adherence to its own policies and the provision of necessary care for dependent residents.
Failure to Provide Effective Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure effective pressure ulcer care and prevention for a resident with multiple health conditions, including deep vein thrombosis, heart disease, diabetes, dementia, and an unstageable pressure ulcer. The resident was assessed with moderate cognitive impairment and was dependent on staff for activities of daily living. Despite being on hospice care and having a care plan that included the use of foam off-loading boots and skin prep for her heels, the resident developed a deep tissue injury (DTI) on her right heel, which worsened over time despite interventions. Observations revealed that the resident's heels were not consistently offloaded from the bed surface, even though staff attempted to use pillows and blankets for elevation. The resident's right heel DTI progressed, showing signs of eschar and mushiness, indicating ineffective offloading. Staff interviews confirmed that the pillows and foam boots were not maintaining their effectiveness in keeping the resident's heels elevated, and there was a lack of updated interventions in the care plan to address the worsening condition. The facility lacked a specific policy for pressure ulcers and failed to provide timely and effective heel off-loading interventions. The care plan was not updated to reflect the resident's changing needs, and the staff did not consistently assess the effectiveness of the interventions. This led to the continued deterioration of the resident's right heel DTI, highlighting a deficiency in the facility's pressure ulcer care and prevention practices.
Failure to Provide ROM Services
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) services for a resident diagnosed with multiple sclerosis and quadriplegia. The resident's care plan, revised on 11/13/23, instructed staff to provide passive range of motion (PROM) to the upper and lower extremities and neck. However, a review of the resident's electronic medical record (EMR) from 02/28/24 through 03/27/24 revealed that staff failed to complete restorative care for eight days when it was supposed to be performed. Observations and interviews with staff confirmed that ROM exercises were not being conducted due to the absence of a restorative aide, who had left the facility about a month or two prior. Certified Nurse Aides (CNAs) and Certified Medication Aides (CMAs) admitted they did not perform ROM exercises with the resident, and some staff were unsure if the resident received the required ROM services at all. The resident's condition was further compromised as her fingernails began to dig into her other fingers due to her hands being clenched tightly. The facility's policy for Restorative Nursing Care required daily performance of restorative nursing care for residents needing such services, including routine ROM exercises. Despite this policy, the facility failed to ensure that the resident received the necessary ROM services, leading to a further decrease in the resident's range of motion and hand contractures. The administrative nurse acknowledged the issue, stating that the restorative program was an ongoing problem due to the lack of a restorative aide.
Failure to Properly Secure and Maintain Catheter Tubing
Penalty
Summary
The facility failed to utilize an anchoring device for a resident with an indwelling urinary catheter, leading to potential injury. The resident, diagnosed with neuromuscular dysfunction of the bladder, had severe cognitive impairment and required extensive assistance for toileting. During catheter care, it was observed that the catheter tubing was not anchored to the resident's thigh, and the anchoring device was ineffective. Staff admitted that the anchor kept coming off, and they did not always reattach it. The facility policy required the use of a catheter securing device to prevent friction and movement at the insertion site, which was not followed in this case. Additionally, the facility failed to ensure that another resident's catheter tubing was kept off the floor. This resident, diagnosed with neurogenic bladder and severe cognitive impairment, was dependent on staff for all activities of daily living. Observations revealed that the catheter tubing was resting directly on the floor on multiple occasions. Staff acknowledged that the tubing should be kept off the floor and placed in a dignity bag, as per facility policy. The failure to adhere to these protocols was noted by the surveyors, indicating a lapse in proper catheter care for the residents involved.
Failure to Monitor Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to monitor a resident's physician-ordered fluid restriction. The resident, who had multiple diagnoses including orthostatic hypotension, hypertension, viral hepatitis C, COPD, chronic kidney disease, and fluid overload, was on a 2000 ml daily fluid restriction. Despite this, the care plan lacked guidance related to the fluid restriction, and staff were not adequately monitoring the resident's fluid intake. The resident himself reported that he managed his fluid intake independently and would get extra fluids if he wanted. Staff interviews revealed a lack of awareness and proper monitoring procedures for the fluid restriction, with no intake sheets or clear guidelines in place. Certified Nursing Assistants and Licensed Nurses were unsure of the specifics of the fluid restriction and believed that dietary staff were responsible for monitoring fluid intake. However, there was no coordinated effort or documentation to ensure compliance with the fluid restriction. The administrative nurse acknowledged that the fluid restriction should have been included in the care plan and that all staff should be aware of it. Additionally, the facility lacked a policy related to fluid restrictions, further contributing to the failure to monitor the resident's fluid intake as prescribed by the physician.
Failure to Monitor Vital Signs and Adhere to Medication Parameters
Penalty
Summary
The facility failed to monitor a resident's vital signs, including blood pressure, at least weekly, as required. Resident 7, who had multiple diagnoses including Parkinson's disease, anxiety, major depressive disorder, and hypertension, was on several medications that required close monitoring. Despite the physician's instructions to monitor vital signs weekly, the last recorded blood pressure was on 03/03/24, showing a reading of 90/48. The facility's administrative nurse confirmed the lack of monitoring due to computer issues, which is against the facility's standard of care policy. Additionally, the resident experienced a lack of bowel movements for 10 days, which was not adequately addressed despite the facility's bowel protocol requiring intervention after three days without a bowel movement. This failure was attributed to issues with the electronic record alerts and lack of follow-up by licensed staff. The facility also failed to follow physician-ordered blood pressure parameters for another resident, Resident 41, who had a diagnosis of hypertension and moderately impaired cognition. The physician had ordered Norvasc to be held if the systolic blood pressure was less than 120. However, the medication was administered multiple times when the resident's blood pressure was below this threshold. Certified Medication Aide S and Licensed Nurse H both confirmed that the medication was given despite the blood pressure being outside the ordered parameters. Administrative Nurse D stated that it was the expectation for staff to follow physician's orders, including holding medication if the blood pressure was outside the parameters. These deficiencies highlight the facility's failure to adhere to its own policies and physician orders, resulting in inadequate monitoring and inappropriate administration of medications. The lack of proper monitoring and adherence to medical instructions could potentially lead to adverse effects on the residents' health, although the report does not specify any direct consequences.
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What surveyors actually found near you
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kansas Christian Home | 1.3 mi | ★★★★★ | 13 | 0 |
| Newton Presbyterian Manor | 2 mi | ★★★★★ | 11 | 0 |
| Bethel Health Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Schowalter Villa | 8.4 mi | ★★★★★ | 0 | 0 |
| Halstead Health And Rehabilitation Center | 8.6 mi | ★★★★★ | 17 | 1 |
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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.