Below average — CMS composite of the measures below.
The next survey window likely opens around March 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 Harrison Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to use its QAPI process effectively after repeated deficiencies involving infection prevention and control, influenza and pneumococcal immunizations, and COVID-19 immunization. Survey review found that required QAPI oversight was inconsistent, with missed attendance by the Medical Director and IP, a long gap between meetings, and no evidence that the committee identified or acted on the ongoing problems. Interviews showed the IP, DON, Medical Director, and Administrator could not explain why the deficiencies continued, and the Administrator stated she had not reviewed QAPI minutes or scheduled a QAPI meeting.
QAPI committee meetings did not occur at least quarterly and did not consistently include required members. Review of the facility’s policy showed the committee was to include the Medical Director or designee, DON, IP, the Administrator, and additional staff, but meeting minutes showed missing required attendees and a six-month-plus gap between meetings. Interviews with the IP, DON, Medical Director, and Administrator confirmed inconsistent attendance and lack of oversight of QAPI meetings.
Infection control practices were not consistently followed, including improper glove use and hand hygiene by Hospitality Aides during ice passes and by an LPN during a fingerstick. Clean and contaminated items were stored together in multiple areas, including the biohazard room, shower room, laundry area, and dirty utility room, and soiled linen receptacles were overfilled and uncovered. A resident with ESBL had no EBP signage in place, and the facility lacked appropriate supplies for handling contaminated laundry.
Advance directive rights were not properly documented for multiple residents. Review of admission records and the Advance Directive Policy and Record forms showed incomplete documentation for residents with both intact and impaired cognition, including missing representative information and no documented evidence that the option to formulate or decline an AD was explained in a way the resident could understand. Interviews with the Admissions Director, Social Services Director, DON, and Administrator confirmed that AD status was not consistently reviewed during care planning and that staff were expected to follow the facility policy.
Missing Controlled Medication Shift Change Documentation: The facility failed to ensure controlled medication counts were documented at shift change on multiple medication carts. Review of the shift change logs showed missing signatures from both outgoing and oncoming nurses on the 100 Hall back cart, 100 Hall split cart, and 200 Hall split cart. An LPN stated she delayed signing until after pharmacy delivery of new inventory, while ADONs reported they were unaware of the missing documentation and did not routinely audit the logs. The DON and Administrator stated signatures were expected at the time of the count.
Improper storage of refrigerated medications, vaccines, and insulin was identified when the medication refrigerator was observed at 48 F, with ice buildup in the freezer and repeated temperature logs below the required 36 F to 46 F range. Fifty-eight Afluria vaccines were tightly packed in a drawer without space for air circulation, and a resident’s insulin was used after its opened and expiration dates. Staff interviews showed uncertainty about the proper temperature range and storage requirements.
The facility failed to include staffing minimums and a recruitment/retention plan in its Facility Assessment. Residents and family members reported long waits for call light response and assistance with incontinence care, including overnight delays and prolonged waits on second shift. CNAs reported working nights with only two staff for 46 residents, feeling rushed, and being unable to get to residents in a timely manner. The DON said staffing was based on HPPD, while the Administrator acknowledged the Facility Assessment did not contain staffing numbers.
A facility failed to ensure residents were offered flu and pneumococcal vaccines and that residents or their representatives received education on the benefits, risks, and side effects. For sampled residents, records lacked consent, declination, or education documentation, and some immunization entries were incomplete or inconsistent, including missing vaccine details and a date discrepancy. The IP reported multiple roles, staffing changes, and unclear responsibility contributed to the documentation breakdown, while the DON, Administrator, and Medical Director stated they expected CDC-guided immunization practices and accurate EMR documentation.
The facility failed to ensure residents were offered the COVID-19 vaccine and that residents or their representatives received education on the vaccine’s benefits, risks, and side effects. For sampled residents, EMRs lacked documentation of vaccine education, administration, or refusal/contraindication, and several consent forms were completed only when the surveyor requested records. The IP stated competing roles, staffing changes, and unclear responsibility contributed to incomplete immunization oversight, while the DON, Administrator, and Medical Director stated vaccine education, consent/declination, and documentation were expected.
Failure to accommodate resident preferences and room conditions affected two residents. One cognitively intact resident with MS was observed crying and repeatedly sitting alone while her TV/cable service frequently failed, despite a care plan noting she liked TV and needed staff encouragement for activities. Another resident was found in a room with a former resident’s belongings still stored there for weeks, and staff acknowledged the items had not been removed.
A resident was transferred to the hospital without written notice of the transfer, the reason for the transfer, or the bed hold policy, and no copy of the notice was kept in the EMR. The record also lacked documentation of the transfer/discharge and the facility did not notify the State LTC Ombudsman. Staff interviews showed the facility relied on verbal notification and only provided transfer and bed hold forms if requested.
Care plans for two residents with chronic pain did not include non-pharmacological interventions. One resident had chronic back pain with low back pain, osteoarthritis, and moderate cognitive impairment, and the other had chronic bilateral lower extremity and left knee pain with osteoarthritis and chronic pain. Both care plans focused on pain meds and monitoring, but omitted measures such as repositioning, heat or cold, supportive devices, and other comfort interventions that the residents said would help.
Urinary catheter bag positioned above bladder: The facility failed to ensure a resident with a urinary catheter had the drainage bag secured below the bladder. The resident had end stage renal disease, diabetes, and Alzheimer's dementia with moderate cognitive impairment. Observations showed the bag on the side of the chair above the bladder on multiple occasions, while staff gave mixed responses about proper positioning. The care plan did not include education about the risks of the bag being on the side of the wheelchair, and the staff competency materials did not address keeping the bag below the bladder.
Incorrect Oxygen Flow Rates: The facility failed to ensure ordered oxygen therapy was provided at the correct LPM for three residents. One resident’s concentrator was found set to zero despite an order for 3 LPM, another resident was observed receiving 1.5 LPM instead of 3 LPM, and a third resident was observed at 2.5 LPM instead of the ordered 2 LPM. Staff interviews confirmed that nurses were expected to verify oxygen settings against the physician orders, but the observed flow rates did not match the documented orders.
Trash and debris were observed around the outdoor dumpster area, including cigarette butts, straws, soda cans, medical gloves, papers, plastics, and plastic utensils. The Maintenance/Housekeeping Director confirmed the area was unacceptable, and the KS and Administrator stated housekeeping and dietary staff were responsible for trash handling and keeping the dumpster area sanitary and the lids closed.
The facility failed to ensure residents received mail on Saturdays, affecting all 49 residents. The SSD took over mail delivery from the Activities Director due to complaints but did not work weekends, resulting in undelivered mail. Staff interviews revealed confusion over mail delivery responsibilities, with the DON unaware of the issue and the Administrator expecting timely delivery.
The facility failed to label and store medications properly, with observations revealing undated, opened, and expired medications in multiple carts. Medications such as inhalers, insulin, and antifungal creams were improperly labeled or stored, and unwasted narcotics were found for a deceased resident. Staff interviews indicated a lack of awareness and adherence to policies, contributing to the deficiencies.
The facility failed to maintain an effective QAPI process, as evidenced by the repeated use of expired insulin, affecting all 49 residents. Despite plans for regular audits, expired and undated medications were found over several months. The DON was responsible for monitoring compliance but was unavailable for an interview during the survey.
The facility failed to maintain an effective infection prevention and control program, as evidenced by an LPN not using PPE in an EBP room and improperly cleaning a glucometer, and an RN cleaning a stethoscope with dirty gloves. Additionally, the facility did not adequately monitor its water system for Legionella, lacking documentation and a process flow diagram to identify risk areas.
The facility failed to document vaccine education for five residents, using outdated Vaccine Information Sheets and not providing updated information to residents or their representatives. Interviews with staff revealed a lack of adherence to facility policy and CDC guidelines, affecting residents with varying cognitive abilities.
The facility failed to document COVID-19 vaccination education and status for four staff members, including two LPNs and a CNA. Employee files lacked evidence of vaccine offering and education, despite interviews confirming some education was provided. Key staff emphasized the importance of following CDC guidelines and maintaining documentation for infection control.
A resident with severe cognitive impairment was observed multiple times without a privacy cover for their catheter bag, which was visible from the hallway. Despite the facility's policy to provide dignity covers, staff were unaware of the oversight, indicating a gap between policy and practice.
A facility failed to include Hospice services in a resident's baseline care plan upon admission, despite a physician's order. The resident, admitted with conditions such as Alzheimer's dementia and major depression, did not have a focus area for Hospice care in the care plan until five days later. Interviews with staff revealed inconsistencies in the understanding and implementation of the baseline care plan policy.
The facility failed to develop timely and comprehensive care plans for two residents, one admitted to Hospice care and another with respiratory needs. The Hospice care plan was delayed by four days, and the respiratory care plan did not address non-compliance with oxygen therapy. Staff interviews revealed a lack of awareness and implementation of individualized care plans, contrary to facility policy.
A resident with chronic respiratory failure did not receive oxygen therapy as per the physician's order, with the oxygen concentrator set higher than the prescribed 3 LPM. Despite the resident's awareness of the correct setting, staff failed to regularly check and adjust the concentrator. The facility's policy on oxygen usage was not followed, and the resident's care plan and records lacked documentation of the oxygen orders.
QAPI Oversight Failure for Infection Control and Immunization Deficiencies
Penalty
Summary
The facility failed to maintain an effective QAPI system to address repeated deficiencies related to infection prevention and control, influenza and pneumococcal immunizations, and COVID-19 immunization. The report states the facility had previously been cited under 42 CFR S483.80 for these issues and that the Plan of Correction required monthly QAPI meetings, monthly audit review, and ongoing monitoring of infection control and immunization practices. Despite those stated expectations, survey review found no evidence that the QAPI committee identified or implemented actions to address the ongoing deficient practices. Review of QAPI meeting minutes showed that the Medical Director or designee was not present at the 05/15/2025 meeting, and there was then a lapse of six months and nine days before another QAPI meeting was held on 12/24/2025. The later meeting minutes showed the Medical Director and the IP were not in attendance. Documentation provided by the facility did not show that the committee identified or implemented actions related to the repeated infection control and immunization deficiencies during either meeting period. During interviews, the IP stated the repeated deficient practices were due to multiple system breakdowns, including lack of dedicated time for infection prevention responsibilities, lack of proactive monitoring, unclear roles and responsibilities, and gaps in implementation and oversight of infection control practices. She also stated changes in ownership and turnover in administrative staff contributed to the repeated deficiencies. The DON stated she began employment on 01/20/2026 and could not explain the repeated infection control deficiencies, while the Medical Director and Administrator also stated they could not speak to why the deficiencies continued. The Administrator stated she had not yet reviewed QAPI meeting minutes or scheduled a QAPI meeting and was unaware of current infection control issues before the surveyors identified them.
QAPI Committee Failed to Meet Quarterly and Lacked Required Attendance
Penalty
Summary
The facility failed to have the Quality Assessment and Assurance (QAPI) group meet at least quarterly and failed to have the required members present. Review of the facility’s QAPI policy showed the committee was to conduct ongoing quality reviews and monitor action plans monthly, and that the committee was to include, at a minimum, the Medical Director or designee, the DON, the IP, and at least three additional staff members, including the Administrator. Review of QAPI meeting minutes showed the Medical Director or designee was not present at one meeting, and both the Medical Director and the IP were absent from another meeting. The record also showed a lapse of six months and nine days between meetings. During interviews, the IP stated she may have missed one or two QAPI meetings in the last year if she had worked the floor the night before, the DON stated she would not have attended if her signature was not on the meeting sheet, the Medical Director acknowledged prior involvement but could not explain the lack of meetings, and the Administrator stated she had not yet reviewed the QAPI minutes or set up a QAPI meeting.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent and control the development and transmission of communicable diseases. Survey findings identified multiple infection control breakdowns, including improper hand hygiene and glove use, storage of contaminated and clean supplies together, lack of a hand-washing sink in a shower room, failure to identify a resident with ESBL as requiring Enhanced Barrier Precautions (EBP), and inadequate storage of medical supplies and clean laundry. The report also noted that nonpermeable aprons or disposable gloves were not available for staff handling contaminated laundry. During observation on the 200 Hall, two Hospitality Aides passed ice while wearing the same gloves between resident rooms and while handling multiple residents' water pitchers and ice supplies. One aide handled a resident's water pitcher, discarded a contaminated straw and water, and left the room to refill the pitcher without performing hand hygiene or changing gloves. Both aides stated they had been educated to wear gloves during the ice pass, while the IP/ADON stated they were also supposed to remove gloves and perform hand hygiene after each ice pass, but that these practices were not consistently implemented. A LPN was also observed performing a blood glucose fingerstick and removing contaminated gloves multiple times without hand hygiene between glove removal and reapplication, while bringing an entire bottle of test strips into the resident's room and placing it on the barrier with a contaminated glucometer. The report also documented environmental and storage concerns. In the 200 Hall biohazard room, clean gloves and unused sharps containers were stored in the same room as red biohazard containers. In the 200 Hall shower room, clean towels, linens, and briefs were stored near the shower stall, there was no hand-washing sink in the room, and a strong fecal odor was present. In the laundry area, staff personal items, drinks, resident belongings, and clean clothing were stored together, clean items were placed on the floor, and the area was used as a pathway to an outdoor medical supply shed. The laundry storage closet contained supplies on the floor, and there were no nonpermeable aprons or disposable gloves available for contaminated laundry handling. The dirty utility room had five overfilled linen receptacles containing bagged and unbagged soiled linen and clothing piled above the rim, with no lids in place. The report further identified that Resident 2 was colonized with ESBL in the urine and had diagnoses including urinary tract infection with ESBL, chronic kidney disease, and adult failure to thrive. Although the resident's care plan addressed infection related to ESBL, there was no EBP signage on or near the room door. The DON, Administrator, Medical Director, IP/ADON, and EVS Director all acknowledged various infection control concerns during interviews, including hand hygiene, glove use, linen storage, and supply storage practices.
Advance Directive Rights Not Properly Documented
Penalty
Summary
The facility failed to ensure that residents were informed of and able to exercise their rights regarding advance directives. Review of the facility policy showed that the facility was to inquire about the existence of advance directives, document any directive in the medical record, include a copy in the record, periodically assess decision-making ability, and review advance directive preferences during care planning. The admission packet also included an Advance Directive Policy and Record form intended to document the status of a resident’s advance directive. For 7 of 41 sampled residents, the Advance Directive Policy and Record forms were incomplete and did not show documented evidence that the opportunity to formulate or decline an advance directive was explained in a manner the resident could understand. R12 had diagnoses including CHF, diabetes mellitus, and depression, and an admission MDS BIMS score of 8, indicating moderate cognitive impairment; she stated she had an advance directive but was not sure whether she had provided it to the facility and did not remember being asked about it in her care plan meeting. R16, R22, R33, R35, R37, and R41 each had incomplete forms with only partial information entered, such as the resident’s name, a date, and staff initials, while representative information was blank or the form noted that documents were not yet received. The residents reviewed included both cognitively intact and cognitively impaired individuals. R16 had a BIMS score of 13 and diagnoses including depression, coronary artery disease, and bipolar disorder; R22 had a BIMS score of 15 and diagnoses including heart failure, diabetes mellitus, and COPD; R33 had a BIMS score of 11 and diagnoses including BPH, renal insufficiency, and diabetes mellitus; R35 had a BIMS score of 15 and diagnoses including CAD, thyroid disorder, and arthritis; R37 had a BIMS score of 5 and diagnoses including stroke, hemiplegia, and malnutrition; and R41 had a BIMS score of 15 and diagnoses including malnutrition, depression, and scoliosis. Interviews with the Admissions Director, Social Services Director, DON, and Administrator confirmed that advance directive information was obtained verbally or through Social Services, that the IDT did not consistently review advance directive status during care plan meetings, and that staff were expected to follow facility policy related to advance directives.
Missing Controlled Medication Shift Change Documentation
Penalty
Summary
The facility failed to ensure proper documentation of the narcotic card count at each change of shift for 3 of 4 medication carts. Review of the Controlled Medication Shift Change Log showed missing signatures on the 100 Hall back medication cart, the 100 Hall split medication cart, and the 200 Hall split medication cart. On the 100 Hall back cart, the oncoming nurse did not sign the log on 04/01/2026, 03/24/2026, and 03/10/2026. On the 100 Hall split cart, the oncoming nurse did not sign on 03/24/2026 and 03/10/2026. On the 200 Hall split cart, the oncoming nurse did not sign on 03/16/2026, and the outgoing nurse did not sign on 02/26/2026 and 01/27/2026. Facility staff and leadership confirmed that controlled medications were expected to be counted and documented by both the outgoing and oncoming nurses at each shift change. An LPN stated she had not signed the log at shift change because she wanted to wait until after pharmacy delivered new inventory, and she stated it was important to sign at the time of shift change to prevent potential diversion. ADONs stated they were not aware of the reasons for the missing documentation and did not conduct routine audits of the medication carts or shift change logs. The DON and Administrator stated that signatures were expected at the time of the count to maintain accountability and accurately identify responsible staff if a discrepancy was identified.
Improper Storage of Refrigerated Medications, Vaccines, and Insulin
Penalty
Summary
Medications and biologicals were not stored in accordance with CDC guidance, manufacturer recommendations, and the facility’s medication storage policy. During observation, the medication storage refrigerator was found at 48 F, above the recommended refrigeration range, and the freezer compartment contained about two inches of ice buildup. Review of the refrigerator temperature logs showed repeated temperatures below the required range of 36 F to 46 F during the month reviewed, including 13 days when temperatures were documented below 36 F. The refrigeration checklist also reflected a lower target of 41 F and included a section for corrective action when temperatures were at or above 41 F. The refrigerator contained 58 single-dose Afluria influenza vaccines stored tightly packed together in a drawer with no space between the boxes for air circulation. The vaccines were stored in the same refrigerator while the unit was observed at 48 F. Review of the CDC Vaccine Storage and Handling Toolkit and the Afluria package insert showed refrigerated vaccines must be maintained between 36 F and 46 F and stored with adequate spacing and air circulation to preserve potency and effectiveness. Resident 30’s insulin was also found to be used after the date it was labeled as opened and after the manufacturer’s expiration date. Staff interviews showed uncertainty about the proper refrigeration range and follow-up expectations when temperatures were out of range. The IP/ADON, ADON, DON, and Administrator all stated medications and vaccines should be stored according to guidelines, but the observations and record review showed the refrigerator temperatures were repeatedly outside the acceptable range and the vaccines and insulin were not stored in accordance with those requirements.
Facility Assessment Lacked Staffing Numbers and Recruitment/Retention Plan
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the staffing resources needed to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment Tool Record for [NAME] Nursing and Rehabilitation Center dated 03/18/2026 showed no documented staffing numbers for licensed nurses, nurse aides, or other nursing personnel needed to meet resident needs. The assessment also did not include information related to maintaining a plan to maximize recruitment and retention of direct care staff. Resident interviews and related record reviews described repeated delays in care and call light response. R2 was admitted with chronic kidney disease stage 2, difficulty walking, and adult failure to thrive, had a BIMS score of 15, and was care planned for falls risk and need for call light within reach. R2 stated she waited over an hour and a half at night for staff to change her and reported another time she was not changed from 7:00 AM to 11:00 AM. R16, admitted with COPD and respiratory failure, had a care plan for ADL/self-care deficits and incontinent care PRN; she stated she had been wet since 7:00 AM and was not changed until staff rushed after the surveyor came by. Additional residents reported similar delays. R19, cognitively intact and care planned for bowel/bladder incontinence and skin integrity, stated call light response could take one to two hours and that delays were more common on second shift, including extended waits for brief changes. R30, who had heart failure, cellulitis, morbid obesity, and unsteadiness, was reported by his POA to have waited for brief assistance for an extended period. R34 stated aides often did not come when scheduled and call lights were not answered in a timely manner. R45, who had respiratory failure, morbid obesity, and generalized weakness, stated night staff were slow after bowel movements and call lights took 30 to 45 minutes to be answered. R52, admitted with a stage 3 sacral pressure ulcer, debility, and muscle weakness, was reported by his son to wait 35 to 40 minutes for call lights to be answered, especially at night. CNA interviews also confirmed staffing concerns, including nights with only two CNAs for 46 residents, residents waiting a long time for help, and staff feeling rushed and exhausted. The DON stated staffing numbers were based on HPPD, but the Administrator acknowledged the staffing numbers were absent from the Facility Assessment and that the assessment would need to be adjusted.
Incomplete influenza and pneumococcal immunization offering, education, and documentation
Penalty
Summary
The facility failed to ensure residents were offered influenza and pneumococcal immunizations and failed to ensure residents or their representatives received education on the benefits, potential risks, and side effects of those vaccines. The facility also failed to maintain medical record documentation showing that education was provided, that each vaccine dose was administered, or that residents refused or had medical contraindications for the immunizations for 5 of 5 sampled residents. Review of CDC guidance showed routine annual influenza vaccination was recommended for all individuals aged six months and older unless contraindicated, and pneumococcal vaccination was recommended based on age and risk factors. The facility’s policy stated residents were to be assessed on admission for pneumonia vaccination history, the immunization was to be documented in the medical record, and residents or representatives had the right to decline vaccination. Despite this, the sampled records did not consistently show consent, declination, education, or complete vaccine documentation. For one resident with acute and chronic respiratory failure, COPD, and CHF, the immunization report showed refusal of influenza and pneumococcal vaccines, but the EMR had no consent, declination, or education documentation, and the resident stated she did not remember being offered the vaccines or receiving a vaccine information sheet. For another cognitively intact resident, the record showed a pneumococcal vaccine entry and influenza vaccine entry, but the documentation lacked manufacturer, lot number, and expiration date, and the resident did not recall signing consent or receiving education. A third cognitively intact resident had only historical vaccine entries without specific dates, and the report contained a discrepancy because vaccine administration dates were listed after the report print date; the EMR also lacked consent and education documentation, and the resident stated she was not provided education. A severely cognitively impaired resident had no documentation of pneumococcal consent, declination, or education for the documented pneumococcal vaccination, and another cognitively intact resident had a refusal listed for pneumococcal vaccination but no consent, declination, or education documentation in the EMR. During interviews, the Infection Preventionist stated she held multiple roles, including staff nurse and ADON, and said competing responsibilities, staffing changes, role confusion, and lack of clear assignment contributed to incomplete documentation and a breakdown in oversight. She stated the facility had prior survey citations for immunization practices and had not sustained compliance. The DON, Administrator, and Medical Director each stated they expected staff to follow CDC guidance, ensure residents or representatives were informed and able to consent or decline, and maintain accurate immunization documentation in the EMR.
Incomplete COVID-19 Vaccine Education, Offering, and Documentation
Penalty
Summary
The facility failed to ensure that residents were offered the COVID-19 vaccine and that residents or their representatives received education about the benefits, potential risks, and side effects of the vaccine. The facility also failed to ensure the medical record contained documentation of vaccine education, administration of each dose, or a resident’s refusal or medical contraindication for 5 of 5 sampled residents: R16, R22, R35, R37, and R41. CMS guidance reviewed by surveyors stated that LTC facilities must offer residents COVID-19 vaccination when vaccine supplies are available and must screen residents for prior immunization, precautions, and contraindications before offering vaccination. R16 was admitted with acute and chronic respiratory failure, COPD, and CHF, and had a BIMS score of 12, indicating moderate cognitive impairment. Her immunization report showed no documented COVID-19 vaccinations or declinations during the vaccination period. A consent form was signed on the same day the surveyor requested the information and showed the resident declined the vaccine, but the EMR contained no documentation that education about the vaccine’s benefits and potential risks had been provided. During interview, R16 stated she did not remember being offered the vaccine or signing a consent form and said she did not receive a vaccine information sheet. R22, R35, and R41 were cognitively intact with BIMS scores of 15, and R37 had severe cognitive impairment with a BIMS score of 5. Their immunization reports also showed no documented COVID-19 vaccinations or declinations during the vaccination period. For R22 and R35, consent forms were signed on the same day the surveyor requested the information; R22’s form indicated she consented but was not administered the vaccine, while R35’s form contained only initials and did not document acknowledgement of receiving vaccine information, understanding risks and benefits, or having the opportunity to ask questions. For R37 and R41, verbal informed consent was obtained from representatives by telephone, and both representatives declined vaccination. In each of these cases, the EMR lacked documentation that education regarding the benefits and potential risks of the COVID-19 vaccine had been provided. During interviews, the Infection Preventionist stated she had multiple roles, including staff nurse and ADON, and said competing responsibilities interfered with infection prevention oversight. She explained that state-supplied vaccines had previously been available, but once they were no longer available she sought direction about ordering vaccines and was told the facility would not cover the cost, so no further action was taken. She also stated she contacted pharmacies to arrange on-site clinics, but no formal determination had been made about when a clinic would occur or who would conduct it. The IP acknowledged that consent documentation was initiated during the survey, that documentation was incomplete, and that the breakdown was related to staffing changes, role confusion, and lack of clear responsibility. The DON, Administrator, and Medical Director each stated that residents should receive vaccine education, that consent or declination should be documented, and that immunizations should be managed in accordance with CDC guidance.
Failure to Accommodate Resident Preferences and Room Conditions
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of 2 of 3 sampled residents, R7 and R8, related to room accommodation and activity preferences. Facility policies stated that residents should receive care and services to attain or maintain the highest practicable well-being, that care should be person-centered and honor resident preferences, and that housekeeping and maintenance should maintain a sanitary, orderly, and comfortable interior. R8, who was admitted with diagnoses including primary progressive multiple sclerosis, abnormal posture, and oropharyngeal dysphasia, had a BIMS score of 14 out of 15 and was cognitively intact. Her care plan stated she needed staff assistance and encouragement to go to activities and that she liked to watch television in her room. Surveyors observed R8 crying in her wheelchair in the hallway with no staff present, and on multiple later observations she was alone in the hallway, by the nurses' station, or in her room with no staff interaction. Staff interviews confirmed her television and cable service frequently stopped working, which upset her because television was one of the only forms of entertainment she enjoyed. The Activities Director stated she liked to sit in the sun and watch sports and crime shows, and the DON and Administrator stated staff were expected to meet her activity needs and understand what upset her. R7 was observed in a room where the bed across from her had several boxes stored underneath and items left on top of an empty bed from a previous resident who had already left the facility. R7 felt bad that the previous resident's belongings had been left in the room. Staff interviews showed the items had remained there for weeks, with LPN and Social Services staff indicating the belongings had not been removed due to unresolved follow-up with the prior resident's family and guardianship issues. The DON stated discharged belongings should be followed up by social services, and the Administrator stated the items should have been placed in the social services office right away and that the current residents could be negatively affected by the items remaining in the room.
Failure to Provide Written Transfer and Bed Hold Notice
Penalty
Summary
The facility failed to notify Resident 16 in writing of her transfer to the hospital and failed to maintain a copy of the transfer notice in her medical record. The record also did not contain documentation of the transfer or discharge, and the facility did not send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. Review of the facility policy titled, Admission, Transfer, and Discharge Standards of Practice, showed that prior to transfer or discharge the resident and/or representative were to be notified of the reason for the transfer or discharge, a copy of the discharge notice was to be sent to the State Ombudsman’s office, and the medical record was to reflect the reason for the transfer or discharge. Resident 16’s EMR contained no written transfer notice or bed hold documentation. Her Face Sheet showed admission with diagnoses including COPD, CHF, and iron deficiency anemia. Her quarterly MDS showed a BIMS score of 12 out of 15, indicating moderate cognitive impairment. During interview, the resident stated she was not informed of the facility’s transfer or bed hold policy and did not sign any paperwork related to the transfer notice. Staff interviews confirmed that the facility relied on verbal notification and that transfer and bed hold notices were only provided if requested, while staff were unable to produce documentation showing that the resident’s transfer was recorded, that written notice was provided, or that the Ombudsman was notified.
Care plans lacked non-pharmacological pain interventions
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for two residents with chronic pain. For one resident, the record showed diagnoses including low back pain, osteoarthritis, and COPD, and the quarterly MDS indicated moderate cognitive impairment and substantial/maximal assistance needs for bed mobility. Her care plan included a pain focus with goals for pain relief and interventions for pain medications and physician notification, but it did not include any non-pharmacological interventions for her chronic back pain. During interview, she stated she had constant pain related to a motor vehicle accident, fractures, and osteoarthritis, and said staff did not offer repositioning, heat or cold, or supportive devices, which she believed would help manage her pain. For the second resident, the record showed diagnoses including primary osteoarthritis of the left ankle and foot, chronic pain, and COPD. Her annual MDS indicated she was cognitively intact and dependent for bed mobility. Her care plan included a pain focus with goals for pain relief, along with interventions to monitor pain every 12 hours and administer pain medications as ordered, but it also lacked non-pharmacological interventions for chronic pain. During interview, she stated she had chronic pain in both lower extremities and the left knee, took scheduled pain medications, and was not offered non-pharmacological interventions such as frequent repositioning or heat or cold. Interviews with the MDS Nurse, an LPN, the DON, the Administrator, and the Medical Director confirmed that non-pharmacological interventions such as repositioning, supportive devices, heat or cold, ROM, distraction, and comfort measures were expected to be part of pain management and care planning. The DON stated residents with chronic pain should have individualized care plans that include appropriate interventions, routine pain assessment, monitoring of effectiveness, and revision as needed. The facility did not provide the requested Care Plan Policy for review.
Urinary catheter bag positioned above bladder
Penalty
Summary
The facility failed to ensure that a resident with a urinary catheter had the urinary collection bag secured below the bladder. The resident was admitted with diagnoses including end stage renal disease, diabetes, and Alzheimer's dementia, and the admission MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The facility's procedure manual, based on Lippincott Nursing Procedures, stated that the drainage bag should be kept below the level of the patient's bladder to prevent backflow of urine into the bladder and reduce the risk of catheter urinary tract infection. Observations showed the resident's urinary catheter bag on the side of the chair above the bladder on multiple occasions. Staff interviews reflected differing understanding of the positioning of the bag: one CNA stated the resident liked the bag on the side of the wheelchair, while another CNA and an RN stated the bag should be below the bladder to drain properly and prevent urinary tract infection. The resident's care plan dated 02/12/2026 did not include an intervention to educate the resident on the risks of urinary tract infection when the urinary collection bag was on the side of the wheelchair, and the staff skill competency sheet did not mention the importance of keeping the urinary catheter collection bag below the resident's bladder.
Incorrect Oxygen Flow Rates
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring that residents who required oxygen therapy received it at the physician-ordered flow rates. The report identified deficiencies for 3 of 3 sampled residents, including R16, R22, and R38, and cited the facility’s procedure resource, which stated that oxygen therapy orders must be verified. The residents had diagnoses that included COPD, congestive heart failure, acute and chronic respiratory failure with hypoxia, heart failure, obesity, and shortness of breath, and the facility had documented oxygen therapy orders for each resident. For R38, the EMR showed an order for oxygen at 3 LPM via nasal cannula. During observation, R38 had a nasal cannula in place, but the oxygen concentrator beside the bed was set at zero. Staff initially gave conflicting information about the ordered flow rate, with one LPN stating it was 1.5 LPM before later confirming the order was 3 LPM and adjusting the concentrator. The resident’s oxygen saturation was checked and found to be 88 percent before the concentrator was plugged in and set to 1.5 LPM, after which the saturation increased to 94 percent. The TAR later reflected oxygen at 3 LPM as ordered. For R16, the physician’s order allowed oxygen at 3 LPM via nasal cannula, and the care plan also directed oxygen at 3 LPM by concentrator. However, observation showed the resident receiving oxygen at 1.5 LPM, and the concentrator remained set at 1.5 LPM on continued observation. For R22, the physician ordered continuous oxygen at 2 LPM via nasal cannula at the hour of sleep and as needed, but observation showed the resident’s oxygen set at 2.5 LPM, and it remained at that setting on later observation. Staff interviews indicated nurses were expected to verify oxygen settings against orders, but the observed settings for these residents did not match the documented physician orders.
Trash and debris left around outdoor dumpsters
Penalty
Summary
The facility failed to ensure the area around the two outside dumpsters was free of trash and debris. Observation of the outdoor dumpster area in a corner of the facility parking lot revealed cigarette butts, straws, soda cans, medical gloves, papers, plastics, and plastic utensils on the ground near the dumpsters. The same conditions were observed again later that morning, showing the debris remained in the area around the dumpsters. Review of the facility’s Housekeeping Services (General) policy stated that housekeeping and maintenance services shall maintain a sanitary, orderly, and comfortable environment. The facility reported that it did not have a specific policy for food-related garbage and/or refuse disposal. During interviews, the Maintenance/Housekeeping Director confirmed housekeeping was responsible for taking out the trash and keeping the dumpster area clean and stated the trash around the dumpster area was unacceptable. The Kitchen Supervisor stated dietary aides were assigned to transport garbage from the kitchen to the dumpster area and that housekeeping was responsible for maintaining the dumpster area in a sanitary condition. The Administrator stated housekeeping staff were responsible for maintaining the trash/dumpster area and expected the dumpster lids to be closed with no trash on the ground.
Failure to Deliver Mail on Saturdays
Penalty
Summary
The facility failed to ensure that all residents had the right to send and receive mail on Saturdays, affecting all 49 current residents. The facility's policy, revised in December 2024, stated that residents had the right to privacy in written communications, including the right to send and promptly receive mail. During a Resident Council meeting, it was reported by 12 residents that they did not receive or send mail on Saturdays, and packages were not received unopened on the day they were delivered. The Social Services Director (SSD) acknowledged that mail was not delivered on Saturdays and stated that the Activities Director was initially responsible for mail delivery on weekends. However, due to complaints, the SSD took over the responsibility but did not work on weekends, resulting in mail not being delivered on Saturdays. Interviews with staff revealed a lack of clarity and communication regarding mail delivery responsibilities. The Activities Director confirmed she did not work on weekends and was informed by the Business Office Manager that the SSD would handle mail delivery. The Director of Nursing (DON) was unaware of the mail delivery issues and stated that not receiving mail or packages on delivery days was a violation of residents' rights. The Administrator expected residents to receive their mail upon delivery to the facility, indicating a disconnect between expectations and actual practices regarding mail distribution.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs used were labeled in accordance with professional standards, as observed in multiple medication and treatment carts. During observations, undated, opened, and expired medications were found in three out of four medication carts and one treatment cart. These included inhalers, insulin vials, insulin pens, laxatives, antifungal powder, and topical creams. Specific instances included a Trelegy Ellipta inhaler with an expired date, an opened and undated bottle of Acid Gone, and albuterol packets without an opened date. Additionally, medications such as tiotropium bromide and Robafen DM Cough Syrup were not in their original packaging and lacked proper labeling. Further observations revealed expired and undated medications in the medication cart for rooms 206-212, including an expired insulin lispro vial, a lactulose bottle, and several inhalers and insulin pens that were opened and unbagged. Unwasted narcotics were also found in the narcotic box for a resident who had expired. Interviews with LPNs and staff indicated a lack of awareness regarding the expiration and proper labeling of medications, with LPNs acknowledging that expiration dates should be checked before administration and that undated medications should be discarded. The treatment cart was also found to contain unlabeled and unbagged medications, including nystatin powder and various antifungal creams. Interviews with staff, including the DON and the Administrator, highlighted expectations for medications to be dated upon opening and checked regularly. The DON admitted to forgetting about narcotics for an expired resident, and the Administrator emphasized the importance of proper packaging and dating to prevent medication errors. Despite weekly audits, the facility's practices did not align with its policies, leading to the observed deficiencies.
Repeated Use of Expired Insulin Highlights QAPI Failures
Penalty
Summary
The facility failed to maintain an effective Quality Assurance Performance Improvement (QAPI) process, as evidenced by the repeated issue of expired insulin being used. During an observation, insulin lispro was found opened, in use, and dated with an expiration date that had already passed. This issue was not new, as a previous survey had already identified the use of expired insulin, indicating a failure to address the problem effectively. The deficiency affected all 49 residents in the facility, highlighting a systemic issue in medication management. The Director of Nursing (DON) was responsible for monitoring compliance regarding the labeling and storage of medications, as outlined in the facility's job descriptions and plan of correction. However, audits performed by the pharmacy technician revealed multiple instances of expired and undated medications over several months. Despite the facility's plan to conduct regular audits, the problem persisted, and the DON was unavailable for an interview regarding the QAPI process during the survey. The Nursing Home Administrator acknowledged that it was the DON's responsibility to monitor QAPI audits to ensure compliance.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by several observations and interviews. One incident involved a Licensed Practical Nurse (LPN) who did not don personal protective equipment (PPE) in an enhanced-barrier precaution (EBP) room before providing direct care to a resident with a wound dressing. The LPN also failed to clean the glucometer according to the manufacturer's instructions, using a disinfectant wipe for only 24 seconds instead of the required two-minute dwell time. This oversight occurred despite the LPN's acknowledgment of the correct dwell time and the importance of following infection control protocols. Another deficiency was observed when a Registered Nurse (RN) cleaned a stethoscope with an alcohol wipe while still wearing dirty gloves after administering medication to a resident. The Director of Nursing (DON) later stated that staff were expected to remove dirty gloves, perform proper hand hygiene, and re-glove before cleaning equipment. However, there was no documentation of staff infection prevention and control practice (IPCP) audits, which the DON acknowledged as necessary to ensure compliance with guidelines. Additionally, the facility failed to assess and monitor the building's water system for Legionella and other opportunistic waterborne pathogens. There was no documentation of control measures such as visible inspections, disinfection, and temperature controls. The facility also lacked a process flow diagram to identify areas where Legionella could grow and spread. Interviews with the Maintenance Director and Administrator revealed a lack of awareness and documentation regarding the water management program, further highlighting the facility's failure to adhere to CDC guidelines and recommendations.
Failure to Document Vaccine Education for Residents
Penalty
Summary
The facility failed to ensure that the medical records of five residents included documentation of education regarding the benefits and potential side effects of immunizations. The facility's policy required that residents be educated and offered available immunizations to minimize the risk of disease transmission. However, the facility did not provide current Vaccine Information Sheets (VIS) for the 2024-2025 vaccines, instead offering outdated sheets from 2023. This lack of updated information and documentation was evident in the records of residents with varying levels of cognitive impairment, as well as those who were cognitively intact. For residents with severe cognitive impairment, such as those with a Brief Interview for Mental Status (BIMS) score of 5 out of 15, there was no documentation that their resident representatives were contacted or provided with updated vaccine information. In the case of residents who were cognitively intact, they reported not receiving any VIS to read or sign before the administration of their vaccines. This lack of education and documentation was consistent across all sampled residents, regardless of their cognitive status. Interviews with facility staff, including the Infection Preventionist (IP), Director of Nursing (DON), Administrator, and Medical Director, revealed a lack of awareness and adherence to the facility's policy and CDC guidelines. The IP and DON acknowledged the importance of providing vaccine education and maintaining proper documentation but could not explain why the sampled resident files lacked this information. The Administrator emphasized the need for compliance with CDC recommendations and facility policies, while the Medical Director expected the facility to follow all policies and procedures.
Failure to Document COVID-19 Vaccination Education and Status
Penalty
Summary
The facility failed to maintain proper documentation of COVID-19 vaccination education, offering, and status for four sampled staff members, including two LPNs, a CNA, and the Business Office Manager. The review of employee files revealed no documented evidence that these staff members were offered the COVID-19 vaccination or received education regarding its benefits, risks, and potential side effects. Interviews with some staff members confirmed that while they received education, they did not sign any documentation acknowledging it or the offering of the vaccine. Interviews with the Infection Preventionist, Director of Nursing, Administrator, and Medical Director highlighted the importance of following CDC guidelines and maintaining documentation of staff immunizations or declinations as part of the facility's infection control program. Despite the facility's policy to educate and offer vaccinations to staff, the lack of documentation in employee files indicates a failure to adhere to these guidelines, which is essential for ensuring the safety of both staff and residents.
Failure to Provide Privacy Cover for Catheter Bag
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by not providing a privacy cover for an indwelling urinary catheter bag. Over several days, observations revealed that the resident's catheter bag was visible from the hallway, as the privacy curtain was not pulled, and the bag was not covered. This lack of privacy was noted during multiple observations, indicating a consistent oversight in maintaining the resident's dignity. Interviews with staff, including CNAs, an LPN/Unit Manager, the Director of Nursing, and the Administrator, confirmed that it was the facility's policy and expectation to provide privacy covers for catheter bags to protect residents' privacy and dignity. Despite this policy, the staff interviewed were unaware of why the resident did not have a dignity cover, highlighting a gap between policy and practice. The resident involved had severe cognitive impairment, as indicated by a low BIMS score, and was admitted with diagnoses including obstructive uropathy and protein calorie malnutrition.
Failure to Include Hospice Services in Baseline Care Plan
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included necessary instructions for providing effective, person-centered care for a resident admitted with Hospice services. The resident was admitted with diagnoses including senile degeneration of the brain, Alzheimer's dementia, anxiety, and major depression. Despite the physician's order to admit the resident with Hospice services, the baseline care plan did not include a focus area for Hospice care until five days after admission. Interviews with facility staff, including an LPN, the MDS Coordinator, the DON, and the Administrator, revealed discrepancies in the understanding and execution of the baseline care plan policy. The LPN and MDS Coordinator indicated that the baseline care plan should be initiated upon admission and completed within 48 hours, including any necessary changes. However, the DON stated that Hospice services were not included in the baseline care plan because it would not alter the level of care provided. The Administrator acknowledged that basic information, including Hospice services, should be included in the baseline care plan at admission.
Deficiencies in Care Planning for Hospice and Respiratory Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for two residents, leading to deficiencies in meeting their medical, nursing, and psychosocial needs. Resident 9 was admitted to Hospice care, but the care plan for Hospice services was not developed until four days after admission. This delay in care planning was acknowledged by the MDS Coordinator, who stated that the care plan should have been developed immediately upon admission to Hospice services. Resident 16, who was admitted with acute on chronic respiratory failure and other conditions, did not have a care plan addressing non-compliance with medical treatments and oxygen therapy. Despite being cognitively intact, the resident was observed adjusting the oxygen concentrator settings, which were not consistent with the physician's orders. Interviews with staff, including the LPN and Infection Preventionist, revealed a lack of awareness regarding the specific focus of the care plan related to the resident's non-compliance and respiratory care needs. The facility's policy emphasized a patient-focused approach, yet the care plans for both residents did not reflect their current status or provide adequate direction for individualized care. The MDS Coordinator and other staff members acknowledged the importance of care plans in ensuring appropriate, resident-specific care, but the deficiencies highlighted a failure to implement timely and comprehensive care plans for these residents.
Failure to Adhere to Oxygen Therapy Orders
Penalty
Summary
The facility failed to provide oxygen therapy according to the Physician's Order for a resident, identified as R16, who was admitted with acute on chronic respiratory failure and encephalopathy. Observations over several days revealed that the oxygen concentrator's flow rate was consistently set higher than the prescribed 3 liters per minute (LPM), with settings observed at 4.5 LPM, 5 LPM, and 4 LPM on different occasions. The resident, who was cognitively intact, confirmed that the oxygen flow rate should be set at 3 LPM and mentioned that the concentrator was old and unable to hold the setting. Despite this, no staff had checked the concentrator to ensure it was functioning correctly. Interviews with facility staff, including the Infection Preventionist (IP) Nurse and the Director of Nursing (DON), revealed a lack of adherence to the facility's policy on oxygen usage, which required regular assessments and documentation of oxygen flow rates. The IP Nurse indicated that the medication nurse was responsible for ensuring correct oxygen settings, but acknowledged that the resident was not care planned for oxygen therapy and that the orders were not included in the Medication Administration Record (MAR) or Treatment Administration Record (TAR). The DON and the Administrator both expressed expectations that staff should follow physician orders to ensure proper care delivery, but were unaware of why the orders were missing from the records.
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 17 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cynthiana
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgemont Healthcare | 0.9 mi | ★★★★★ | 1 | 0 |
| Cedar Ridge Health Campus | 2.6 mi | ★★★★★ | 2 | 0 |
| Bourbon Heights Nursing Home | 13.5 mi | ★★★★★ | 0 | 0 |
| Willowbrook Healthcare | 14.1 mi | — | 0 | 0 |
| Robertson County Health Care Facility | 15.7 mi | ★★★★★ | 0 | 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.