Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Jena Nursing And Rehabilitation Center, Llc during CMS and state inspections, most recent first.
Medical Director Did Not Participate in Quarterly QAA Meetings: The facility failed to ensure the Medical Director took part in quarterly QAA meetings. Record review showed no documentation of the Medical Director attending any QAA program meetings over several months, and both the Administrator and the previous Medical Director confirmed the absence of attendance.
Failure to Follow EBP During Resident Care: Staff did not wear required gown and gloves during high-contact care for multiple residents with EBP orders, including suctioning for residents with trachs and PEG tube care and a bed bath for residents with PEG tubes. PPE was available, EBP signage was posted, and the DON confirmed the staff should have used PPE; one LPN stated she did not know what EBP meant.
Failure to honor a resident’s room privacy and dignity occurred when a confused resident repeatedly wandered into another resident’s room despite complaints to staff. The affected resident, who had intact cognition and required varying levels of assistance with ADLs, reported that staff dismissed his concerns, while multiple staff members confirmed the wandering behavior and the Administrator acknowledged it should not have happened.
A resident admitted with schizoaffective disorder, HIV, bipolar disorder, and insomnia did not have a baseline care plan developed within the required 48 hours. The Unit Manager confirmed she was responsible for completing and tracking baseline care plans, and verified the resident’s plan was not completed on time.
A resident with seizures, MDD, insomnia, HTN, and constipation had documented behaviors including hitting, punching, kicking staff, and throwing feces, yet the care plan did not include a behavior plan. The MDS also noted the resident was short tempered and easily annoyed, and staff confirmed the care plan had not been revised to reflect the behaviors.
Failure to provide needed grooming and hygiene assistance: two residents who were dependent for ADLs did not receive adequate personal care. One resident with severe cognitive impairment and total ADL dependence was observed with untrimmed, jagged fingernails and black debris under the nails despite a care plan calling for nail care during daily baths. Another resident, dependent for bathing and personal hygiene, was observed with dirty, dry/flaky, matted hair, and staff, the hospice nurse, and the DON confirmed the hair was not clean and needed washing.
Respiratory equipment was not properly changed, labeled, or stored for a resident receiving nebulizer treatment. An undated aerosol mask attached to a nebulizer was observed on the resident’s nightstand, open to air, and remained there on a later observation. An LPN confirmed the mask was open to air and not stored properly, and the DON confirmed the mask and tubing had not been dated or stored properly.
A resident with ESRD, DM2, depression, anxiety, bipolar disorder, and parkinsonism did not receive ordered Renvela for an extended period despite an active EMAR order. Review showed repeated hold periods and no doses administered across multiple months, while the dialysis RD said the medication was used for elevated phosphorus and had been filled previously. Staff interviews showed confusion about whether dialysis or the facility pharmacy should refill the medication, and the DON confirmed the medication was not readily available even though it should have been.
Failure to notify the physician of a resident’s severe pain occurred when a resident admitted after ORIF to the L femur and R wrist reported pain and the ordered PRN opioid was not yet available from the pharmacy. The LPN used comfort measures, but the pain persisted and the physician was not called; the NP later stated he would have ordered Tylenol until the pain med was available.
A resident admitted after ORIF surgery for a femur fracture and wrist fracture had an order for PRN hydrocodone-acetaminophen, but the medication had not arrived from the pharmacy. The resident reported severe pain, cried, and said the pain was 10/10, yet staff only used repositioning and pillows and did not notify the physician about the uncontrolled pain. The resident went without pain medication overnight and did not receive anything for pain until the next day.
Failure to promptly resolve a resident representative's grievances: a resident with intact cognition, pain, and recent fractures reported delayed pain meds, raw chicken, rude treatment by an LPN, and poor hair care. The daughter raised these concerns to the DON more than once, but no grievance was completed and the Administrator confirmed the complaints were not formally addressed.
A resident admitted with acute and chronic respiratory failure with hypoxia was discharged from the facility, but the Ombudsman Notification log did not show that the LTC Ombudsman was notified. An LPN stated she had not reported discharges to the Ombudsman for months and confirmed she was responsible for submitting the notification log; the Administrator also confirmed the facility did not provide 30-day notices to the Ombudsman.
A resident with intact cognition, multiple chronic conditions, and an indwelling urinary catheter had an NP and physician order for Clindamycin 1% topical medication to be applied twice daily to a penile erosion site. Review of the TAR showed repeated missing documentation of the evening dose on numerous days within the ordered treatment period, with no recorded reasons for omission. The DON acknowledged the lack of documentation, and an LPN admitted administering the topical medication without documenting it on the TAR, contrary to facility policy requiring documentation of each administered or omitted dose.
A resident with multiple medical conditions, including acute respiratory failure, UTI, and a stage 3 pressure ulcer, experienced a new onset of elevated heart rate ranging from 130–137 bpm that persisted throughout a shift. An LPN recognized this as a change in condition and discussed possible hospital transfer with the resident and spouse, who declined, but did not notify the NP despite facility policy requiring provider notification for significant changes in vital signs. The NP later reported receiving no notification of this change, and the DON confirmed that increased heart rate constitutes a change in condition that should have been reported.
Surveyors found that the facility failed to obtain and document an updated CNA registry verification before re-hiring a CNA who had previously been terminated. Review of the CNA’s personnel file showed an original registry check from the initial hire but no verification completed at the time of re-hire, and the administrator confirmed that no such documentation existed.
The facility failed to post complete daily nurse staffing information as required. Surveyors observed that Daily Nursing Staff Posting forms for consecutive days were displayed without documenting the resident census at the start of the shift, the daily nursing hours required, or the actual nursing hours worked. An RN responsible for staff development confirmed that these required data elements were not posted for those days and acknowledged that she had routinely posted the forms without the missing information.
Two residents with physician orders and care plans for Enhanced Barrier Precautions (EBP) during wound care did not receive care in accordance with the facility’s infection control policy. During separate wound care procedures, a treatment RN failed to wear a gown and did not change gloves between cleaning the wounds and applying ointments, powder, or clean dressings. The corporate RN confirmed that EBP requires staff to wear a gown and gloves for wound care and to change gloves after cleaning and before applying clean dressings or ointments.
A resident with a history of anoxic brain damage, cardiac arrest, and venous thrombosis was started on Apixaban for deep vein thrombosis, which was identified as a significant change in condition. The facility did not complete the required Significant Change MDS Assessment within 14 days of this change, as confirmed by MDS staff.
Two residents with complex medical histories had MDS assessments that did not accurately reflect their clinical status, including falls and antipsychotic medication use, despite documentation in their records and care plans. Staff confirmed the inaccuracies in the assessments.
A resident with a history of deep vein thrombosis and on Apixaban therapy was not care planned for anticoagulant therapy, despite staff acknowledging this should have been addressed. The resident had intact cognition and multiple significant diagnoses, but the care plan did not reflect the need for anticoagulant management.
The facility did not ensure person-centered care plans were developed and implemented for several residents. One resident with quadriplegia did not have a functioning bed alarm as ordered, with repeated observations showing the alarm was disconnected and improperly placed. Another resident who smoked was not care planned for smoking, despite facility policy and completed evaluation. A third resident with complex medical and psychiatric conditions had only a generalized care plan, lacking comprehensive, individualized interventions. Staff responsible for care planning acknowledged these deficiencies.
The facility did not meet professional standards by failing to properly document and assess a resident's skin condition, neglecting to obtain monthly weights for another resident as required, and administering medication by the wrong route to a resident with a G-tube. These deficiencies involved incomplete assessments, lack of adherence to care plans, and failure to follow physician orders.
A resident with moderately impaired cognition and multiple psychiatric diagnoses was physically assaulted by another resident after refusing a request, resulting in facial lacerations and emergency room evaluation. Both individuals had no prior history of physical aggression, and the incident was confirmed through staff interviews and record review.
A resident with schizophrenia and intact cognition was prescribed Risperdal 1mg twice daily, but there was no evidence that a gradual dose reduction was attempted or that a clinical contraindication was documented. Despite a consultant pharmacist's recommendation for a dose reduction, the physician did not provide a documented response, and the medical record lacked required documentation regarding the use of the antipsychotic medication.
Three residents had MDS assessments that did not accurately reflect their up-to-date COVID-19 vaccination status, despite immunization records showing they had received the required doses. The Infection Preventionist confirmed the discrepancy between the MDS documentation and the actual vaccination records.
The facility did not ensure that residents dependent on staff for ADLs received necessary grooming and hygiene care. A resident with impaired mobility was observed with unkempt hair and unshaven facial hair, while two other residents missed multiple scheduled bed baths, resulting in foul odors and inconsistent hygiene. Staff interviews and documentation confirmed that required care was not consistently provided.
A resident with multiple health conditions and at risk for pressure ulcers was not turned or repositioned as required by her care plan. Staff interviews and observations confirmed the resident remained in the same position for several hours, and necessary interventions were missing from both electronic and paper records. The DON acknowledged these omissions, resulting in a failure to provide necessary services to maintain skin integrity.
A resident who required continuous tube feeding and water flushes did not receive enteral nutrition as ordered by the physician. The feeding pump was found turned off, with both the resident and LPN unaware of the duration. Another LPN reported turning off the feeding due to the resident's stomach pain and later restarting it, but there was no documentation of the interruption. The DON was informed of issues but could not determine the cause or length of the feeding lapse.
The facility did not complete required annual performance reviews or provide regular in-service education for two CNAs, as shown by missing or outdated documentation in their personnel records. Both the administrator and HR confirmed the absence of these evaluations during interviews.
Multiple infection control deficiencies were identified, including an LPN administering medications via PEG tube without wearing a gown as required by EBP policy, a nurse failing to perform hand hygiene during wound care and contaminating supplies, and improper storage of both unused and used resident care items directly on the floor and in shower areas. Additionally, a visibly soiled shower curtain was observed, with staff unaware of cleaning protocols.
Two residents experienced incidents involving suspected abuse or unexplained injuries that were not reported immediately to management as required. In one case, an LPN observed bruising on a resident with severe cognitive impairment but failed to notify management, and in another, an LPN delayed reporting an abuse allegation made by a resident with moderate cognitive impairment. Both staff members later acknowledged the delay in reporting.
A facility failed to ensure controlled medications were administered and documented correctly for multiple residents. An LPN signed out doses of medications at times when she had already clocked out, and there was no documentation in the eMAR. The LPN admitted to pre-pulling medications and administering them early, against physician's orders, leading to false documentation of administration times.
The facility failed to document the effectiveness of pain management for five residents, as required by policy. Residents received pain medication without prior or post-administration assessments, and doses were not recorded on the eMAR. The DON confirmed the lack of documentation, highlighting a systemic issue in pain management practices.
A resident with a history of behavioral issues physically abused another resident by hitting them after an altercation involving a wheelchair. The incident was captured on surveillance, confirming the sequence of events. Both residents were assessed with no injuries reported.
A resident with a history of chronic left hip dislocation did not receive timely care due to a missed orthopedic specialist appointment. The resident, who required substantial assistance and had impaired cognition, was in pain and immobile. The facility failed to ensure transport to the appointment, leading to a delay in necessary medical evaluation and treatment.
A resident with a history of mental health issues physically assaulted another resident in the dayroom, despite staff presence. The altercation began when the aggressive resident attempted to take another resident's food tray, leading to a verbal confrontation and subsequent physical fight. The incident resulted in a skin tear for the aggressor and a reported head injury for the other resident, indicating a failure in the facility's abuse prevention measures.
A resident with a PEG tube did not receive the prescribed nutritional and hydration support due to incorrect feeding and flush rates set by the facility staff. The resident's feeding was set at 40ml/hr instead of the prescribed 50ml/hr, and water flushes were administered at 30ml every 3 hours instead of 50ml/hr. Additionally, the feeding and flush bags were not labeled as required. Staff interviews confirmed these discrepancies, highlighting a failure to follow the registered dietitian's recommendations.
The facility failed to maintain a clean, comfortable, and homelike environment in Rooms a, b, and c, with issues including dust, trash, dead insects, stained and loose ceiling tiles, non-functional lights, and a dirty window pane obstructing the outside view.
The facility failed to meet professional standards of quality by not obtaining required labs for a resident with multiple diagnoses and not notifying a physician of a dietician's recommendations for another resident's tube feeding regimen.
The facility failed to ensure that residents who were unable to carry out ADLs received necessary grooming and personal hygiene services. Several residents were observed with long facial hair and untrimmed, dirty fingernails, despite their care plans indicating they required assistance. Interviews with residents and staff, as well as record reviews, confirmed these deficiencies.
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The resident, who has multiple diagnoses and requires total assistance with all activities of daily living, was observed with 1/4 inch facial hair on her chin. An RN confirmed that the facial hair should have been shaved but was not.
The facility failed to act promptly on grievances reported by residents during a Resident Council meeting. Concerns about CNA performance were documented and given to the DON, but no follow-up or investigation was conducted.
A resident with multiple diagnoses, including Acute Respiratory Failure and Anoxic Brain Damage, was not provided with the correct tube feeding regimen as recommended by the dietician. Despite the plan of care specifying a different feeding rate and flush schedule, the resident continued to receive inadequate nutrition and hydration.
The facility failed to post daily nurse staffing information. An observation revealed that the posted information was outdated by several days, and the DON confirmed that it should have been updated daily but was not.
The facility failed to ensure that pureed foods were prepared according to standardized recipes, resulting in the use of unmeasured ingredients and methods that did not conserve nutritional value for three residents. Dietary staff admitted to not using recipes and the dietary manager confirmed the lack of adherence to the facility's policy on pureed food preparation.
The facility failed to ensure that all staff adhered to Enhanced Barrier Precautions for a resident with a tracheostomy and mechanical ventilation. A hospice CNA provided direct care without wearing the required PPE, despite signage and equipment indicating the need for such precautions. The CNA admitted to not understanding the signage, and the nurse confirmed that hospice staff were expected to follow the posted instructions.
Medical Director Did Not Participate in Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure the Medical Director participated in the Quality Assessment and Assurance (QAA) process quarterly meetings. Review of the Monthly and Quarterly QAA records showed no documented evidence that the Medical Director attended any QAA program meetings from 12/2025 through 05/2026. During interview, the Administrator confirmed the previous Medical Director had not attended any QAA program meetings during that period and stated she should have. In a separate telephone interview, the previous Medical Director also confirmed she had not attended any quarterly QAA meetings from 12/2025 to 05/2026.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain its infection prevention and control program by not following Enhanced Barrier Precautions for residents with indwelling devices. The facility’s policy stated that EBP applies to residents with devices such as tracheostomies, feeding tubes, and urinary catheters, and that gown and gloves are to be used during high-contact care activities. Surveyors observed staff providing care without the required PPE for multiple residents who had EBP orders in place. Resident #7 was admitted with diagnoses including acute respiratory failure and encounter for attention to tracheostomy, and had a physician’s order for Enhanced Barrier Precautions. During observation, a respiratory therapist suctioned the resident without wearing any PPE, even though EBP signage was posted on the bedroom door and PPE was available in the hallway or on the back of the door. Resident #34 had similar diagnoses and an EBP order, and was also observed being suctioned by the same respiratory therapist without PPE. Resident #73 had a diagnosis of acute respiratory failure and an EBP order, and was observed being suctioned without PPE under the same conditions. Resident #17 had diagnoses including iron deficiency anemia, hypotension, traumatic brain injury, and major depressive disorder, with moderate cognitive impairment on the quarterly MDS. The resident had a PEG tube and an active care plan and physician’s order for EBP related to the PEG/catheter. A LPN administered a bolus PEG feeding without wearing gown and gloves and stated she did not know what EBP meant. Resident #31 also had a PEG tube and an active care plan for EBP. Two CNAs provided a complete bed bath without wearing gown and gloves, and one CNA stated she understood EBP required PPE for residents with PEG tubes but did not wear it during the bath.
Failure to Honor Resident Room Privacy and Dignity
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity in a manner that promoted the resident’s quality of life by not honoring the resident’s choice regarding another resident entering his room. Resident #10 had diagnoses including hemiparesis following cerebral infarction affecting the left non-dominant side, type 2 diabetes mellitus, bipolar disorder, unspecified dementia, PTSD, generalized anxiety, and schizophrenia. The resident’s quarterly MDS showed a BIMS score of 15, indicating intact cognition, and documented that he required set-up assistance with eating, personal hygiene, and oral hygiene, and substantial to maximal assistance with toileting hygiene, dressing, and bathing. Resident #10 stated that Resident #27, who lived across the hall, had been coming into his room and that he had complained to staff, but nothing had been done. During the interview, Resident #27 entered the doorway of Resident #10’s room. Staff interviews confirmed that Resident #27 had a history of wandering into other residents’ rooms, including Resident #10’s room, and that staff had seen him in multiple residents’ rooms. The Administrator acknowledged awareness that Resident #27 propelled himself throughout the facility and was confused, and confirmed that if staff were aware of him wandering into Resident #10’s room, they should have reported it. The Administrator also confirmed that Resident #27 should not have been wandering into Resident #10’s room.
Failure to Complete Baseline Care Plan Within Required Timeframe
Penalty
Summary
The facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care within 48 hours of admission for Resident #78. Resident #78 was admitted on 05/29/2026 with diagnoses including Schizoaffective Disorder, Unspecified; Asymptomatic Human Immunodeficiency Virus; Bipolar Disorder; and Insomnia. Review of the medical record showed that Resident #78 did not have a baseline care plan. During interview, Resident #78 stated he was new to the facility and had recently been admitted. The Unit Manager stated she was responsible for completing baseline care plans, including follow-up to ensure they were completed within the required 48-hour timeframe, and confirmed that Resident #78's baseline care plan was not developed or completed within 48 hours, although it should have been.
Care Plan Not Updated for Resident Behaviors
Penalty
Summary
The facility failed to ensure the Comprehensive Resident Centered Plan of Care was revised to include behaviors for one resident. The resident was admitted with diagnoses including Other Seizures, Essential Hypertension, Major Depressive Disorder, Insomnia, and Constipation. The Annual MDS indicated a BIMS could not be performed and noted the resident was short tempered and easily annoyed. During observation, the resident was seated in the day room in a Geri chair and was hitting the side of the chair constantly. Staff interviews and record review showed the resident had ongoing behaviors that were documented in multiple nursing notes and EMAR entries, including hitting, punching, kicking at staff during direct care, and throwing feces in the room. A CNA reported these behaviors to the Adm and DON. Review of the resident’s care plan showed there was no plan of care for behaviors, and the MDS Nurse and DON both confirmed the care plan had not been revised to reflect the resident’s behaviors.
Failure to Provide Needed Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to perform ADLs received the necessary services to maintain grooming and personal hygiene. The deficiency involved two sampled residents: one resident with hemiplegia and hemiparesis following cerebral infarction, dementia, anxiety, and an unstageable pressure ulcer, and another resident with osteomyelitis, anxiety disorder, major depressive disorder, pain, unspecified dementia, and nonspecific skin eruptions. Facility policy stated that residents unable to carry out ADLs independently were to receive appropriate support and assistance with hygiene, including bathing, dressing, grooming, and oral care. For the first resident, the quarterly MDS showed severe cognitive impairment and total dependence for all ADLs. The care plan directed staff to check nail length and trim and clean the nails on bath day and as necessary, and the task log showed a daily bed bath on the day shift, with the last documented bath completed on 06/01/2026. However, observations on 06/01/2026, 06/02/2026, and 06/03/2026 showed untrimmed, jagged nails with a black unknown substance underneath the fingernails. A CNA stated the resident required total care, received a daily bed bath, and that the fingernails should not have looked that way, and a unit manager also confirmed the nails were untrimmed, jagged, and dirty. For the second resident, the quarterly MDS showed the resident was dependent for oral hygiene, toileting hygiene, shower/bathe, and personal hygiene, and required set-up or clean-up assistance with eating. The care plan called for a daily bed bath and assistance with personal hygiene and oral hygiene, but the bath roster did not document when the resident’s hair had been washed. Observations showed the resident’s hair was dirty, dry/flaky, and matted to the head, and the resident could not say when it had last been washed. The resident’s sister reported that the hair was not being washed regularly and that complaints to staff had been ignored. An LPN, another LPN, the hospice nurse, and the DON each confirmed the hair was dirty, dry/flaky, and needed to be washed.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident by not ensuring respiratory equipment was properly changed, labeled, and stored. The resident had an admission date of 04/20/2023 and diagnoses including iron deficiency anemia, morbid obesity, diffuse traumatic brain injury with loss of consciousness, and unspecified convulsions. On 06/01/2026, an undated aerosol mask attached to a nebulizer machine was observed on the resident’s nightstand, open to air. The resident had an order for ipratropium-albuterol solution, 1 vial inhaled orally four times a day for wheezing and cough for 5 days, with a start date of 05/28/2026. On 06/02/2026, the same aerosol mask remained on the nightstand, open to air. An LPN confirmed the mask was open to air and not labeled or stored properly, and the DON confirmed the aerosol mask and tubing had not been dated or stored properly.
Failure to Provide Ordered Phosphate Binder
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure accurate acquiring, receiving, dispensing, and administration of medications for Resident #59, who was admitted with ESRD, type 2 diabetes mellitus with unspecified complications, depression, anxiety, bipolar disorder, and parkinsonism. The resident’s annual MDS showed a BIMS score of 15, indicating intact cognition. Review of the EMAR showed an order for Sevelamer Carbonate (Renvela) 800 mg, 1 tablet by mouth before meals for disorders of phosphorus metabolism, with a start date of 04/17/2026, but the resident did not receive the medication from 04/18/2026 through 04/30/2026. Further review of the May 2026 EMAR showed the same Renvela order with multiple hold periods, and the resident did not receive any doses during that month. Review of the June 2026 EMAR showed the medication remained on hold and had not been administered from 06/01/2026 through the time of review. The dialysis RD stated the resident was on a fluid restriction and was prescribed Sevelamer Carbonate because of elevated phosphorus, that dialysis and the facility communicated through forms and faxed orders, and that the medication had been filled last on 03/27/2026 and 04/20/2026. Staff interviews revealed the facility believed dialysis normally refilled the medication, but the pharmacy said it could fill it if needed. The DON stated she did not know the resident had gone without the medication and confirmed the facility did not have it readily available even though it should have.
Failure to Notify Physician of Resident Pain When PRN Medication Was Unavailable
Penalty
Summary
The facility failed to ensure the physician was notified of a change in condition for Resident #3 when the resident reported severe pain and no pain medication was available to administer. Resident #3 was admitted on 04/02/2026 with diagnoses including pain, generalized anxiety disorder, fractures of the left femur and right wrist status post ORIF on 03/25/2026, hypertension, and morbid obesity. Admission orders included Hydrocodone-Acetaminophen 10/325 mg by mouth every 6 hours as needed for pain, and the resident’s record also showed a later order for Tylenol 325 mg, 2 tablets by mouth every 6 hours as needed for pain. A nursing progress note documented that the resident arrived by ambulance in stable condition and had pain rated 6/10. During interviews, Resident #3 stated she was hurting badly on admission, cried from pain, and went a whole day without receiving her pain medication because it had not arrived from the pharmacy. The resident said she was not offered Tylenol and could not recall asking for it. The LPN caring for the resident confirmed the resident continued to complain of pain, comfort measures such as repositioning and pillows did not relieve it, and the LPN did not call the physician even though she should have. The NP stated he had not been notified of the resident’s pain and would have ordered Tylenol until the pain medication was available. The Administrator, Corporate Nurse, and DON also confirmed the physician was not notified.
Failure to Provide Timely Pain Management After Post-Surgical Admission
Penalty
Summary
Safe, appropriate pain management was not provided for a resident admitted after surgery for a left femur fracture and a right wrist fracture. The resident arrived to the facility by ambulance with an order for Hydrocodone-Acetaminophen 10/325 mg every 6 hours as needed for pain, but the medication had not arrived from the pharmacy. The resident reported severe pain, stated the pain was 10 out of 10, cried because the leg hurt so badly, and said she was not offered or given any pain medication during the first night at the facility. The resident’s record showed diagnoses including pain, generalized anxiety disorder, hypertension, morbid obesity, and status post ORIF to the left femur and right wrist. The 5-day MDS documented intact cognition, lower extremity impairment, and pain rated at 10, described as the worst pain imaginable. The care plan identified a potential for altered comfort and included interventions such as anticipating pain relief needs, giving medications as ordered, notifying the physician if interventions were unsuccessful, and repositioning for comfort. Nursing documentation and staff interviews showed the resident continued to complain of pain after admission. A nursing note stated the resident requested to be transferred to the hospital because pain medication had not arrived from the pharmacy, and the ambulance was called, but the resident later refused transport. Staff reported using repositioning and pillows for comfort, but the resident continued to cry and complain of pain. The DON and other staff confirmed the physician was not notified of the increased pain, and the NP stated he would have ordered Tylenol if he had been informed. The resident did not receive pain medication until the following day, when Tylenol was administered.
Failure to Promptly Resolve Resident Grievances
Penalty
Summary
The facility failed to make a prompt effort to resolve grievances filed by a resident's representative for Resident #3. Resident #3 was admitted with diagnoses including pain, generalized anxiety disorder, fractures of the lower end of the left femur and right wrist, hypertension, and morbid obesity. Her 5-day MDS showed a BIMS score of 15, indicating intact cognition, and documented that she required assistance with several ADLs and had pain rated 10 at the time of assessment. During interview, Resident #3 stated that after admission she did not have pain medication available for almost 24 hours, was served raw chicken, and was spoken to rudely by an LPN, and she told her daughter about these issues. Resident #3's daughter reported that she complained to the DON about the lack of pain medication, raw chicken, rude treatment by the LPN, and the resident's hair not being washed, including a second complaint about the rude treatment and hair care concerns. The DON acknowledged speaking with the daughter on two occasions and stated she thought she had taken care of the issues, but she did not complete a grievance because she believed the concerns were resolved. The Administrator confirmed the complaints were not brought to her attention and that a grievance should have been completed but was not.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to ensure that a copy of the written notice of discharge was sent to the Office of the State Long-Term Care Ombudsman for a resident who was discharged from the facility. The facility’s undated discharge and transfer policy stated that prior to a resident being transferred or discharged, the facility must provide written notice to the resident, and if known, a family member or legal representative and the LTC ombudsman, at least 30 days before discharge or as soon as practicable for an immediate transfer or when the resident has not resided in the facility for 30 days. Record review showed the resident was admitted with a primary diagnosis of acute and chronic respiratory failure with hypoxia and was later discharged from the facility. Review of the Ombudsman Notification log for March 2026 did not show that the Ombudsman was notified of the discharge. During interview, the LPN stated she had not reported discharges to the Ombudsman since August 2025 and confirmed she was responsible for submitting the notification log. The Administrator also confirmed the facility did not provide 30-day notices to the Ombudsman and acknowledged there was no documentation that the resident’s discharge was reported as required.
Failure to Accurately Document Topical Antibiotic on TAR
Penalty
Summary
The facility failed to ensure medications were accurately documented on the Treatment Administration Record (TAR) in accordance with its medication administration policy. The policy required staff to document each medication as it was prepared on the MAR/TAR and to document a reason if a medication was not given as ordered. For one resident with intact cognition, admitted with diagnoses including depression, stage 4 sacral pressure ulcer, paraplegia, presence of urogenital implants, neuromuscular dysfunction of the bladder, and an indwelling urinary catheter, a nurse practitioner ordered Clindamycin 1% topical ointment to be applied to a penile erosion site twice daily for 14 days. The corresponding physician order specified Clindamycin Phosphate External Solution 1% topical, to be applied to the penile erosion site twice daily for infection over the same 14-day period. Review of the resident’s January–February 2026 TAR showed missing documentation for the 6:00 p.m. dose of the Clindamycin topical medication on multiple dates within the treatment period, with no entries indicating administration or reasons for omission. During interview, the DON confirmed there was no documentation on the identified dates and acknowledged that nurses should have documented on the TAR after administering the topical medication. In a separate interview, an LPN stated she remembered the Clindamycin 1% topical order and confirmed she did not document on the TAR after administering the ointment, despite being required to do so.
Failure to Notify NP of Resident’s Elevated Heart Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow its policy requiring notification of the attending physician extender and resident representative when there is a significant change in a resident’s condition, including unstable vital signs such as pulse. The facility’s policy titled "Notification of a Change in a Resident's Status" specifies that the physician/NP and responsible party must be notified for significant changes in or unstable vital signs. Resident #5, admitted with diagnoses including acute respiratory failure, depression, urinary tract infection, a stage 3 pressure ulcer of the left buttock, and infection of the skin and subcutaneous tissue, had a Quarterly MDS indicating moderately intact cognition with a BIMs score of 8. During a morning medication pass, the LPN observed that Resident #5’s heart rate was elevated between 130–137 beats per minute and identified this as a new change in condition. The LPN reported that the elevated heart rate persisted throughout her shift. She asked the resident and the resident’s husband if they wanted to go to the hospital, and both declined. Despite recognizing that facility practice and policy require notifying the physician or NP of a change in condition even when a resident refuses transfer, the LPN did not notify the NP of the elevated heart rate. The NP later stated he expects to be notified of any change from baseline and confirmed he had not been informed of this event. The DON also confirmed that an increased heart rate is a change in condition and that the NP should have been notified, establishing that the required notification did not occur for this resident’s elevated heart rate.
Failure to Obtain CNA Registry Verification Prior to Re-Hire
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) registry verification was obtained prior to the re-hire of one CNA. Record review showed that this CNA had an initial hire date of 10/22/2012, a termination date of 04/19/2018, and a re-hire date of 10/10/2018. The personnel file contained a CNA registry verification dated 10/22/2012, corresponding to the original hire, but there was no documented evidence that a new CNA registry verification was obtained at the time of re-hire. During an interview on 03/18/2026 at 11:50 a.m., the administrator confirmed that the facility did not have documentation showing that a CNA registry verification was completed prior to re-hiring this CNA as required. This deficiency was identified for 1 of 2 CNA personnel records reviewed, specifically for the CNA who had a break in employment and was subsequently re-hired without updated registry verification documentation in the personnel record.
Failure to Post Complete Daily Nurse Staffing Information
Penalty
Summary
The facility failed to properly complete and post required daily nurse staffing information. On 03/18/2026 at 8:45 a.m., surveyors observed a Daily Nursing Staff Posting form dated 03/18/2026 on a bulletin board in the middle of the facility that did not include the resident census at the start of the shift, the daily staffing hours required, or the actual hours worked. At the same time, a Daily Nursing Staff Posting form dated 03/17/2026 was also observed without the resident census, daily staffing hours required, or actual hours worked documented or updated from the previous day. In an interview on 03/18/2026 at 9:20 a.m., the Staff Development Coordinator RN confirmed that for both 03/17/2026 and 03/18/2026 the facility did not post the resident census, daily nursing hours required, or the actual nursing hours provided, and acknowledged that she had always posted the forms without this required information but should not have. No specific residents, medical histories, or clinical conditions were mentioned in the report in relation to this deficiency.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves failure to implement the facility’s infection prevention and control program, specifically its Enhanced Barrier Precautions (EBP) policy for high-contact resident care activities such as wound care. The facility’s policy, last reviewed on 03/01/2026, requires staff to use gown and gloves during EBP and to change gloves between cleaning and applying ointments or dressings. Resident #2, admitted on 09/03/2025 with a primary diagnosis of Acute Respiratory Failure with Hypoxia, had an order and care plan in place for EBP in relation to wound care. On 03/16/2026 at 2:25 p.m., during wound care for Resident #2, S6 TXRN did not wear a gown and did not change gloves between cleaning the wounds and applying ointments and powder, contrary to the EBP protocol. Resident #3, admitted on 07/02/2024 with a primary diagnosis of Restless Legs Syndrome, also had an order and care plan for EBP. On 03/16/2026 at 2:45 p.m., during wound care for Resident #3, S6 TXRN again failed to follow EBP protocol by not wearing a gown and not changing gloves between cleaning and redressing the wound. In an interview on 03/16/2026 at 3:15 a.m., S2 CorpRN confirmed that EBP procedures require direct care staff to wear a gown and gloves during wound care and that S6 TXRN should have worn a gown and changed gloves after cleaning a wound and before applying clean dressings or ointments, as required by facility policy.
Failure to Complete Timely Significant Change MDS Assessment After Initiation of Anticoagulant Therapy
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) Assessment within 14 days after a significant change in a resident's condition. Record review showed that a resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a history of venous thrombosis and embolism. The resident was not on anticoagulant therapy at the time of a quarterly MDS assessment, but physician orders later indicated the initiation of Apixaban for a history of deep vein thrombosis. Interview with the MDS staff confirmed that the initiation of anticoagulant therapy constituted a significant change in the resident's status, and acknowledged that the required Significant Change MDS Assessment was not completed within the mandated timeframe.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the status of two residents. For one resident with a history of seizures, traumatic brain injury, dementia with behavioral disturbance, and delirium, incident reports and electronic medical records documented unwitnessed falls and the administration of antipsychotic medication. However, multiple MDS assessments did not indicate any falls in the relevant periods, nor did they accurately record the use of antipsychotic medication, despite physician orders and medication administration records showing otherwise. Another resident with Parkinson's disease and severely impaired cognition experienced falls, including one with injury, as documented in the care plan and electronic medical record. Despite this, the resident's quarterly MDS assessment failed to accurately reflect the occurrence of these falls. Staff interviews confirmed that the MDS assessments for both residents did not accurately represent their clinical status as required.
Failure to Care Plan for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for one resident who had a history of deep vein thrombosis and was receiving anticoagulant therapy with Apixaban. The resident was admitted with diagnoses including anoxic brain damage, cardiac arrest due to another underlying condition, and a personal history of venous thrombosis and embolism. Despite having intact cognition as indicated by a BIMS score of 15, the resident's care plan did not address the ongoing anticoagulant therapy. This omission was confirmed through interviews with facility staff, who acknowledged that anticoagulant therapy should have been included in the resident's care plan.
Failure to Develop and Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans for multiple residents, resulting in unmet needs and noncompliance with physician orders and facility policies. For one resident with quadriplegia, seizures, and a PEG tube, staff did not ensure the bed alarm was properly placed, connected, or functioning as ordered. Observations over several days showed the bed alarm control box was detached and not connected, with the alarm mat misplaced in a Geri chair rather than on the bed. The resident was unable to locate her call light and reported a history of falls, while staff confirmed the bed alarm was not in use as required by the physician's order. Another resident who smoked cigarettes was not care planned for smoking, despite a completed Smoking Evaluation Tool and facility policy requiring individualized care plans for smokers. The resident's care plan did not address smoking, and the LPN responsible for care plans acknowledged this omission during review. Facility policy specifies that all smokers must have a care plan based on their evaluation, but this was not implemented for the resident in question. A third resident with multiple complex diagnoses, including schizophrenia, anxiety disorder, and chronic liver disease, had only a single, generalized care plan area focused on disease management. The care plan lacked comprehensive, person-centered interventions and did not address the resident's full range of needs, strengths, preferences, or goals. The LPN responsible for care plans confirmed that a comprehensive care plan had not been developed or implemented in a timely manner for this resident.
Failure to Meet Professional Standards in Skin Audits, Medication Administration, and Weight Monitoring
Penalty
Summary
The facility failed to ensure that care and services provided to residents met professional standards of quality in several instances. For one resident with multiple diagnoses including COPD, heart failure, and impaired mobility, the facility's policy required weekly head-to-toe skin audits with documentation of any identified skin conditions. However, a nurse failed to document observed bruising during a body audit and did not perform a complete assessment, as she did not lift the resident's shirt to check for additional injuries. This resulted in undisclosed bruising being identified only after notification from hospital staff, rather than through the facility's own assessment process. Another resident with schizophrenia and morbid obesity was not weighed monthly as required by facility policy and the resident's care plan. The resident's last recorded weight was several months prior, despite interventions in the care plan specifying monthly weights and provider notification for significant changes. The Director of Nursing confirmed that the resident had not been weighed as required. Additionally, a resident with anoxic brain damage and a tracheostomy did not receive medication as ordered by the physician. The physician's order specified that Baclofen should be administered via G-tube, but an LPN crushed the medication and administered it orally. Both the LPN and the unit manager confirmed that the medication was not given by the correct route, and the physician's order had not been updated to reflect any changes following a swallow study. This resulted in the resident not receiving medication as prescribed.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Harm
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. On 05/20/2025 at 4:09 p.m., one resident was struck multiple times on the head by another resident after refusing a request for a cigarette. This assault caused lacerations to the victim's left cheek, right cheek, forehead, and chin, requiring evaluation at the emergency room. Both residents involved did not have a prior history of physical aggression toward others, as confirmed by their medical records and staff interviews. The facility's abuse prevention policy states a commitment to protecting residents from abuse, including physical abuse such as hitting. Despite this policy, the incident occurred, and the injured resident, who had moderately impaired cognition and diagnoses including depression, anxiety, mood disorder, and seizures, suffered actual harm. The aggressor had intact cognition and diagnoses of schizoaffective disorder and major depressive disorder with psychotic symptoms. The event was substantiated through interviews, medical record reviews, and the facility's own investigation report.
Failure to Attempt or Document Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of schizophrenia, who was admitted on 11/06/2020, was found to be receiving Risperdal 1mg twice daily without evidence of a gradual dose reduction (GDR) attempt or documentation that a GDR was clinically contraindicated. The resident's most recent MDS assessment indicated intact cognition and ongoing use of antipsychotic medication, yet there was no record of a GDR being attempted. Additionally, a consultant pharmacist had recommended a GDR for Risperdal, but there was no documented response from the physician to this recommendation. The medical record lacked any documentation supporting either a GDR attempt or a clinical reason for not pursuing one.
Inaccurate MDS Documentation of COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessments accurately reflected the COVID-19 vaccination status for three out of five residents reviewed for vaccinations. For these residents, the most recent MDS assessments indicated that their COVID-19 vaccinations were not up to date. However, a review of their immunization records showed that they had received the required COVID-19 vaccine doses, with dates documented for each administration. During an interview, the Infection Preventionist confirmed that the residents should have been considered up to date with their vaccinations according to facility policy, and acknowledged that the MDS assessments did not accurately reflect this status.
Failure to Provide Required ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for residents who were unable to perform these tasks independently, resulting in deficiencies in grooming and personal hygiene. One resident with impaired mobility due to Muscular Dystrophy, who was dependent on staff for all ADLs, was observed with unkempt hair, dried sputum, and long facial hair. Staff interviews confirmed that the resident's grooming needs, including shaving and face washing, had not been met as required by facility policy. Two additional residents, both dependent on staff for bathing and personal hygiene, did not receive daily bed baths as specified in their care plans and facility policy. Documentation and staff interviews revealed that these residents missed multiple scheduled bed baths over a period of days. Observations noted foul odors in their rooms, and one resident reported only receiving bed baths upon request, with significant gaps between baths. Review of facility records, care plans, and staff schedules confirmed that the required ADL care, including daily bed baths and grooming, was not consistently provided. Staff acknowledged the missed care and, in one instance, admitted to documenting a bed bath that was not actually performed. The deficiencies were corroborated by direct observation, resident interviews, and review of care documentation.
Failure to Provide Required Turning and Repositioning for At-Risk Resident
Penalty
Summary
Staff failed to provide necessary services to maintain optimal skin integrity for one resident who was at risk for pressure ulcers. The resident, who had multiple diagnoses including spinal stenosis, Alzheimer's disease, morbid obesity, and was always incontinent of bowel and bladder, required moderate assistance for bed mobility and was care planned to be turned and repositioned every two hours and as needed. Observations over several hours showed the resident remained in the same position in bed, and interviews with CNAs confirmed that the resident had not been turned or repositioned during their shifts. The resident also confirmed she was unable to reposition herself and was not routinely turned by staff. Further review revealed that the resident's care plan included the need for regular turning and repositioning, but this intervention was not reflected in the facility's electronic charting system or on the paper kardex. The DON confirmed these omissions and acknowledged that the required tasks were not listed as they should have been. Staff interviews corroborated that the resident was not turned or repositioned as required by her care plan, resulting in a failure to provide necessary services to prevent pressure ulcers.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on tube feeding and water flushes did not receive enteral feedings as ordered by the physician. The resident had diagnoses including acute respiratory failure, hyperlipidemia, hypothyroidism, and insomnia, and was admitted with a care plan indicating the need for tube feeding due to nothing by mouth status. Physician orders specified Glucerna 1.5 at 60ml/hr via pump and water flushes at 250ml every 4 hours. Review of the medication administration record and progress notes for the relevant dates showed no documentation that the tube feeding was held or refused. On observation, the resident's feeding pump was found turned off, and the resident was unaware of how long it had been off. The LPN on duty at the time was also unaware that the pump was off and had not been notified of any issues during shift change. Another LPN from the previous shift reported turning off the tube feeding due to the resident's complaint of stomach pain and turning it back on a few hours later, but could not recall hearing the feeding alarm during the night. The DON was notified of issues with the tube feeding but did not know why or for how long the feeding had been off, despite the resident's orders requiring continuous feeding.
Failure to Complete Annual CNA Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews and provide regular in-service education based on those reviews for two of three certified nursing assistants (CNAs) reviewed. Personnel records showed that one CNA, hired in November 2023, did not have an annual performance review completed within the past 12 months, with the last documented review dated prior to their hire date. Another CNA, hired in May 2024, also had no evidence of an annual performance review in the past 12 months. During interviews, the administrator acknowledged that annual performance reviews had been requested but not provided, and the HR representative confirmed that the personnel records lacked evidence of completed annual performance evaluations for the affected CNAs. No information about the medical history or condition of any residents was included in the report, and the deficiency was limited to the facility's failure to observe and document CNA job performance and provide related training as required.
Infection Control Lapses in Medication Administration, Wound Care, and Environmental Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in staff adherence to established protocols. During a medication pass for a resident with quadriplegia and a PEG tube, an LPN administered medications and flushed the tube without wearing a gown, despite the facility's Enhanced Barrier Precautions (EBP) policy requiring both gown and gloves for such procedures. The LPN acknowledged forgetting to don a gown, and the Director of Nursing confirmed this was not in compliance with policy. The resident's medical record indicated ongoing PEG tube care for administration of Baclofen and Gabapentin. Further deficiencies were observed during wound care, where a treatment nurse failed to perform hand hygiene before preparing and applying wound dressings. The nurse handled clean gauze with ungloved hands, placed it into a cup, and then sprayed it with wound cleanser, contaminating the supplies. The nurse admitted to not performing hand hygiene and using the contaminated gauze on the resident's wound, which was inconsistent with the facility's standard precautions policy. Additional observations revealed improper storage of resident care items, with unused supplies such as adult briefs, wash basins, and under-pads stored directly on the floor, and used basins and a soiled urinal left on the shower floor. A shower curtain was also found to be visibly soiled, with staff unable to state the cleaning frequency or protocol. Facility administration confirmed these storage and cleanliness issues were not in accordance with expected standards.
Failure to Immediately Report Suspected Abuse and Injuries of Unknown Origin
Penalty
Summary
The facility failed to ensure that incidents of suspected abuse and injuries of unknown origin were reported immediately to management staff for two residents. In the first case, a resident with severe cognitive impairment and multiple medical conditions, including COPD and heart disease, was found to have bruising on the right eye and hip area. Although an LPN observed these bruises while accompanied by the resident's responsible party, she did not notify management at the time, believing the issue had already been addressed. Management only became aware of the bruising after being informed by a marketer who visited the resident in the hospital several days later. In the second case, a resident with moderate cognitive impairment and a history of dementia and anxiety reported to a CNA that two women were trying to harm her. The CNA relayed this to an LPN, who assessed the resident but delayed reporting the allegation of abuse to the administrator, sending a text message several hours later instead of immediately. Both staff members acknowledged during interviews that they should have reported these incidents to management without delay, as required by facility policy.
Controlled Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that controlled medications were administered as ordered and documented correctly for five residents. The deficiencies were identified through a review of medical records and interviews. The facility's policy required that when administering controlled medications, authorized personnel must record the administration on the MAR/eMAR and enter specific information on the Controlled Drug Record, including the date and time of administration, amount administered, signature of the person preparing the dose, and quantity reconciled. However, discrepancies were found in the documentation of medication administration for several residents. For Resident #1, the Controlled Drug Record for Norco 10-325mg showed doses signed out by an LPN at times when the LPN had already clocked out, and there was no documentation of these doses in the eMAR. Similar issues were found for Resident #2, where doses of Norco and Ativan were signed out without proper documentation, and the LPN had clocked out before the recorded administration times. Resident #3's records also showed doses signed out without proper documentation, and the LPN had clocked out before the recorded times. Resident #4's records revealed doses signed out without documenting a time or signature, and the LPN had clocked out before the recorded administration times. Resident #R1's records showed a dose of Tramadol signed out after the LPN had clocked out. Interviews with the Director of Nursing (DON) confirmed that the LPN documented giving controlled medications at times after she had already clocked out. The LPN admitted to pre-pulling medications and administering them early, which was against the physician's orders. The DON confirmed that the LPN did not follow the facility's policies and procedures for medication administration, leading to false documentation of medication administration times.
Failure to Document Pain Management Effectiveness
Penalty
Summary
The facility failed to provide appropriate pain management for five residents by not assessing the effectiveness of pain medication after administration. The facility's policy requires documentation of the date, time, dose, route, and effectiveness of PRN medications, but this was not followed. For each resident, there was no documentation of pain assessment prior to or after administering pain medication, nor were the doses recorded on the electronic Medication Administration Record (eMAR). Resident #1, with diagnoses including heart failure and hip dislocation, received Norco for pain on multiple occasions without documented assessments of pain or effectiveness. Similarly, Resident #2, who has severe cognitive impairment and multiple diagnoses, received Norco without proper documentation or assessment. Resident #3, with chronic heart failure and osteoarthritis, also received pain medication without documented assessments, and the doses were not recorded on the eMAR. Resident #4, who is cognitively intact and has spinal stenosis, received Norco without documented pain assessments or nurse signatures. Lastly, Resident #R1, with anemia and hypertension, received Tramadol without documentation of pain assessment or effectiveness. The Director of Nursing confirmed the lack of documentation for all residents, indicating a systemic issue in pain management practices at the facility.
Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident #11, who has a history of Schizoaffective Disorder, Bipolar Type, and Traumatic Brain Injury, was involved in an altercation with Resident #12, who also has Schizoaffective Disorder and a history of behavioral issues. The incident occurred when Resident #12, while propelling himself in a wheelchair, unknowingly rolled over Resident #11's foot. In response, Resident #11 pushed the wheelchair away, leading Resident #12 to stand up and hit Resident #11 in the shoulder. The altercation escalated as both residents stood up and swung their arms at each other, although no further physical contact was made. Resident #12 lost his balance and fell to the floor. Staff members, including S9 Central Supply and S8 LPN, intervened shortly after the incident. Both residents were assessed and found to have no physical injuries, and neither resident reported any pain. The facility's surveillance footage confirmed the sequence of events, showing that Resident #11 was not the aggressor. The incident was reported to the facility's administration, and it was noted that Resident #12 had a history of behavioral issues. The facility's failure to prevent this altercation highlights a deficiency in ensuring residents' safety from abuse by other residents.
Failure to Ensure Timely Specialist Appointment for Resident
Penalty
Summary
The facility failed to ensure that a resident received timely treatment and care in accordance with professional standards of practice. The resident, who had a history of chronic recurrent spontaneous left hip dislocation, was referred to an orthopedic specialist following a hospital admission. Despite the referral, the resident did not attend the scheduled appointment with the orthopedic specialist due to a missed ambulance transport, which was not noticed by the facility staff. The resident, who had moderately impaired cognition and was dependent on assistance for mobility and hygiene, expressed ongoing pain and immobility due to the dislocated hip. The resident's medical records indicated a need for urgent orthopedic consultation and potential surgical intervention. However, the facility's failure to ensure the resident's transport to the specialist appointment resulted in a delay in receiving necessary medical evaluation and treatment.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a deficiency. Resident #3, who has a history of mental health issues including Schizoaffective Disorder and Major Depressive Disorder, was involved in an altercation with Resident #4. Resident #3's care plan noted a risk for altered mental status and behaviors, including outbursts and aggression. Despite these known risks, Resident #3 was able to engage in a physical altercation with Resident #4 in the dayroom. Resident #4, who has Parkinson's Disease, Major Depressive Disorder, and moderate cognitive impairment, was involved in the incident when Resident #3 attempted to take another resident's food tray. Resident #4 verbally intervened, which led to Resident #3 approaching and physically assaulting Resident #4. The altercation escalated to both residents hitting each other and falling to the floor, resulting in a skin tear for Resident #3 and a reported knot on Resident #4's head. The incident was witnessed by S2 CNA, who was present in the dayroom and attempted to intervene by verbally instructing Resident #3 to stop. Despite these efforts, the altercation occurred, highlighting a failure in the facility's ability to prevent resident-to-resident abuse. The facility's policy on abuse prevention emphasizes protecting residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this case.
Failure to Maintain Prescribed Nutritional and Hydration Status for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident with a PEG tube maintained acceptable nutritional and hydration status as per the resident's comprehensive assessment. The resident, who had multiple diagnoses including chronic kidney disease, cerebrovascular disease, and dependence on a ventilator, was observed receiving tube feeding at a rate lower than prescribed. The prescribed rate was 50ml/hr for both Glucerna 1.5 and water flush, but the actual rate was set at 40ml/hr for the feeding and 30ml every 3 hours for the water flush. Additionally, the feeding and flush bags were not labeled with the resident's name, date, and time as required by the facility's policy. Interviews with facility staff confirmed the discrepancies in the feeding and flush rates. An LPN acknowledged that the rates were not set according to the physician's orders and that the bags were not labeled as they should have been. The Director of Nursing also confirmed that staff failed to implement the recommended changes to the feeding and flush rates made by the registered dietitian. This oversight in following the prescribed nutritional and hydration regimen for the resident led to the deficiency noted in the report.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in several resident rooms. Specifically, Rooms a, b, and c were observed to have a large amount of dust, trash, and dead insects in the corners between the beds and windows. Additionally, the window pane in Room a was covered with mildew and a green and brown substance, obstructing the outside view. The ceiling tiles in Rooms a and b were loose, had exposed insulation, and were stained brown. Furthermore, the over bed wall-mounted lights in Room b were not operational over both beds. These deficiencies were confirmed during observations on two separate days and were corroborated by S10 Maintenance, who acknowledged that the rooms had not been properly cleaned and that the ceiling tiles needed to be replaced, repaired, or painted. S10 Maintenance also confirmed that the light bulbs in Room b needed replacement and that the window pane in Room a should have been cleaned to allow the resident an outside view.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure services were provided to meet professional standards of quality for Resident #43 and Resident #268. For Resident #43, who had diagnoses including Chronic Respiratory Failure, Type 2 Diabetes Mellitus, and Paroxysmal Atrial Fibrillation, the facility did not obtain the required quarterly labs in December 2023 as ordered by the physician. This was confirmed by the Director of Nursing during an interview, acknowledging that the labs should have been collected but were not present in the medical record or Echart. For Resident #268, who had diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Tracheostomy status, the facility failed to notify the physician of the dietician's recommendations to adjust the tube feeding regimen. Despite the dietician's assessment recommending changes to the enteral feeding to meet the resident's nutritional needs, there was no documentation that the primary care physician had been informed. This was confirmed by both the Corporate RN and the primary care physician, who expressed concern over not being notified and indicated the need for immediate action to assess the resident's hydration status.
Failure to Provide Necessary ADL Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out Activities of Daily Living (ADLs) received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that Residents #1 and #4 were free from facial hair and failed to provide nail care to dependent residents, including Residents #11, #17, #21, #38, #48, and #62. These deficiencies were observed during various times and confirmed through interviews with the residents and staff members, as well as through record reviews of the residents' care plans and medical records. Resident #1, who has diagnoses including cerebral infarction and dementia, was observed with long facial hair despite his care plan indicating he required assistance with grooming. Resident #1 reported asking several staff members to shave him but had not been shaved. Similarly, Resident #4, who has diagnoses including diabetes and COPD, was observed with thick gray facial hair and long, dirty fingernails. Resident #4 confirmed that it had been weeks since his nails were trimmed and over a week since he had been shaved. Other residents, such as Resident #17, #21, #38, #48, and #62, were observed with long, untrimmed fingernails, some with dark substances underneath. These residents required assistance with ADLs due to various medical conditions, including dementia, hemiplegia, and schizophrenia. Interviews with the residents and staff confirmed that the necessary grooming and nail care had not been provided, despite being outlined in their care plans. The Director of Nursing (DON) also confirmed these observations during the survey.
Failure to Maintain Resident Dignity by Ensuring Removal of Facial Hair
Penalty
Summary
The facility failed to maintain dignity for a female resident by not ensuring she was free of facial hair. The facility's policy states that both male and female residents should be free of facial hair unless otherwise noted in the care plan. The resident, who has diagnoses including Unspecified Dementia, Chronic Obstructive Pulmonary Disease, Schizoaffective Disorder, Anxiety Disorder, and Dysphagia, requires total assistance with all activities of daily living. An observation revealed that the resident had 1/4 inch facial hair on her chin. An interview with an RN confirmed the presence of the facial hair and acknowledged that it should have been shaved but was not.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to act promptly on grievances concerning issues of resident care and life in the facility reported by residents during a monthly Resident Council meeting. Specifically, during the 02/13/2024 meeting, residents raised concerns about not being able to lay down when they wanted to when agency CNAs were working, not receiving baths, and CNAs not passing out ice. The concerns were documented and given to the Director of Nursing (DON) on 02/14/2024, with a response due by 02/23/2024. However, there was no documented evidence of an investigation into these concerns, and no follow-up was provided to the Resident Council. Interviews with the Activity Director and members of the Resident Council confirmed that the DON had not provided a follow-up or spoken to the Resident Council about the documented concerns. The Activity Director, who was responsible for assisting the Resident Council with setting up meetings and keeping minutes, confirmed that the concerns were given to the DON but no action was taken. The DON also confirmed that a follow-up should have been provided but was not. This failure to address and investigate the grievances reported by the residents constitutes a deficiency in the facility's grievance handling process.
Failure to Meet Nutritional Needs for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure services were provided according to the resident's Comprehensive Plan of Care for a resident who required tube feeding. The resident, who had multiple diagnoses including Acute Respiratory Failure, Anoxic Brain Damage, and Hypertension, was observed on multiple occasions receiving Jevity 1.5 at 50ml per hour with 50ml H20 flushes every 6 hours. However, the Registered Dietician's assessment recommended a different regimen of Jevity 1.5 at 62ml per hour with 42ml/hour flush continuous every hour to meet the resident's nutritional needs. Despite the dietician's recommendations, the resident continued to receive the incorrect tube feeding settings, as confirmed by observations and an interview with the Corporate RN. This discrepancy resulted in the resident not receiving adequate nutrition and hydration as per the Comprehensive Plan of Care, highlighting a failure in the facility's adherence to the prescribed nutritional plan for the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the nurse staffing information was posted daily. On 04/02/2024 at 9:30 a.m., an observation revealed that the daily nurse staffing information posted was dated 03/29/2024. During an interview on the same day at 11:56 a.m., the Director of Nursing (DON) confirmed that the nurse staffing information should have been updated daily but was not.
Failure to Follow Standardized Recipes for Pureed Foods
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods which conserved nutritional value for three residents who were ordered and served pureed diets. The facility's approved recipes for pureed roast turkey and pureed turnip greens were not followed. Instead, dietary staff prepared these items without referring to the standardized recipes, resulting in the use of unmeasured ingredients and methods that did not align with the facility's policy on pureed food preparation. Specifically, one dietary staff member admitted to adding milk and bread to the turkey without measuring or using a recipe, while another staff member also failed to follow the recipe when preparing the pureed turkey and turnip greens for serving. This was confirmed through interviews and observations with the dietary manager and staff, who acknowledged the lack of adherence to the recipes and the absence of recipe references during food preparation. The deficiency was identified during a review of the facility's approved 2024 Lunch Menu and the corresponding recipes for pureed foods. The facility's policy on pureed food preparation emphasized the use of standardized recipes to ensure quality, flavor, palatability, and maximum nutritive value. However, the dietary staff did not follow these guidelines, leading to the preparation of pureed foods that did not meet the required standards. This failure was observed and confirmed by the dietary manager, who acknowledged that the staff should have referred to the recipes but did not. The dietary manager also attempted to correct the issue by printing the recipes and preparing the pureed food items herself, but still did not adhere to the recipe instructions.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain infection control practices to prevent and control the spread of an infectious communicable disease. Specifically, the facility did not ensure that all staff adhered to Enhanced Barrier Precautions for a resident who was colonized or infected with a multidrug-resistant organism (MDRO). The facility's policy required the use of gowns and gloves during high-contact resident care activities for such residents. However, an observation revealed that a hospice CNA was providing direct care to a resident with a tracheostomy and mechanical ventilation without wearing the required PPE, despite the presence of signage and equipment indicating the need for Enhanced Barrier Precautions. The hospice CNA admitted to seeing the signage but did not understand its purpose and had not read it. The CNA was informed by facility staff that the sign and equipment were placed because state surveyors were in the building. Further interviews with the respiratory therapist and the resident's nurse confirmed that the hospice CNA was not wearing the appropriate PPE and that hospice staff were expected to follow the posted instructions. The nurse was unsure if all hospice staff had been made aware of the new precautions, although they should have been informed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Jena
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lasalle Nursing Home | 2.4 mi | ★★★★★ | 3 | 0 |
| The Columns Rehabilitation And Healthcare Center | 16.6 mi | ★★★★★ | 1 | 0 |
| Legacy Nursing And Rehabilitation Of Pollock | 21 mi | ★★★★★ | 9 | 0 |
| Haven Nursing Center | 27.5 mi | ★★★★★ | 0 | 0 |
| Tioga Community Care Center | 27.6 mi | ★★★★★ | 1 | 0 |
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