Below average — CMS composite of the measures below.
The next survey window likely opens around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Legacy Nursing And Rehabilitation Of Pollock during CMS and state inspections, most recent first.
Failure to Provide Needed ADL Assistance and Grooming Care: A facility failed to ensure three residents received needed hygiene and grooming assistance. One resident had dirty fingernails, another had long toenails despite orders for nail care, and a third dependent resident did not receive a scheduled bath and still had stubble facial hair. Staff confirmed the nail care and bath were not completed as expected.
An LPN failed to sign the narcotic count sheet at the start of shift and did not immediately document accurate controlled substance counts after administering meds to multiple residents. During reconciliation, several controlled meds had logged counts that were one unit higher than the amounts actually observed in the medication packs, and the DON confirmed the documentation was not completed as required.
Infection control practices were inconsistent when an LPN and another LPN returned used glucometers to the med cart without sanitizing them, a CNA placed soiled linen and a brief on the resident’s floor before bagging them, clean lift pads were stored on the soiled side of the laundry room, and staff gave conflicting accounts of disinfectant dwell time and cleaning practices.
Failure to Honor Resident Bathing Preference: A resident with intact cognition and diagnoses including COPD, MDD, parkinsonism, GAD, and dementia stated she preferred morning showers, but staff routinely bathed her in the afternoon or evening instead. Interviews and task records showed the resident was not given a choice about shower timing, and a CNA reported she was bathed at night or after lunch; the DON confirmed the resident's morning preference was not honored.
Failure to Limit PRN Psychotropic Medication Order: A resident with epilepsy, vascular dementia, schizophrenia, anxiety, and depression had an active PRN lorazepam order that remained on the eMAR beyond the 14-day limit for PRN psychotropic meds. The consultant noted the order required prescriber review to continue, but no current rationale or evaluation was documented, and the DON confirmed the resident had no behaviors or outbursts and the order had been overlooked.
Nebulizer Mask Left Open to Air: A resident with quadriplegia, COPD, DM2, and depression had PRN nebulizer orders, but surveyors observed the nebulizer mask lying open to air on the nightstand instead of being stored in a plastic bag as required by the facility policy. The mask remained unsecured on a later observation, and the ADON confirmed it should have been bagged after use but had not been.
Care Plan Lacked Dementia Interventions: A resident with dementia diagnoses did not have a care plan that included dementia-focused interventions. The resident's MDS showed intact cognition, but the resident still required assistance with eating, toileting, bed mobility, and transfers. The LPN/MDS acknowledged the care plan did not include or support dementia interventions.
A resident with severe dementia and behavioral symptoms, including wandering and hypersexuality, was not provided with the ordered 1:1 observation during night shifts. Despite physician orders and care plan directives, staff confirmed that the required supervision was not consistently implemented, resulting in a failure to deliver appropriate treatment and services.
A resident with severe cognitive impairment and a history of falls did not have their care plan updated with new fall interventions after multiple incidents. Despite staff acknowledging that care plans should be revised after each fall, no new interventions were added, and existing interventions remained unchanged.
Two residents with severe cognitive impairment and multiple comorbidities experienced unwitnessed falls or falls with head injury, but neurological checks were not completed for the required 72 hours as per facility policy. Instead, checks were only performed for significantly shorter periods, as confirmed by the DON through record review and interview.
Two residents did not receive wound care as ordered on multiple occasions, and weekly wound assessments were not performed as required by facility policy. The DON and Wound Care Nurse confirmed that wound care was missed on several dates and that a deep tissue injury was not assessed for two weeks after discovery.
A resident with severe cognitive impairment and depression did not receive prescribed Trazodone on multiple days because the medication was not available in the facility. An LPN confirmed the medication was missing and did not follow up with the pharmacy, and the DON acknowledged the missed doses and lack of follow-up.
A resident with COPD and other health issues did not receive proper respiratory care as the facility failed to maintain cleanliness of the oxygen concentrator. The nasal cannula was found uncovered and unlabeled, and the concentrator had brown stains and a dusty filter, contrary to the facility's policy.
The facility failed to administer controlled medications at the time they were signed out, affecting multiple residents, and did not conduct lab work as per physician orders for a resident with severe cognitive impairment. Discrepancies were found between medication records and actual counts, and monthly Depakote levels were missed for a resident with specific medical needs.
The facility did not meet the nutritional needs of residents by failing to follow the menu's portion sizes for pureed diets. During a lunch service, dietary staff used a 3 oz scoop instead of the required 4 oz scoop for pureed meatloaf, affecting nine residents. The dietary manager confirmed the error, admitting to forgetting to check scoop sizes before serving.
The facility failed to ensure pureed foods were prepared by methods conserving nutritional value for nine residents on pureed diets. The dietary cook did not follow the approved menu recipe, using unmeasured ingredients and relying on experience instead. The dietary manager confirmed the absence of recipe adherence, and the RD emphasized the importance of following recipes for adequate caloric intake.
A resident with severe cognitive impairment and multiple medical conditions did not receive timely incontinent care, as confirmed by observations and family grievances. The resident was often found in soiled briefs for extended periods, despite facility policies and recent measures to ensure proper care. Staff interviews revealed inconsistencies in care, and management acknowledged past issues and ineffective processes.
The facility did not include the Medical Director or a designee in the Quality Assessment and Assurance (QAA) process, as required by their policy. The QAA committee must include the Medical Director, Administrator, DON, and three other staff members. The Medical Director's absence was confirmed for meetings in March and June 2024, with no documented evidence of attendance.
A facility failed to maintain proper infection control during wound care for a resident with stage 4 pressure injuries. A treatment nurse did not change gloves or sanitize hands after handling contaminated materials, contrary to the facility's policy. The staff were unaware of the need for hand hygiene between glove changes, as the policy did not specify this requirement.
The facility failed to ensure that residents who were unable to carry out ADLs received necessary services for grooming and hygiene due to staffing shortages. Multiple residents reported not receiving scheduled baths, and staff interviews confirmed the facility was frequently short-staffed, leading to missed care.
The facility failed to provide adequate care due to staffing shortages, resulting in residents not receiving scheduled baths and supervision for smoking. Multiple residents reported not receiving necessary ADL assistance, and staff confirmed the lack of sufficient CNAs to meet care needs.
Failure to Provide Needed ADL Assistance and Grooming Care
Penalty
Summary
The facility failed to ensure residents who were unable to complete activities of daily living received needed assistance with grooming and personal hygiene for Residents #10, #56, and #67. Resident #10 had diagnoses including dementia, schizoaffective disorder, depressive type, and anxiety, and her quarterly MDS showed a BIMS of 14 with supervision/touching assistance needed for personal hygiene. On 09/29/2025 and again on 09/30/2025, observations showed black substance on her fingers and beneath her nail beds, and on 09/30/2025 a LPN confirmed her fingernails were in need of cleaning and should have been cleaned by staff. Resident #56 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, morbid obesity, and polyosteoarthritis. Her quarterly MDS showed a BIMS of 13 and partial/moderate assistance needed with personal hygiene, and her care plan directed staff to assist with hygiene and grooming. She also had orders for weekly fingernail and toenail trimming as needed and daily foot inspection. On 09/30/2025, she stated her toenails had not been trimmed and wanted them trimmed, and observation showed her toenails were long; a LPN confirmed they needed trimming. Resident #67 had diagnoses including cerebral infarction, hemiplegia and hemiparesis, and altered mental status, and his quarterly MDS showed a BIMS of 5 with total dependence for bathing, toileting, transfers, and bed mobility. His care plan directed staff to assist with bathing and grooming. On 09/29/2025 and 09/30/2025, he stated he had not had a bath, and observation showed stubble facial hair; staff interviews confirmed he did not receive a bath on the scheduled day even though he should have.
Inaccurate Controlled Substance Counts and Missing Narcotic Signatures
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administration of controlled medications for residents. During a controlled medication reconciliation on 10/01/2025, the oncoming nurse for Cart A, an LPN, did not sign the Narcotic Count Record at the beginning of the shift as required by the facility policy, which states that one licensed nurse from the off-going shift and one licensed nurse from the oncoming shift must count and sign the Narcotic Count Sheet in front of the narcotic box. The same LPN confirmed that after administering controlled substances for multiple residents, she did not immediately document the accurate counts on the Individual Controlled Substances Record. For residents receiving medications including oxycodone/APAP, alprazolam, belbuca, clonazepam, lacosamide, tramadol, hydrocodone/APAP, lorazepam, and diazepam, the logged counts were each one tablet/patch higher than the amounts observed in the blister packs or zip-loc bag. The DON stated that controlled substances are to be logged and documented immediately after administration, and confirmed the LPN should have documented the narcotic count at the beginning of the shift and the accurate count after administration, but did not.
Infection Control Lapses in Equipment Cleaning, Linen Handling, and Environmental Cleaning
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not disinfecting reusable medical equipment after use, not handling soiled linen and soiled items in a sanitary manner, not storing clean linen in a sanitary manner, and not following consistent infection control practices for cleaning and disinfecting the environment. Facility policy stated reusable medical devices were to be cleaned after each resident use and that soiled linen was to be placed in an impervious bag, securely closed, and transported without contaminating the resident environment. The X-Effect disinfectant label required a 5-minute dwell time, and staff interviews confirmed that dwell time should be followed. During observation, an LPN used a glucometer for finger sticks and returned it to the medication cart container without sanitizing it, and the LPN confirmed the equipment should have been sanitized first. A second LPN was observed doing the same with a glucometer later that morning and also confirmed it should have been sanitized before being placed back in the container. A CNA assisting a resident with ADL care placed a soiled adult brief and soiled linen directly on the resident's floor before later placing the items into soiled linen barrels. In the laundry room, clean mechanical lift pads were observed stored on the soiled side, and the laundry staff confirmed clean items should not be stored there. Staff interviews also showed inconsistent cleaning practices, including one housekeeper stating he sometimes wiped disinfectant off right away when in a hurry and a CNA stating she did not know the dwell time for the disinfectant used in the shower room.
Failure to Honor Resident Bathing Preference
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice for Resident #8, who had diagnoses including COPD, major depressive disorder, parkinsonism, generalized anxiety disorder, and dementia. Her quarterly MDS showed a BIMS of 15, indicating intact cognition, and her care plan documented that she required staff assistance with all ADLs and included a preference for bathing in the tub/whirlpool in the morning and morning showers. Review of the bathing/showering task flow chart showed Resident #8 received showers in the afternoon or evening on multiple dates, despite her stated preference for mornings. During interviews, Resident #8 said she had issues with her bath days, that she was told when she would bathe rather than being allowed to choose, and that she preferred morning showers but did not get them. A CNA stated she was bathed at night by nightshift aides and did not know why she was not getting morning showers, while another CNA stated the resident was supposed to get showers on certain mornings but did not receive one until after lunch and then was redressed in the same dirty clothing. The DON stated she was not aware of why the resident's morning preference was not honored, but it should have been, and confirmed staff should not redress a resident in the same dirty clothing unless it had been washed by laundry.
Failure to Limit PRN Psychotropic Medication Order
Penalty
Summary
The facility failed to ensure that a resident’s PRN order for a psychotropic medication was limited to 14 days. Resident #90 was admitted with diagnoses including epilepsy, vascular dementia, schizophrenia, generalized anxiety disorder, and major depression disorder. The resident had an order for lorazepam 0.5 mg by mouth every 8 hours as needed for anxiety, with the order dated 12/13/2024, and the medication remained listed as active on the July, August, and September 2025 eMARs even though no doses were documented during those months. The facility’s psychotropic medication policy stated that PRN orders for psychotropic drugs, excluding antipsychotics, are limited to 14 days unless the prescriber evaluates the resident and documents the rationale and duration for extending the order. The pharmaceutical consultant noted on 07/29/2025 that the PRN lorazepam order was limited to an initial 14 days and required prescriber evaluation to continue, with a note that the resident still uses it. Further record review found no current rationale or evaluation by a physician or practitioner for continued use of the PRN lorazepam after that date. The DON stated the resident did not have behaviors or outbursts and confirmed the lorazepam PRN order should have been discontinued and had been overlooked.
Nebulizer Mask Left Open to Air
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when the facility failed to ensure respiratory equipment was properly stored for Resident #14. Resident #14 was admitted on 10/24/2023 with diagnoses including quadriplegia, COPD, type 2 diabetes mellitus, and major depressive disorder, and had physician orders for PRN nebulized albuterol and ipratropium-albuterol for shortness of breath and wheezing. The facility’s undated Nebulizer CPAP Machine Cleaning Policy and Procedure stated that tubing, mouthpiece, and mask should be stored in a plastic bag when not in use. On 09/29/2025, surveyors observed Resident #14’s nebulizer mask dated 09/24/2025 lying on the nightstand near the nebulizers, open to air and not secured in a bag. A follow-up observation on 09/30/2025 showed the mask still on the nightstand, not secured in a bag. During interview, the ADON confirmed the mask was lying open to air on the nightstand and stated it should have been bagged after use, but had not been.
Care Plan Lacked Dementia Interventions
Penalty
Summary
The facility failed to ensure a resident with dementia received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents reviewed for dementia. Resident #10 was admitted with diagnoses including dementia in other diseases classified elsewhere, mild without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizoaffective disorder, depressive type. The resident's quarterly MDS showed a BIMS score of 14, indicating intact cognition, and the resident required setup or clean-up assistance for eating, toileting, and bed mobility, with supervision or touching assistance for transfers. Review of the resident's care plan, initiated on 09/08/2025 with a review date of 11/23/2025, revealed no evidence of a dementia care focus with appropriate interventions. During interview on 10/01/2025 at 9:33 a.m., the S6 LPN/MDS acknowledged that the care plan did not include and support dementia with interventions.
Failure to Provide Ordered 1:1 Observation for Resident with Dementia
Penalty
Summary
A resident with diagnoses of dementia, anxiety, and psychosis was admitted to the facility and exhibited severe cognitive impairment, as indicated by a BIMS score of 3. The resident displayed behavioral symptoms that interfered with activities, intruded on the privacy of others, and disrupted the living environment, including hypersexual behaviors and significant wandering. Due to these behaviors, a physician's order was in place for 1:1 observation every shift, and the care plan included this intervention to address the resident's needs. Despite the physician's order and care plan, the facility failed to provide 1:1 observation for the resident during the night shifts from 6:00 p.m. to 6:00 a.m. on multiple occasions. Staff interviews confirmed that the required 1:1 observation was not consistently implemented during these hours. This lapse in following the ordered intervention resulted in the resident not receiving the appropriate treatment and services necessary to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Update Care Plan with New Fall Interventions After Multiple Falls
Penalty
Summary
The facility failed to revise and update the care plan for a resident after multiple falls, as required. Record review showed that a resident with severe cognitive impairment and multiple diagnoses, including Parkinsonism, dementia, and a history of falls, experienced several falls on specific dates. Despite these incidents, the care plan did not reflect any new or individualized fall interventions after each event. The interventions listed in the care plan were all initiated prior to the first fall and remained unchanged throughout subsequent falls. Interviews with facility staff confirmed that new interventions should have been added to the care plan after each fall, regardless of whether incident reports had been closed. The MDS nurse acknowledged that no new interventions were care planned following the resident's falls and attributed this to waiting for the DON to close out incident reports. The DON also confirmed that the care plan should have been updated after each fall, even if the incident reports were still open.
Failure to Complete Required Neurological Checks After Falls
Penalty
Summary
The facility failed to provide services that meet professional standards of quality by not completing neurological checks for the required 72 hours following unwitnessed falls or falls with head injury for two residents. According to the facility's policy, neurological checks should be implemented for 72 hours in such cases. For one resident with severe cognitive impairment and multiple diagnoses including dementia, depression, and diabetes, neurological checks were only completed for 21, 32, and 33 hours after three separate falls, rather than the required 72 hours. The Director of Nursing (DON) confirmed that the checks were not completed as required. Another resident, also with severe cognitive impairment and multiple diagnoses such as Parkinsonism, major depressive disorder, and dementia, experienced falls resulting in head injury. For this resident, neurological checks were only completed for 9 and 21 hours after two separate falls. The DON acknowledged that neurological checks should have been completed for 72 hours in both cases but were not. These findings were based on record review and staff interviews.
Failure to Provide Timely Wound Care and Assessments
Penalty
Summary
The facility failed to provide necessary treatment and services to promote healing and prevent new pressure ulcers for two residents with skin issues. For one resident with multiple diagnoses including diabetes, malnutrition, and dementia, physician orders were in place for daily wound care to several sites, including diabetic ulcers, abrasions, and skin tears. However, review of the Treatment Administration Record (TAR) revealed that wound care was not completed on several specified dates for all affected areas. The Director of Nursing confirmed that wound care was not performed on the weekends as required. For another resident with a history of fractures, heart failure, and anemia, physician orders were in place for daily wound care to a stage 3 pressure injury and an unstageable pressure injury. The TAR indicated that wound care was not performed on multiple dates for the sacral wound and a deep tissue injury (DTI) to the right ankle. Additionally, after the DTI was discovered, there was no wound assessment or measurement completed until two weeks later, despite facility policy requiring weekly wound assessments and documentation. The Wound Care Nurse acknowledged that the assessment was missed, and the Director of Nursing confirmed the lapses in wound care provision. Facility policy required that skin and wounds be documented upon admission, readmission, weekly, and as needed, with detailed assessments at least weekly or with each dressing change. The failure to perform wound care as ordered and to complete timely and thorough wound assessments for both residents constituted a lack of adherence to professional standards of practice and facility policy.
Failure to Administer Antidepressant as Ordered
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including depression and dementia, did not receive their prescribed antidepressant medication, Trazodone, on four separate days. The resident's care plan specifically included the intervention to administer medications as ordered by the physician. However, review of the Medication Administration Record showed missed doses, and progress notes indicated the medication was not available in the facility on those dates. Interviews with facility staff confirmed that the medication was not administered because it was not present in the medication cart or medication room, despite being ordered. The LPN responsible was aware of the missing medication but did not follow up with the pharmacy to resolve the issue. The DON also confirmed the missed doses and acknowledged that the nurse should have contacted the pharmacy when the medication was unavailable.
Failure to Maintain Cleanliness of Oxygen Equipment
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for a resident with a history of Chronic Obstructive Pulmonary Disease, cardiac pacemaker, and cerebral infarction. The resident had an active physician order for oxygen therapy to maintain oxygen saturation levels above 90% during episodes of shortness of breath. However, during an observation, it was noted that the resident's oxygen concentrator was not maintained according to the facility's policy. The nasal cannula was found uncovered and unlabeled on top of the concentrator, which had brown stains and a filter heavily covered with dust. The Assistant Director of Nursing (ADON) confirmed the deficiencies during an interview, acknowledging that the nasal cannula should have been covered and labeled, and the concentrator should have been clean. The facility's policy required that all surface areas of the oxygen concentrator be cleaned with disinfectant wipes or spray as needed, and that the oxygen tubing, cannula, and mask be stored in a plastic bag when not in use. Additionally, the policy stated that the oxygen concentrator filter should be washed weekly. These procedures were not followed, leading to the observed deficiencies in the resident's respiratory care.
Medication Administration and Lab Work Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were administered at the time they were signed out by the nurse, affecting nine residents. During a narcotic reconciliation, discrepancies were found between the Individual Controlled Substance Record and the actual number of tablets on hand for several residents. For instance, one resident's record indicated that a tablet of Norco was administered, but the medication card showed an extra tablet remaining. Similar discrepancies were observed for other residents with medications such as Xanax, Oxycodone, Ativan, Lorazepam, and Clonazepam. The LPN involved admitted to signing out medications ahead of time, rather than at the time of administration. Additionally, the facility failed to conduct lab work in accordance with physician orders for one resident. This resident, who had severe cognitive impairment and multiple diagnoses including Schizoaffective Disorder and Epilepsy, had a physician's order for monthly Depakote level checks. However, the records showed that these levels were only checked in April and July, missing the required checks for May and June. The ADON confirmed that the monthly Depakote levels were not conducted as ordered. These deficiencies highlight a failure in the facility's medication administration and lab work processes, as evidenced by the discrepancies in controlled substance records and the missed lab work for a resident with specific medical needs. The observations and interviews conducted during the survey revealed these lapses in adhering to professional standards of quality care.
Failure to Adhere to Menu Portion Sizes for Pureed Diets
Penalty
Summary
The facility failed to meet the nutritional needs of residents by not adhering to the established menu guidelines for portion sizes. On 07/22/2024, during the lunch service for residents on a pureed diet, the facility's dietary staff used a 3 oz scoop instead of the required 4 oz scoop for serving pureed meatloaf. This discrepancy was observed by surveyors and confirmed through an interview with the dietary manager, who acknowledged the error and admitted to forgetting to check the scoop sizes prior to meal service. This oversight affected the nutritional adequacy of meals for nine residents receiving mechanically altered diets.
Failure to Follow Pureed Diet Recipes
Penalty
Summary
The facility failed to ensure that pureed foods were prepared by methods that conserved nutritional value for nine residents who were ordered and served pureed diets. On 07/22/2024, the facility's approved menu indicated that the pureed diet lunch should include specific serving sizes of beef meatloaf, black-eyed peas, cauliflower with cheese mix, and pound cake. However, during an observation, the dietary cook was seen using eight 3oz meat patties, an unmeasured amount of bread crumbs, and three cups of water in a blender without following a recipe. The dietary cook admitted to not using a recipe due to her experience, believing the added water and breadcrumbs would suffice for the nine residents. The dietary manager confirmed that the recipes for pureed meals were not followed because they could not be located, although they should have been used. Additionally, the registered dietitian stated that recipes should be followed to ensure residents receive adequate caloric intake. This lack of adherence to recipes potentially compromised the nutritional value of the meals served to the residents on pureed diets.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary incontinent care for a resident with severe cognitive impairment and multiple medical conditions, including Type 2 Diabetes Mellitus and Unspecified Dementia. The resident was dependent on staff for all activities of daily living, including toileting and personal hygiene. Despite the facility's policy to maintain skin cleanliness and prevent breakdown, the resident's family filed multiple grievances over several months, reporting that the resident was often found saturated with urine and feces. The family marked the resident's diapers to track changes, revealing that the resident remained in soiled briefs for extended periods. During an observation, the Director of Nursing (DON) confirmed the resident was wearing a soiled brief marked from hours earlier, indicating a lack of timely care. Interviews with staff revealed inconsistencies in care, with a CNA unable to recall the last time the resident was changed and conflicting reports about care provided by a hospice aide. The DON acknowledged past issues with timely incontinent care for the resident and admitted that recent measures, such as ambassador rounds by management, were not implemented on the day of the survey.
Medical Director Exclusion from QAA Meetings
Penalty
Summary
The facility failed to include the Medical Director or a designee in the Quality Assessment and Assurance (QAA) process, as required by their policy. The policy specifies that the QAA committee must consist of at least the Medical Director, Administrator, Director of Nursing (DON), and three other staff members designated by the facility. During an interview and record review, it was revealed that the Medical Director or a designee had not been included in the QAA process sign-in sheets for the meetings held in March 2024 and June 2024. The Director of Nursing confirmed the absence of documented evidence of the Medical Director's attendance at these quarterly meetings.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper wound care practices observed during a survey. Specifically, a treatment nurse did not change gloves or perform hand hygiene after handling contaminated materials while providing wound care to a resident with stage 4 pressure injuries on both ischium areas. The nurse removed the old dressing and, without changing gloves or sanitizing hands, reached over the clean field to obtain new supplies and cleanse the wound. This action was contrary to the facility's policy and procedure for dressing changes, which aims to protect the wound, prevent irritation and infection, and promote healing. During an interview, the treatment nurse acknowledged the failure to follow proper hand hygiene protocols. Further investigation revealed that the staff were not aware of the need to sanitize hands between glove changes during wound care, as the existing wound care policy did not explicitly state this requirement. The Assistant Director of Nursing (ADON) confirmed the oversight and recognized the need for policy updates to ensure compliance with infection control regulations.
Failure to Provide Necessary ADL Services Due to Staffing Shortages
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. Resident #1, who has multiple diagnoses including quadriplegia and chronic obstructive pulmonary disease, did not receive a scheduled bed bath due to a shortage of Certified Nursing Assistants (CNAs). This was confirmed by both the resident and the Assistant Director of Nursing (ADON), who acknowledged that the bed bath was neither provided nor documented on the specified date. Similarly, Resident #3, who requires partial assistance with bathing, did not receive a bath as requested due to insufficient staffing, as confirmed by both the resident and a Licensed Practical Nurse (LPN) on duty. The LPN admitted that only one CNA was available on the hall, which led to the resident not receiving the bath on that shift. Additional residents, including #R1, #R2, #R3, and #R4, also reported not receiving scheduled baths due to staff shortages. Interviews with various CNAs and the CNA Supervisor confirmed that the facility was frequently short-staffed, leading to missed baths and inadequate care. The Resident Council Meeting minutes further corroborated the ongoing issue of insufficient CNA staffing during specific shifts. The facility's Administrator also confirmed the shortage of CNAs, which directly impacted the residents' ability to receive necessary ADL care, including bathing and hygiene. This consistent lack of adequate staffing and failure to provide essential care services resulted in the identified deficiencies in the facility's operations.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to have sufficient staff to meet the needs of residents, resulting in inadequate care for several individuals. Resident #1, who has multiple diagnoses including quadriplegia and chronic obstructive pulmonary disease, did not receive a scheduled bed bath due to a lack of CNAs. This was confirmed by both the resident and the Assistant Director of Nursing (ADON), who noted that the care was not documented as provided on the specified date. Resident #3, who requires partial assistance with activities of daily living (ADLs) and has a Foley catheter, also did not receive a bath as requested due to insufficient staffing. The resident expressed frustration over not receiving a bath for two days, and this was corroborated by an LPN who acknowledged the staffing shortage on the hall. Similar issues were observed with other residents, including #R1, #R2, #R3, and #R4, who all reported not receiving scheduled baths due to the facility's staffing issues. Additionally, residents #R5 and #R6, who require supervision while smoking, were unable to smoke at their appointed times because there was only one CNA available on their unit. This was confirmed by the CNA on duty, who stated that she had to wait for additional help before she could supervise the residents' smoke breaks. The facility's staffing shortages were further highlighted in Resident Council Meeting minutes and interviews with various staff members, including the CNA Supervisor and the Administrator, who confirmed the ongoing staffing challenges.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Pollock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tioga Community Care Center | 8.4 mi | ★★★★★ | 1 | 0 |
| The Oaks Care Center | 10.3 mi | ★★★★★ | 7 | 0 |
| Hilltop Nursing & Rehabilitation Center | 12 mi | ★★★★★ | 16 | 2 |
| Matthews Memorial Health Care Center | 13.9 mi | ★★★★★ | 10 | 0 |
| Legacy Nursing At St. Christina | 14 mi | ★★★★★ | 23 | 0 |
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