Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Resthaven Living Center during CMS and state inspections, most recent first.
A resident with a history of cerebral infarct, cognitive communication deficit, and moderate cognitive impairment experienced increased confusion and was transferred to the hospital. Facility policy required prompt notification of the resident representative for significant changes in condition and hospital transfers, but the assigned LPN did not notify the resident’s responsible party and did not document the transfer or any notification in the nurse’s notes. The responsible party reported learning of the hospitalization only when contacted by the hospital, and the DON confirmed that the LPN should have notified the responsible party.
Surveyors identified that two residents received incorrect medication dosages during an observed med pass, resulting in a 12% medication error rate. One LPN administered a 25 mg dose of Sertraline instead of the ordered 50 mg, while another LPN gave a 50 mg Zinc capsule instead of 220 mg and a 10 mcg Vitamin D3 tablet instead of 1250 mcg. In each case, the nurses later confirmed, after reviewing the MAR and medication packaging, that they had not verified the correct dosages before administration, contrary to facility policy requiring multiple label checks to ensure the right medication and dose.
Surveyors identified unsanitary food service conditions when an ice machine contained ice mixed with visible pink sludge, which the dietary manager acknowledged was not sanitary despite recent cleaning. In addition, a cook demonstrated washing pots and pans in a 3-compartment sink using an incorrect sequence of wash, sanitize, and rinse, while the sanitizer dispenser was installed in the middle basin labeled as the rinse sink instead of the final basin. The dietary manager and administrator both confirmed that the ice machine should be clean and that the correct 3-compartment sink process is wash, rinse, then sanitize.
Surveyors found that a bulk grease disposal container located outside behind the kitchen was in poor condition, with its lid left open and black grease accumulated on top of the container and on the surrounding concrete, mixed with leaves. The dietary manager acknowledged that the container had been in this unsanitary condition for several months, with grease present on and around it, and confirmed the lid remained open. The administrator also confirmed awareness that the lid had been left open, that rain caused grease to spill over onto the concrete, and that the container had been in poor condition for an extended period, resulting in improper containment of refuse with the potential to affect 82 residents.
Surveyors found that a resident shower room (Shower Room A) was not maintained in a sanitary and comfortable condition, with a black, fuzzy substance observed on the tile where the wall met the floor below the shower head. A CNA confirmed the substance had been present for a long time and described the room as neither comfortable nor sanitary, stating that both maintenance and the administrator were aware of the ongoing issue. The maintenance staff member acknowledged the substance had been present for months in a shower room used by residents and agreed it was not being properly maintained, and the administrator confirmed awareness of the problem and that the substance should not have been present.
Surveyors found that staff failed to keep call lights within reach for two residents whose care plans required accessible call systems. One resident with moderate cognitive impairment and multiple conditions, including osteoarthritis and prior cerebral infarction, was observed with her call light on the floor, out of reach, despite being able to use it. Another resident with severe cognitive impairment, mobility issues, and diabetic polyneuropathy was observed in a geri-chair with the call light rolled up on a bedside table, also out of reach, even though she could use it to request help. Staff, including a CNA, a supervisor, and the DON, confirmed that both residents were capable of using their call lights and that facility policy requires call lights to be easily reachable at all times.
A resident’s Discharge MDS assessment was inaccurately coded as a discharge to a short-term general hospital, despite nursing notes documenting that the resident left the facility via wheelchair using personal transportation and against medical advice. During interviews, the MDS nurse acknowledged the discharge status should have been coded as a discharge to home/community, and the DON stated an expectation that MDS nurses complete assessments to accurately reflect each resident’s discharge status.
A resident with documented mental health conditions, including Bipolar Disorder, Depression, and Anxiety Disorder, was readmitted and had a PASRR Level I form completed by an LPN using only hospice referral records, which did not list Bipolar Disorder. The LPN did not review the resident’s prior admission records, where Bipolar Disorder was clearly documented, resulting in a PASRR Level I that listed only Major Depression and Anxiety Disorder. Upon review, quality improvement staff and the LPN confirmed that the Bipolar Disorder diagnosis should have been included but was omitted.
A resident with an indwelling port and sacral wound infection was on Enhanced Barrier Precautions (EBP) with posted signage and physician orders requiring gown and gloves for high-contact care, including device care or use. An LPN was observed administering IV Vancomycin through the resident’s chest port while not wearing a gown, contrary to the facility’s EBP policy and the instructions on the EBP sign. In a subsequent interview, the LPN acknowledged that a gown should have been worn, and the DON confirmed that appropriate PPE is required for residents on EBP, including during IV medication administration via a port.
The facility failed to employ a certified dietary manager, as the previous manager was fired weeks ago, and the acting manager lacked the necessary certification. The administrator confirmed no staff held the required certification, potentially affecting 84 residents consuming food from the kitchen.
The facility failed to store food according to professional standards, potentially affecting 84 residents. Expired items, including cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, were found in the kitchen. The facility's policy requires safe food handling practices, but these items were not discarded as they should have been, as confirmed by S1ADM.
A resident with Glaucoma was inaccurately assessed in their MDS, which indicated clear speech and adequate vision. However, therapy notes and staff interviews confirmed the resident had slurred speech and inadequate vision. The ADON acknowledged these issues, highlighting the need for accurate MDS coding.
A facility failed to change a resident's oxygen tubing and humidifier bottle as per physician orders, which required weekly changes every Sunday night. An observation revealed that the equipment was not changed on the scheduled date, and an LPN confirmed the oversight. The DON was notified of the failure to adhere to the schedule.
The facility failed to accurately document the MAR for two residents, leading to discrepancies in their medical records. One resident's oxygen equipment was not changed as recorded, and another resident's lab test was documented without being conducted. The involved LPNs confirmed the inaccuracies, and the DON verified the errors.
The facility failed to ensure proper PPE use during care for a resident on Enhanced Barrier Precautions. Two CNAs were observed providing care without wearing gowns, despite facility policy and signage indicating the requirement. Interviews confirmed staff awareness of the PPE requirement, yet compliance was not maintained.
The facility did not ensure that the most recent survey results were available for resident review. An observation revealed that the State Survey Binder only contained results from 2022, missing the 2023 annual recertification and 2024 complaint surveys. Interviews with a CNA and the DON confirmed the absence of these documents, which should have been accessible to residents.
The facility did not post the current nurse staffing data, as observed on a bulletin board by the nurses' station. The report was dated the previous day, and both the Administrator and the DON confirmed the oversight, acknowledging that the current report should have been posted.
The facility failed to document neurological assessments after unwitnessed falls for two residents. Despite staff claims of performing neuro checks, no documentation was found for one resident, and incomplete documentation was found for another. The DON confirmed the absence and incompleteness of these records, indicating a failure to adhere to the facility's policy.
The facility failed to limit PRN orders for psychotropic medications to 14 days and did not indicate the duration for the PRN orders for a resident with Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety. Interviews confirmed that the facility did not follow its policy requiring prescriber evaluation and duration documentation for PRN psychotropic medications.
The facility failed to ensure accurate resident assessments. A resident diagnosed with Major Depressive Disorder had an MDS assessment that did not reflect this active diagnosis. Staff responsible for MDS assessments confirmed the inaccuracy.
The facility failed to maintain accurate records when an LPN did not document the administration of Morphine for a resident with multiple diagnoses, including Dementia and Polyosteoarthritis. The LPN confirmed administering the medication but did not record it on the MAR, as expected by the Director of Nursing.
The facility failed to designate a staff member to coordinate care with hospice representatives, resulting in an incomplete hospice binder for a resident. Interviews with staff confirmed the absence of a designated coordinator and missing hospice plan of care documents.
Failure to Notify Responsible Party of Resident’s Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party (RP) of a significant change in condition and transfer to the hospital, contrary to its own policy. The facility’s policy titled “Change in a Resident’s Condition or Status” (revised May 2017) states that the resident representative must be promptly notified of changes in the resident’s medical or mental condition and when it is necessary to transfer the resident to a hospital. Resident #1 was admitted with diagnoses including cerebral infarct and cognitive communication deficit, and her son was listed as her RP. A quarterly MDS dated 02/09/2026 documented a Brief Interview for Mental Status score of 8, indicating moderate cognitive impairment. The facility’s Emergency Transfer Log showed that Resident #1 was transferred to the hospital in January 2026 for a change in status, specifically increased confusion. However, review of the resident’s nurse’s notes for that period revealed no documentation of the hospital transfer and no documentation that the RP was notified. In an interview, the RP stated he was not informed by the facility that the resident had been sent to the hospital or the reason for the transfer, and that he only learned of the hospitalization when the hospital called him with an update. The LPN assigned to the resident on the date of transfer confirmed that the resident was transferred due to increased confusion, acknowledged there was no documentation of the transfer or RP notification, and confirmed she did not notify the RP. The DON also confirmed that the resident was transferred due to increased confusion and that the LPN should have notified the RP of the transfer.
Medication Administration Errors Resulting in 12% Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, as required, resulting in a calculated error rate of 12% during an observed medication pass. Surveyors observed 25 medication administration opportunities and identified 3 errors involving two residents. Facility policy on administering medications, revised April 2019, states that medications are to be administered safely, timely, and as prescribed, and that the individual administering the medication must check the label three times to verify the right resident, medication, dosage, time, and route before administration. For one resident, an LPN administered Sertraline HCL 25 mg by mouth instead of the ordered Sertraline HCL 50 mg once daily. The nurse later reviewed the physician’s orders and the medication card and confirmed that the dose given was incorrect and that she had failed to verify the dosage prior to administration. For another resident, a different LPN administered Zinc 50 mg instead of the ordered Zinc Sulfate 220 mg, and Vitamin D3 10 mcg instead of the ordered Vitamin D3 1250 mcg given on specific mornings. This nurse also confirmed, upon review of the physician’s orders and medication containers, that both dosages were incorrect and acknowledged she had not checked the medication dosages prior to administration. The DON stated he expected staff to check medications against physician orders prior to administration and confirmed medications should be given in the correct dosage as ordered by the physician.
Unsanitary Ice Machine and Improper Three-Compartment Sink Use
Penalty
Summary
Surveyors found that the facility failed to store, prepare, and distribute food under sanitary conditions in the kitchen, affecting the ice machine and pot and pan sanitation. During observation of the kitchen ice machine, surveyors noted a low level of ice mixed with pink sludge, including visible pink sludge in the right front corner of the machine; the dietary manager confirmed the presence of the pink sludge and acknowledged it was not sanitary, despite stating the machine had been serviced and cleaned two days earlier. In a separate observation of pot washing at the 3-compartment sink, a cook demonstrated her process and stated she washed, sanitized, and rinsed pots and pans, while the sanitation dispenser was actually installed in the second sink labeled “rinse,” rather than in the third sink. The dietary manager confirmed that the sanitizer was in the wrong compartment and that the correct sequence for the 3-compartment sink should be wash, rinse, then sanitize, and the administrator confirmed that the ice machine should not have pink sludge and that the 3-compartment sink should be used in the proper wash, rinse, sanitize order.
Improper Maintenance and Containment of Bulk Grease Disposal Container
Penalty
Summary
Surveyors identified a deficiency related to improper disposal and containment of grease waste when they observed a large bulk grease disposal container located outside next to the facility wall behind the kitchen with its lid open. The container had a large amount of black grease on top and on the surrounding concrete area, with leaves mixed into the spilled grease. During interview, the dietary manager stated the bulk grease container was in poor condition, confirmed the lid was open, and acknowledged that grease had been present on top of the container and on the surrounding concrete area since September 2025, describing the situation as unsanitary. In a separate interview, the administrator confirmed awareness of the bulk grease container’s location and condition, stating that the lid had been left open and that rain caused grease to spill over onto the surrounding concrete, and further confirmed the container had been in poor condition for some time and needed to be removed. This deficient practice involved failure to ensure refuse containers were in good condition and that waste was properly contained, and it had the potential to affect 82 residents residing in the facility.
Failure to Maintain Sanitary and Comfortable Resident Shower Room
Penalty
Summary
The facility failed to ensure that Shower Room A was maintained in a safe, sanitary, and comfortable condition for residents, staff, and the public. During an observation on 01/13/2026 at 3:00 p.m., surveyors noted a black, fuzzy substance on the tile below the shower head where the wall tile met the floor in Shower Room A. At 3:03 p.m., a CNA (S6CNA) confirmed the presence of this substance, stated that Shower Room A was not a comfortable and sanitary environment, and reported that the black fuzzy substance had been present for a long time and was an ongoing problem. She further stated that the maintenance staff member (S7MNT) and the administrator (S1ADM) were both aware of the condition of Shower Room A. At 3:30 p.m., S7MNT confirmed he was aware that Shower Room A, which was used by residents, had a black fuzzy substance on the tile where the wall met the floor and that it had been present for months, acknowledging that the room was not maintained in a comfortable and sanitary manner. At 4:03 p.m., S1ADM also confirmed awareness of the black fuzzy substance in Shower Room A and acknowledged that it should not have been present and that the shower room should have been maintained in a comfortable and sanitary manner. No specific residents, medical histories, or clinical conditions were described in relation to the use of Shower Room A, only that it was a resident shower room used by residents and that its condition did not meet sanitary and comfort standards.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ call lights were within reach as required by facility policy and individual care plans. The facility’s policy on the Resident Call Light System, revised 06/2023, states that staff must ensure the call light is easily reachable by the resident. Resident #2, admitted with multiple diagnoses including bilateral primary osteoarthritis of the hip, mild neurocognitive disorder with behavioral disturbance, vertebral compression fractures, intellectual disabilities, schizophrenia, and cerebral infarction, had an MDS BIMS score of 11, indicating moderate cognitive impairment. Her care plan specified that she was to have a working and reachable call light and be encouraged to use it for assistance as needed. On 01/12/2026 at 9:40 a.m., surveyors observed Resident #2’s call light on the floor and not within her reach. During an interview at 9:50 a.m., S13CNA confirmed that Resident #2 was able to use the call light and that it was not within her reach. Resident #51, admitted with diagnoses including difficulty in walking, other lack of coordination, primary generalized osteoarthritis, type 2 diabetes mellitus with diabetic polyneuropathy, and muscle wasting and atrophy, had an MDS BIMS score of 7, indicating severe cognitive impairment. Her care plan documented that she required staff assistance with ADLs, was to have a working, reachable call light, and was to be encouraged to use the call light for assistance. On 01/12/2026 at 9:01 a.m., surveyors observed Resident #51 sitting in a geri-chair with her call light rolled up on the bedside table, not within her reach. At 9:20 a.m., S12SUP confirmed that the call light was not within the resident’s reach, stated it should have been, and confirmed that Resident #51 was capable of using the call light to call for assistance. On 01/14/2026 at 10:25 a.m., S2DON acknowledged awareness that the call lights for both residents had been found out of reach and stated that the facility’s process is for staff to place call lights within residents’ reach before exiting the room and to ensure call lights are within reach at all times.
Inaccurate Coding of Resident Discharge Status on MDS Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s assessment accurately reflected the resident’s discharge status. Review of the Discharge MDS assessment for Resident #92, with an ARD of 12/10/2025, showed the resident was coded as having been discharged to a short-term general hospital. However, nursing notes documented that on 12/10/2025 at 11:20 a.m., the resident left the facility via wheelchair using his own transportation. In an interview, the MDS nurse (S9MDS) confirmed that the resident had left the facility against medical advice and that the Discharge MDS was inaccurately coded, stating it should have indicated a discharge to home/community instead of to a hospital. The DON (S2DON) stated he expected MDS nurses to complete all assessments to accurately reflect each resident’s discharge status. This inaccurate coding of the discharge location for Resident #92 on the Discharge MDS constituted the identified deficiency in ensuring accurate resident assessments.
Failure to Include Bipolar Disorder Diagnosis on PASRR Level I Evaluation
Penalty
Summary
The facility failed to ensure that a resident with an identified mental health diagnosis was accurately referred for a PASRR Level II evaluation, resulting in an incomplete PASRR Level I form. The resident was initially admitted with documented diagnoses of Bipolar Disorder, Depression, and Anxiety Disorder, and later readmitted with the same conditions. However, review of the PASRR Level I form completed on 07/30/2025 showed that only Major Depression and Anxiety Disorder were listed, and the Bipolar Disorder diagnosis was omitted. The LPN who completed the PASRR Level I form stated she relied solely on clinical records from the referring hospice agency, which did not list Bipolar Disorder, and did not review the resident’s initial admission records because she did not have access to them at that time. Upon later review of the initial admission clinical records, both the LPN and the quality improvement staff member confirmed that Bipolar Disorder had been an established diagnosis and should have been included on the PASRR Level I form but was not.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to follow its own infection prevention and control policy for Enhanced Barrier Precautions (EBP) for a resident with an indwelling medical device. The facility’s policy, revised in 03/2024, states that EBP requires the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms (MDRO), including device care or use such as central lines and ports. Resident #95’s clinical record showed an order to implement and maintain EBP during high-contact care starting 11/19/2025, an order allowing access to a port dated 08/24/2023, and an order for daily IV Vancomycin for a sacral wound infection dated 01/02/2026. An EBP sign was posted on the resident’s door, instructing that staff must wear gloves and a gown for high-contact activities including device care or use. On 01/13/2026 at 1:02 p.m., a surveyor observed an LPN (S4LPN) administering IV Vancomycin via the resident’s right chest port without wearing a gown, despite the EBP signage and the resident’s active EBP orders related to his port and wounds. During an interview immediately afterward, the LPN confirmed that the resident was on EBP due to his port and wounds and acknowledged that she should have worn a gown while providing direct resident care but did not. Later, the DON (S2DON) stated that when a resident is on EBP, he expected staff to wear appropriate PPE when providing direct resident care, confirmed that EBP is initiated for residents with indwelling medical devices such as a port, and further confirmed that appropriate PPE should be worn during IV medication administration through a port.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ staff with the appropriate competencies and skills to manage the food and nutrition service, as evidenced by the absence of a certified dietary manager. This deficiency was identified during interviews and record reviews, revealing that the previous dietary manager had been fired 2-3 weeks prior, and the acting manager, S3DA, did not possess certification in food service or dietary management. Furthermore, the facility administrator, S1ADM, confirmed that neither he nor any other staff members held the necessary certification. This lack of qualified personnel had the potential to impact the 84 residents who consumed food prepared by the facility's kitchen.
Expired Food Items Found in Kitchen
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, which had the potential to affect 84 residents who were served meals from the kitchen. During an observation of the kitchen food preparation area, several expired items were found, including opened containers of cayenne pepper, Italian seasoning, crushed red pepper, and sage rub, all of which had passed their manufacture expiration dates. The facility's policy on Food Receiving and Storage, revised in 2014, mandates that foods be received and stored in compliance with safe food handling practices. An interview with S1ADM confirmed that 84 residents eat from the kitchen and acknowledged that the expired items should have been discarded but were not.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status, specifically for one resident diagnosed with Glaucoma. The resident's quarterly MDS inaccurately indicated clear speech and adequate vision, despite therapy progress notes and multiple staff interviews confirming the resident had slurred speech and inadequate vision. Interviews with the resident and various staff members, including a physical therapist, occupational therapist, and speech therapist, consistently noted the resident's slurred speech and vision issues. The Assistant Director of Nursing also acknowledged the resident's slurred speech and vision loss, emphasizing the importance of accurate MDS coding.
Failure to Change Oxygen Tubing and Humidifier Bottle as Scheduled
Penalty
Summary
The facility failed to provide necessary respiratory care and services in accordance with accepted professional standards of practice for a resident with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma. The resident's physician orders required that the oxygen tubing and humidifier bottle be changed every Sunday night and as needed for contamination. However, an observation on 12/09/2024 revealed that the oxygen tubing and humidifier bottle were labeled with the date 12/01/2024, indicating they had not been changed as required on 12/08/2024. An LPN confirmed the oversight during an interview, acknowledging that the change should have occurred but did not. The Director of Nursing was also informed of the failure to adhere to the scheduled change.
Inaccurate Documentation in MAR for Two Residents
Penalty
Summary
The facility failed to accurately document the Medication Administration Record (MAR) for two residents, leading to discrepancies in their medical records. For Resident #3, who was admitted with Chronic Obstructive Pulmonary Disease and Mild Intermittent Asthma, the MAR indicated that oxygen tubing and humidifier bottles were changed on a specific date. However, observations revealed that the equipment was not changed as documented, with the items still labeled from a previous date. The LPN responsible for the documentation confirmed that the change did not occur as recorded. Similarly, for Resident #290, who was on long-term anticoagulant therapy, the MAR inaccurately reflected that a PT/INR lab test was collected on a certain date. However, there were no lab results to support this entry, and the laboratory confirmed that no such test was conducted on that date. The LPN involved acknowledged the error in documentation, and the Director of Nursing confirmed the inaccuracies in the MAR, emphasizing that all records should accurately reflect the services provided.
Inadequate PPE Use During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper use of Personal Protective Equipment (PPE) by staff members while providing care to a resident under Enhanced Barrier Precautions (EBP). Specifically, the facility's policy on transmission-based precautions required staff to wear gloves and gowns during high-contact activities such as dressing and transferring residents. However, during an observation, two certified nursing assistants (CNAs) were seen dressing, emptying a urostomy bag, and transferring a resident without wearing the required gowns. Interviews with the involved CNAs and the Director of Nursing (DON) confirmed that the staff was aware of the requirement to wear gowns when providing direct care to residents on EBP, yet they failed to comply with this protocol. The resident in question had been admitted with diagnoses including paraplegia, neuromuscular dysfunction of the bladder, and ileostomy status, necessitating the use of EBP to prevent infection transmission. Despite the presence of signage on the resident's door indicating the need for PPE, the staff did not adhere to the facility's infection control policy, leading to the identified deficiency.
Survey Results Not Available for Resident Review
Penalty
Summary
The facility failed to ensure that the results of the most recent annual survey and complaint surveys were available for resident review. During an observation on December 8, 2024, it was noted that the State Survey Binder at the nurse's station only contained survey results from December 8, 2022. Interviews with a CNA and the Director of Nursing confirmed that all survey results were supposed to be kept in this binder. However, upon review, it was confirmed that the survey results from the annual recertification survey dated November 29, 2023, and the complaint surveys dated April 23, 2024, and May 31, 2024, were missing from the binder and had not been made available for resident review as required.
Failure to Post Current Nurse Staffing Data
Penalty
Summary
The facility failed to ensure that the current nurse staffing data was posted daily, which had the potential to affect any of the 85 residents residing in the facility. On the morning of December 9, 2024, an observation revealed that the Daily Staffing Report posted on the bulletin board by the nurses' station was dated December 8, 2024, indicating it was not current. Interviews conducted with the Administrator (S1ADM) and the Director of Nursing (S2DON) confirmed that the posted staffing report was outdated and acknowledged that the current report had not been posted as required.
Failure to Document Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure services were provided to meet quality professional standards for two residents reviewed for falls. Specifically, the facility did not document neurological assessments after unwitnessed falls for Resident #1 and Resident #3. Resident #1, who had diagnoses including repeated falls, cerebrovascular disease, and hemiplegia, experienced unwitnessed falls on three occasions. Despite claims from staff that neurological checks were performed, no documentation was found in the clinical records. Interviews with the LPNs and the DON confirmed the absence of documented neurological assessments for these incidents. Resident #3, who had diagnoses including polyosteoarthritis, dementia, and difficulty in walking, experienced multiple unwitnessed falls. The facility's documentation of neurological assessments for these falls was incomplete. The DON confirmed that neuro checks should be completed and documented at specific intervals following unwitnessed falls, but the records for Resident #3 did not meet these requirements. This lack of proper documentation indicates a failure to adhere to the facility's policy on falls and neurological assessments.
Failure to Limit PRN Psychotropic Medications to 14 Days
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary psychotropic medications. Specifically, the facility did not limit PRN orders for psychotropic drugs to 14 days and did not indicate the duration for the PRN orders for one resident. Resident #3, who had diagnoses including Dementia, Schizophrenia, Major Depressive Disorder, and Anxiety, had active PRN orders for Lorazepam and Temazepam without documented end dates. The facility's policy required that PRN psychotropic medications be limited to 14 days and that the prescriber evaluate the resident before extending the order and provide a duration for the pharmacotherapy. However, this policy was not followed for Resident #3's medications. Interviews with the Consultant Pharmacist and the Director of Nursing (S1DON) confirmed that PRN orders for psychotropic medications should be limited to 14 days and require a prescriber evaluation before extension. The Consultant Pharmacist acknowledged the oversight, while the S1DON was unable to confirm whether hospice PRN medications were subject to the same 14-day limitation. This failure to adhere to the facility's policy resulted in the deficiency noted in the report.
Inaccurate Resident Assessment
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the resident's status. Specifically, Resident #4, who was admitted to the facility and diagnosed with Major Depressive Disorder on 03/02/2024, had an inaccurate quarterly MDS assessment with an ARD of 03/14/2024. The diagnosis of Major Depressive Disorder was not coded as an active diagnosis in Section I of the MDS. During an interview, S2MDS, who is responsible for MDS assessments, confirmed that the diagnosis should have been accurately coded. S1DON also confirmed that the MDS should reflect all active diagnoses accurately.
Failure to Document Administered Narcotic Medication
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards and practices for one of the residents reviewed. Specifically, the facility did not ensure that an LPN documented the administration of narcotic medications on a resident's Medication Administration Record (MAR). The resident, who had diagnoses including Polyosteoarthritis, Lack of Coordination, Muscle Wasting, Dementia, and Difficulty in Walking, was readmitted to the facility and required Morphine for pain management. On the specified date, the LPN removed Morphine from stock but did not document its administration on the MAR. During a phone interview, the LPN confirmed administering the medication but could not recall if it was documented. The Director of Nursing reviewed the MAR and confirmed that staff are expected to document any administered medication.
Failure to Coordinate Hospice Care
Penalty
Summary
The facility failed to designate a member of the interdisciplinary team to coordinate care with hospice representatives, as required by their policy. This deficiency was evidenced by the absence of up-to-date hospice binders for a resident who was readmitted to the facility and admitted to hospice services. Specifically, the hospice binder for the resident lacked the most recent hospice plan of care documents. Interviews with staff, including an LPN and the Director of Nursing (DON), confirmed that there was no designated staff member responsible for coordinating hospice care and that the hospice binder was incomplete.
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Illustrative
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 Bogalusa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Living Center | 16.8 mi | ★★★★★ | 5 | 0 |
| Fair City Health And Rehab | 17.1 mi | ★★★★★ | 5 | 0 |
| Pearl River Co Nursing Home | 19.4 mi | ★★★★★ | 0 | 0 |
| Bedford Care Center Of Picayune | 21.4 mi | ★★★★★ | 11 | 6 |
| Picayune Rehabilitation And Healthcare Center | 21.6 mi | ★★★★★ | 1 | 1 |
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