Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Oak Post Acute Care during CMS and state inspections, most recent first.
Call lights were left out of reach for two residents whose care plans required them to be kept within reach. One resident with hemiplegia, weakness, and a healing R humerus fracture had her call light found in a laundry basket, while another resident with CHF, weakness, and a R BKA had her call light hanging below the side rail and later near the floor. Both residents stated they used their call lights for staff assistance, and staff confirmed the call lights were not reachable.
A resident with a suprapubic catheter and neurogenic bladder had the catheter tubing observed without a securement device during ADL care and again during catheter care. Staff, including a WC, an LPN, CNAs, and the DON, confirmed the catheter should have been secured at all times and that the physician order was not followed.
A facility failed to ensure medications were actually consumed for two residents whose MARs showed scheduled meds as administered. One resident with multiple chronic conditions and intact cognition had morning meds and prior-night Tylenol left at the bedside, and he stated staff routinely left meds for him to take later. Another resident with CHF had Lasix documented as given, but a tablet was still found in a cup on the bedside table. Staff confirmed nurses were responsible for observing residents take all meds and that medications should not be left at the bedside.
A resident with a Stage 4 sacral pressure ulcer and moderate cognitive impairment was observed multiple times lying on a deflated air mattress with the pump off and unplugged. The resident stated she was uncomfortable and felt like she was lying on the bedframe. Staff confirmed the air mattress should have been on and functioning properly at all times and checked during rounds.
Failure to Provide Proper Toenail Care: A resident with DM, chronic venous disease, and intact cognition had thick, long toenails extending past the tips of the toes, with no care plan documentation for foot care and no record of podiatry involvement. Staff, including the CNA, LPN, wound care nurse, SW, and DON, acknowledged the toenails needed trimming, but the resident had not been seen by podiatry since admission and the facility lacked specialty clippers for the thick nails.
A resident with a gastrostomy tube had continuous enteral feeding ordered, but the feeding pump was observed showing an inactive error and not infusing during multiple checks. An LPN stated the tube feeding had likely been paused for hours and confirmed it should not have been stopped that long; the DON confirmed tube feedings should be given at the ordered rate.
Improperly Labeled Oxygen Tubing: A resident with COPD and an order for oxygen therapy was observed with portable oxygen tubing that was not labeled with the change date. An LPN confirmed the tubing should have been labeled, and the DON stated oxygen tubing should be changed weekly and labeled with the change date.
Medication refrigerator temperatures in Med Room A were not documented on multiple days on the Nursing Refrigerator Checklist. The S3ADON and DON reviewed the record and confirmed the missing entries, and the DON stated night shift nurses were responsible for documenting the temperatures each night.
Infection Control: Failure to Use Required PPE and Hand Hygiene During EBP Care. Staff did not follow EBP precautions for two residents with devices, including a resident with a suprapubic catheter and a resident with a PEG tube. During observed care, CNAs and an LPN failed to perform hand hygiene, changed gloves improperly, and did not don gowns during high-contact care and device care, despite EBP signs and orders being in place.
A facility failed to consistently identify and supervise unsafe smokers or control their smoking paraphernalia. One resident with TBI, Parkinson’s disease, and moderate cognitive impairment was seen smoking in another resident’s room while oxygen was in use, and later was found smoking in his room with cigarettes in his possession. Another unsafe smoker was observed holding cigarettes despite care plan interventions requiring supervision and staff control of smoking supplies. Staff interviews showed confusion about smoking status and inconsistent awareness of who was unsafe.
A facility failed to consistently identify and manage unsafe smokers. One resident with TBI, Parkinson’s disease, and moderate cognitive impairment was documented as an unsafe smoker requiring supervision, yet staff repeatedly treated him as a safe smoker and he was found smoking in another resident’s room and later in his own room. Another resident with epilepsy, nicotine dependence, and mobility/coordination problems was also listed as an unsafe smoker requiring staff-controlled smoking supplies and supervision, but she was observed holding cigarettes in her wheelchair. Staff interviews showed conflicting knowledge of smoking status, and some staff involved in smoking oversight had not attended the smoking-related in-service.
Failure to provide coffee when requested. A resident with moderate cognitive impairment was observed asking for coffee while in his wheelchair, but an LPN and an OT told him no because it was not coffee time and directed him to wait for posted coffee hours or a later event. The DON stated residents could ask staff for coffee after those hours and that residents should be able to have coffee whenever they wanted.
A resident who was incontinent and dependent for bed mobility developed new skin changes on the buttocks that were first observed by a CNA and reported to an LPN, who noted reddened, open skin and applied skin prep but did not notify the MD or responsible party and did not ensure documentation of the assessment. No skin assessment was recorded at that time, and several days later a treatment nurse identified a new stage 3 sacral pressure ulcer during a body audit, at which point the NP and family were notified and wound treatment orders were obtained. This sequence of events reflects a failure to follow the facility’s policy requiring immediate notification of the physician, resident, and family when a reddened area or wound is identified.
The facility failed to follow its Enhanced Barrier Precautions (EBP) policy requiring gown and glove use during high-contact care for residents with wounds and indwelling devices. A resident with a stage 3 pressure ulcer and another resident with multiple lower extremity ulcers and an indwelling urinary catheter were on EBP, yet a treatment nurse performed wound care and a CNA emptied a urinary catheter and changed a brief wearing only gloves and no gown. In one case, EBP signage was missing from the door; in others, signage was present but not followed. The DON later confirmed that residents with wounds and urinary catheters should be on EBP and that staff should wear both gown and gloves for wound care and catheter care.
Inaccurate MDS Coding for Medications, PASRR Status, and Restraints: A resident was incorrectly coded for antipsychotic use despite no order or administration, another resident was incorrectly coded for insulin despite no insulin being ordered or given, a resident with schizophrenia and depression was not coded for current Level II PASRR status despite a Level II determination, and two residents were incorrectly coded as having bed rails used as restraints even though the devices were used as safety aids for mobility, repositioning, and transfers.
Improper food storage and labeling were observed in the kitchen, including opened food items that were not dated or sealed and prepared drink and fruit items that were not labeled. The dietary manager confirmed the items should have been dated, labeled, and sealed, and the administrator later acknowledged the same.
A facility failed to keep accurate MAR and care records for three residents. One resident’s Lasix was documented as given even though the LPN left the tablet at the bedside and did not witness ingestion; another resident’s PRN oxycodone entries did not match the MAR and narcotic log; and a resident with a colostomy had no documentation showing bag changes, despite concerns raised by the resident and confirmation by the DON and ADON that the record was incomplete.
A resident admitted with Bipolar Disorder and unspecified psychosis had PASRR Level II recommendations for ACT, a SUD assessment, and outpatient counseling services, but the clinical record showed none of these services were implemented or even attempted. The ADM confirmed the PASRR Level II recommendations had not been carried out or incorporated into the resident’s transitions of care.
Invalid consent was obtained for a resident’s bed rails/grab bars used for bed mobility and repositioning. The resident was cognitively intact and had orders for grab bars x2, but the restraint/safety device consent form was incomplete, with blank sections for the device, use, target behaviors, medical symptoms, and less restrictive approaches, and the resident signature was undated.
Insulin pens were not labeled with opened dates in two med carts. An LPN found one resident's Lantus pen and another resident's Lantus pen opened without dates, and both LPNs confirmed they did not know when the pens had been opened. The DON stated nurses were expected to date insulin pens when removed from the refrigerator and before placing them in med carts.
A resident with intact cognition and orders for Lasix BID was found with a scheduled Lasix tablet left in a cup on her bedside table instead of being observed taking it. The resident said she did not take the dose because she woke after 1:00 p.m. and did not want to urinate all night. An LPN confirmed she left the medication at the bedside and should have witnessed the resident consume it; the DON confirmed nurses should witness medication ingestion and medications should never be left at the bedside.
A resident with multiple pressure ulcers did not have required interventions, such as turning and heel floating, accurately documented by CNAs on several shifts. Staff interviews confirmed that documentation was incomplete, despite physician orders and facility policy requiring timely and accurate recordkeeping.
A nurse left multiple oral and liquid medications at the bedside of a cognitively intact resident without a physician's order for self-administration, contrary to facility policy. The resident confirmed the medications were her morning doses, which she had not yet taken. Both the LPN and DON acknowledged that medications should not have been left at the bedside without proper authorization.
A resident with a history of cognitive impairment and high fall risk fell on the smoking patio due to inadequate supervision. The resident, identified as a wanderer and unsafe smoker, was left unsupervised when the assigned smoking aide was not present, leading to the resident's fall while attempting to maneuver his wheelchair over uneven concrete.
A resident with a history of falls experienced an unwitnessed fall, and the facility failed to notify the physician and family as required by policy. Interviews revealed that the charge nurse did not complete an incident report or communicate the fall to the necessary parties, despite the resident being a high fall risk. The Director of Nursing was unaware of the incident, highlighting a lapse in protocol adherence.
A facility failed to complete a comprehensive MDS assessment in a timely manner for a resident admitted to the facility. The resident's admission MDS assessment was still 'in progress' beyond the required 14-day timeframe. Interviews with the MDS coordinator and DON confirmed the delay, indicating non-compliance with regulatory requirements for timely assessments.
A facility failed to implement fall prevention interventions for a resident with paraplegia and a history of falls. The care plan required a fall mat at the bedside, but observations showed it was not in place. Interviews with the resident and staff revealed inconsistencies in the use of the fall mat, with some staff only using it during transfers. The MDS coordinator and DON confirmed the expectation for continuous use of the fall mat to minimize fall risk.
A facility failed to develop a comprehensive care plan for a resident within 7 days after the completion of the Admission MDS assessment. The resident's care plan only included a baseline care plan without specific interventions for ADL assistance, fall risk, nutritional services, or skin care. Staff confirmed the comprehensive care plan was not completed by the required date, indicating a lapse in policy adherence.
The facility failed to document required census checks for two residents with severe cognitive impairments, one at risk of elopement and the other with a history of wandering. Despite physician's orders for regular checks, the Task logs showed no documentation of these checks. Interviews with staff confirmed the absence of documentation, highlighting a lapse in maintaining accurate records.
The facility did not maintain adequate CNA staffing levels on several night shifts, falling short of the required 4 CNAs by having only 3. This staffing deficiency was confirmed by interviews with CNAs and the facility's administrator, highlighting a failure to meet the facility's own staffing policy.
The facility failed to notify the Ombudsman of emergency transfers for two residents, as required by policy. One resident with a history of cerebral infarction and falls was transferred after a fall, and another resident with dementia was transferred for evaluation. These transfers were not documented on the Ombudsman Emergency Transfer Log.
The facility failed to implement comprehensive care plans for three residents, leading to deficiencies in care. A resident with hemiplegia did not receive a required PT evaluation after a fall. Another resident's wandering behavior was not documented in the care plan despite staff observations. A third resident with a history of falls did not receive the ordered 30-minute checks, as staff were unaware of the requirement. These oversights highlight significant gaps in communication and documentation within the facility.
A resident with Morbid Obesity and Functional Quadriplegia did not receive timely incontinent care, resulting in her being left saturated in urine for several hours. Despite activating the call light at 7 p.m., care was not provided until the shift change at 10 p.m. The facility's protocol requires incontinent care every two hours and before shift changes, which was not followed in this instance.
The facility failed to document ADL care accurately for two residents, both requiring extensive assistance. One resident, with a thoracic spinal cord injury, and another with chronic obstructive pulmonary disease, had multiple missing entries in their bed bath logs. Staff interviews confirmed the absence of documentation, highlighting a breach in maintaining complete medical records.
A facility failed to administer Ativan as ordered for a resident with Bipolar Disorder. The nurse received an order for Ativan 1 mg IM for agitation and aggression but did not administer it because the resident calmed down. The nurse did not contact the nurse practitioner to discontinue the order, contrary to facility policy. The DON stated that staff should follow physician's orders and contact the physician if a medication is not given.
The facility failed to ensure nursing staff had the necessary competencies, resulting in unsafe resident transfers and inadequate smoking interventions. A resident was injured during an improper transfer, and several residents were found smoking unsupervised in non-designated areas. Staff lacked training and documentation of competency, contributing to these deficiencies.
The facility failed to effectively use its resources, leading to deficiencies in resident care. A resident requiring a Hoyer lift was injured during an improper transfer by a CNA. Additionally, several residents identified as unsafe smokers were found smoking unsupervised, and staff lacked training in implementing safe smoking interventions. The facility also failed to ensure staff competency, with no documented evaluations or skills check-offs for several employees.
The facility failed to ensure resident safety in transfers and smoking practices. A resident requiring a Hoyer lift was improperly transferred, resulting in a fall and injury. Additionally, residents assessed as unsafe smokers were found smoking unsupervised, with staff unaware of their needs. Documentation and communication lapses contributed to these deficiencies.
The facility failed to refer residents with mental health diagnoses for PASRR Level II evaluations as required. Four residents with conditions such as Anxiety Disorder, Schizophrenia, and Depression did not have the necessary evaluations on file. Staff interviews confirmed the oversight in submitting the required forms to the state agency.
A resident with End Stage Renal Disease did not receive the prescribed liberal renal diet, which included a 1000 ml fluid restriction and no soups. The resident reported receiving soup and insufficient food portions. Observations and staff interviews confirmed the resident's lunch lacked protein and included soup, contrary to dietary orders.
The facility failed to properly store medications, with loose pills found in two medication carts and expired drugs in one. Additionally, a medication refrigerator was observed to be at an incorrect temperature, with no corrective action taken. These deficiencies were confirmed by the LPNs and DON.
The facility did not ensure dietary staff were trained to test the chemical dishwasher for chlorine. An observation revealed a staff member using the dishwasher without testing for chlorine, and interviews confirmed the lack of training and documentation for five dietary staff.
The facility failed to adhere to professional standards for food storage and labeling, affecting 81 residents. Observations revealed multiple food items in the kitchen, refrigerator, freezer, and dry pantry without proper labels indicating open or expiration dates. An interview confirmed these items should have been labeled according to the facility's policy.
The facility failed to ensure that two residents understood the binding arbitration agreement they signed upon admission. Both residents, admitted from the hospital, stated they were not aware of what an arbitration agreement was and confirmed that no one explained it to them. The staff member responsible assumed understanding due to a lack of questions, leading to uninformed consent.
The facility failed to implement an effective QAPI process, resulting in ongoing noncompliance with quality deficiencies such as therapeutic diets, food storage, abuse reporting, and enhanced barrier precautions. Despite notes indicating compliance, the current administrator confirmed the lack of documentation and acknowledged the deficiencies affecting 88 residents.
The facility failed to implement an effective infection prevention and control program, as staff did not adhere to PPE requirements for residents on Enhanced Barrier Precautions. An LPN administered medications without a gown, and a CNA provided care without PPE. Additionally, urine-soiled laundry was not promptly removed from a resident's room, posing an infection control risk.
The facility failed to provide a safe, clean, and homelike environment, with issues such as uncovered and broken light fixtures, scuffed walls, missing paint, rusted vents, and broken blinds observed in multiple rooms and hallways. A resident reported a windowsill board with exposed nails had been in disrepair for about a month. Staff confirmed these concerns, acknowledging the facility's failure to maintain a proper environment.
The facility failed to accurately code MDS assessments for two residents, one with a PASRR Level II status and another receiving hospice care. The assessments did not reflect the residents' actual conditions, as confirmed by staff interviews, indicating a lapse in following the facility's policy for accurate resident assessments.
The facility failed to implement comprehensive care plans for residents, leading to deficiencies such as unrecorded hospice status, improper ostomy care, missed medical appointments, and unaddressed transfer and smoking needs. These oversights were confirmed through staff interviews and record reviews.
A resident with Type 2 DM and a foot ulcer did not receive scheduled baths on several Saturdays over four months, despite being cognitively intact and not refusing care. The facility's policy required assistance with bathing at least three times weekly, but there was no documentation of completed baths. Interviews confirmed the lack of documentation and failure to provide scheduled care.
Call Lights Left Out of Reach for Two Residents
Penalty
Summary
The facility failed to ensure that resident call lights were within reach for 2 of 34 residents reviewed. The facility policy titled Call Lights: Accessibility and Timely Response stated that staff will ensure the call light is within reach of the resident. Resident #57 was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, generalized muscle weakness, a healing greenstick fracture of the right humerus, and gait and mobility abnormalities. Her MDS indicated she was cognitively intact, had a functional limitation affecting one side of her upper and lower extremity, was always incontinent of bowel, and was dependent on staff for toileting hygiene. Her care plan included ensuring her call light was within reach, yet during observation her call light was found inside her laundry basket and out of reach. The resident stated she was not sure where it was and had been missing for a while, and she confirmed she could not reach it. A CNA also observed and confirmed the call light was inside the laundry basket and out of reach. Resident #58 was admitted with diagnoses including morbid obesity due to excess calories, chronic combined systolic and diastolic CHF, generalized muscle weakness, and acquired absence of the right leg below the knee. Her MDS showed a BIMS of 12, indicating moderate cognitive impairment, and she was always incontinent of bowel and bladder and dependent on staff for toileting hygiene. Her care plan identified her as at risk for falls and included keeping her call light within reach. During observations, her call light was seen hanging below the side rail and later near the floor, both times out of reach while she was lying in bed. The resident stated she used her call light when she needed staff assistance and confirmed she could not reach it. Multiple staff members observed and confirmed the call light was out of reach, and the DON later confirmed that if a resident can use the call light, it should be kept in reach.
Failure to Maintain Suprapubic Catheter Securement
Penalty
Summary
The facility failed to ensure Resident #57’s comprehensive plan of care was implemented when the resident’s urinary catheter securement device was not in place as ordered. Resident #57 was admitted with diagnoses including neuromuscular dysfunction of the bladder and had an indwelling suprapubic catheter documented on the quarterly MDS. The resident’s current physician order directed staff to change the suprapubic catheter securement device every day shift starting on the 6th and ending on the 6th each month, and the care plan identified the resident as having an indwelling suprapubic catheter, neurogenic bladder, and risk for infection. During observations, Resident #57’s suprapubic catheter tubing was seen stretched out in the abdominal fold with no securement device in place. This was observed during ADL care by two CNAs and again during catheter care by a WC. Interviews confirmed the securement device was missing on both occasions, and staff stated the catheter should have been secured at all times to prevent it from being pulled on or out. The DON also confirmed the catheter should have been secured and that the physician order should have been followed.
Medications Left at Bedside Without Verification of Consumption
Penalty
Summary
The facility failed to ensure medications were observed and consumed as ordered for two residents whose medications were documented as administered but were later found left at the bedside. Resident #34 had diagnoses including Type 2 Diabetes Mellitus, chronic venous hypertension, hypertensive heart disease, heart failure, GERD, major depressive disorder, constipation, polyosteoarthritis, chronic back pain, and morbid obesity. His quarterly MDS showed a BIMS of 15, indicating intact cognition. His physician orders included multiple scheduled medications, and he did not have an order for self-administration or for medications to be left at the bedside. On the morning of the observation, Resident #34 had two medication cups on his bedside table, one containing his morning medications and another containing two Tylenol tablets. He stated the nurse brought the Tylenol the prior night and he never took them, and that his morning medications were delivered around 8:00 a.m. An LPN later confirmed that medications should never have been left at the bedside and that nurses should always observe the resident take medications to ensure they were consumed as ordered. Resident #34 later stated he took his morning medications after the surveyor left and that the nurse always left his medications at his bedside for him to take when he wanted. Resident #59 had diagnoses including hypertensive heart disease with heart failure and acute or chronic diastolic congestive heart failure, and his quarterly MDS showed a BIMS of 14, indicating intact cognition. His physician order included Lasix 40 mg at 8:00 a.m., and the MAR documented it as administered. However, during observation, a white tablet remained in a medication cup on his bedside table, and the resident stated he had taken his morning medication but did not realize a tablet was left behind. The LPN confirmed the tablet was Resident #59's 8:00 a.m. Lasix and acknowledged that nurses were responsible for ensuring residents took all of their medication and that she had not done so. The DON also confirmed nurses were responsible for ensuring residents consumed all medications before leaving the room and that medications should never be left at the bedside.
Air Mattress Not Functioning for Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Failure to provide appropriate pressure ulcer care occurred for a resident with a Stage 4 sacral pressure ulcer and spastic quadriplegic cerebral palsy. The resident’s quarterly MDS showed a BIMS of 12, indicating moderate cognitive impairment, and she was dependent on staff for turning and repositioning. Her physician orders and care plan included a pressure reducing air mattress to bed for the sacral pressure ulcer. During observations, the resident was found in bed multiple times with the air mattress pump turned off and the power cord unplugged from the wall and lying on the floor under the bed. The mattress was observed deflated while the resident was lying on it, and she stated she was uncomfortable and that it felt like she was lying on the bedframe. Staff interviews confirmed the air mattress should have been plugged in, on, and functioning properly at all times, and that CNAs and nurses were responsible for checking it during rounds. The DON stated air mattresses and pumps should be checked during every two-hour round.
Failure to Provide Proper Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care for a resident with Type 2 Diabetes Mellitus, chronic venous hypertension with ulcer and inflammation of the left lower extremity, chronic venous insufficiency, and morbid obesity. The resident had intact cognition and required supervision or touching assistance with personal hygiene, but the clinical record contained no documentation of foot care in the care plan and no documentation that he had been seen by a podiatrist. The facility’s nail care policy stated that residents with diabetes should have toenail trimming performed by a physician or practitioner. Observations showed the resident’s bilateral toenails were thick and long, extending past the tips of his toes, and the resident stated that nobody had offered to trim them and that they were too long. The resident’s wife also stated his toenails needed to be trimmed badly. Staff interviews showed the CNA, LPN, wound care nurse, social worker, and DON were aware of the need for toenail care or podiatry involvement, but the resident had not been seen by podiatry since admission and his toenails remained untrimmed. The wound care nurse stated the toenails were very thick and required specialty clippers that the facility did not have, and the DON stated the toenails should not have gone that long without trimming.
Tube Feeding Not Infusing as Ordered
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received tube feeding formula as prescribed. Resident #77 was admitted with a diagnosis of Gastrostomy Status, and the current physician order directed continuous enteral feeding of Isosource 1.5 at 70 milliliters per hour. During observations on 06/01/2026 at 8:55 a.m., 10:46 a.m., and 11:38 a.m., the resident's feeding tube was attached to a pump that displayed an error reading of "Notice pump inactive." During an interview at 11:39 a.m., an LPN stated the feeding pump was not infusing, that the resident had continuous tube feedings ordered, and that it had probably been paused since around 5:00 a.m.; she also stated she had not looked at it when she came on shift. She confirmed the tube feeding should not have been paused for that period of time. The DON later confirmed that tube feedings should be administered at the ordered rate.
Improperly Labeled Oxygen Tubing
Penalty
Summary
The facility failed to provide necessary respiratory care in accordance with professional standards of practice by not properly labeling respiratory care equipment for Resident #74. The resident was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Hypertensive Heart Disease without Heart Failure, and Cough, and his quarterly MDS showed a BIMS of 15, indicating he was cognitively intact. Physician orders directed staff to check oxygen saturation every shift for shortness of breath and to place the resident on 2 liters of oxygen by nasal cannula if saturation was lower than 90%. During an observation, the resident was sitting up in bed with a portable oxygen canister and tubing attached, and the tubing was not labeled with the date. An LPN observed and confirmed that the tubing connected to the portable oxygen canister was not labeled with the change date and should have been. The DON later confirmed that oxygen tubing should be changed weekly and labeled with the change date.
Medication Refrigerator Temperatures Not Documented
Penalty
Summary
Drugs and biologicals used in the facility were not stored in accordance with currently accepted professional principles because temperatures for the medication refrigerator in Med Room A were not documented. During an observation of Med Room A with S3ADON, review of the Nursing Refrigerator Checklist for May 2026 showed no temperature documentation for 05/23/2026, 05/24/2026, and 05/29/2026 through 05/31/2026. S3ADON reviewed the checklist and confirmed the missing entries, stating that night shift nurses were responsible for documenting the medication refrigerator temperatures each night. On 06/03/2026, S2DON also reviewed the same checklist for the refrigerator in Med Room A and confirmed that the temperatures should have been documented daily by the night shift nurses and were not.
Infection Control: Failure to Use Required PPE and Hand Hygiene During EBP Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to help prevent the development and transmission of infection. The deficiency involved staff not performing hand hygiene, not using gloves properly, and not using the required PPE while providing care to residents on Enhanced Barrier Precautions (EBP). The facility’s policy stated that EBP requires targeted gown and glove use during high-contact resident care activities, including dressing, bathing, transferring, providing hygiene, changing briefs, device care or use, and wound care. Resident #57 had diagnoses including neuromuscular dysfunction of the bladder and other disorders of the urinary system and had physician orders for suprapubic catheter care and EBP. During observation, staff provided ADL care without performing hand hygiene, changed gloves inconsistently, and did not don gowns while performing high-contact care such as emptying the urinary catheter bag, perineal care, changing the brief, assisting with turning and transferring, changing clothing, brushing hair, and removing bed linens. Resident #77 had a diagnosis of gastrostomy status and physician orders for PEG tube care and feeding and EBP. During observation, an LPN entered the room with gloves on and provided direct PEG tube care without donning a gown. Staff interviews confirmed they were not aware of the EBP status or acknowledged that gowns, glove changes, and hand hygiene should have been used.
Unsafe Smoking Supervision and Control Failures
Penalty
Summary
The facility failed to maintain an effective system to identify unsafe smokers and ensure supervision and other smoking-related interventions were consistently implemented. The deficiency involved two residents who had been assessed as unsafe smokers. One resident had diagnoses including traumatic brain injury and Parkinson’s disease and was documented as moderately cognitively impaired on a quarterly MDS. His smoking evaluation stated he was not able to smoke safely and required constant staff supervision while smoking. Another resident had diagnoses including epilepsy, nicotine dependence, lack of coordination, and abnormalities of mobility, and her smoking assessment also identified her as an unsafe smoker with interventions including a smoking apron, clothes pins/tips, supervision while smoking, and staff storage of smoking supplies. The unsafe smoking system failed when the first resident was observed smoking in another resident’s room while that other resident was receiving oxygen via nasal cannula and had an oxygen concentrator nearby. Staff removed him from the room, but interviews showed multiple staff members were unaware he was an unsafe smoker. Later, he was observed smoking in his own room, and staff found cigarettes in his pocket and nightstand. Interviews also showed conflicting understanding among staff about whether he was a safe or unsafe smoker, and some staff believed he was safe and could smoke independently. The record also showed that the resident’s smoking status had been documented in the care plan and on the smoker list, yet several staff members stated they did not know he was unsafe. The second resident, who had been assessed as an unsafe smoker, was observed holding two unlit cigarettes while seated in a wheelchair in the dining room entryway. The observation showed she had smoking paraphernalia in her possession despite being identified as unsafe. Interviews with staff confirmed that unsafe smokers were not supposed to have cigarettes or lighters and were supposed to be supervised while smoking. The report also noted that staff education related to accident and hazard prevention did not include all relevant staff members, and there was no documented evidence of additional education after the resident’s smoking incident. The facility’s smoking policy stated that residents who could not smoke safely would not be allowed to smoke without supervision and that smoking paraphernalia for unsafe smokers would be maintained by staff.
Failure to Identify and Supervise Unsafe Smokers
Penalty
Summary
The facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain the highest practicable physical, mental, and psychosocial well-being for each resident. The deficiency centered on an ineffective system for identifying unsafe smokers and implementing smoking safety interventions for two residents who were assessed as unsafe smokers. The facility’s smoking policy stated that residents who could not smoke safely would not be allowed to smoke without supervision, that unsafe smoking paraphernalia would be maintained by staff, and that all personnel caring for residents with smoking restrictions would be alerted to the interventions. The Smoke Monitor job summary also required staff to know which residents were unsafe smokers and to obtain an updated list of those residents and their interventions. One resident had diagnoses including traumatic brain injury and Parkinson’s disease and had a BIMS score of 12, indicating moderate cognitive impairment. His smoking evaluation identified him as an unsafe smoker who required constant supervision while smoking, and his physician’s orders and care plan also reflected that he required supervision. Despite this, he was found smoking in another resident’s room while that resident had oxygen in use, and later was found smoking in his own room. Staff interviews showed conflicting understanding of his smoking status: multiple CNAs and Smoke Monitors stated he was a safe smoker and did not require supervision, while the smoking list available to staff identified him as an unsafe smoker requiring supervision. The Smoke Monitors stated they received a daily list, but one stated she did not know he was unsafe and believed his status had changed without notification. A second resident had diagnoses including epilepsy, nicotine dependence, lack of coordination, and abnormalities of mobility. Her care plan identified her as an unsafe smoker who required a smoking apron, clothes pins/tips, supervision while smoking, and staff storage of smoking supplies. The smoker’s list also identified her as an unsafe smoker with those interventions. However, during observation she was seen sitting in her wheelchair at the dining room entryway holding two whole unlit cigarettes. The facility administrator confirmed that unsafe smokers were not supposed to have cigarettes or lighters in their possession and expected staff to implement the interventions in the care plan and smoking assessment. The record also showed that staff education related to accident and hazard prevention did not include several staff members who were involved in smoking supervision.
Failure to Provide Coffee When Requested
Penalty
Summary
The facility failed to provide drinks consistent with Resident #R7’s preferences when he requested coffee. Resident #R7 was admitted to the facility and his quarterly MDS with an ARD of 02/20/2026 showed a BIMS of 8, indicating moderate cognitive impairment. On 05/05/2026 at 12:25 p.m., he was observed self-propelling in his wheelchair while holding a drinking tumbler and waving it in the air. When asked if he wanted coffee, he indicated yes, and S4LPN was notified that he wanted coffee. S4LPN shook her head and said no. At 12:28 p.m., S15OT told Resident #R7 he could not have coffee because it was not coffee time and said he could only have coffee at the posted coffee times. She also stated he did not ask for water and only wanted coffee all day, and told him he could get coffee later at a party. On 05/06/2026, S4LPN confirmed she told him he could not have coffee and stated residents should be able to have coffee whenever they wanted. The posted coffee sign showed coffee was available only from 7:00 a.m. to 8:00 a.m. and 10:00 a.m. to 10:30 a.m., while S2DON stated residents could ask staff for coffee after those hours and that residents should be able to have coffee whenever they wanted.
Failure to Promptly Notify Physician of New Sacral Skin Breakdown
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a physician when there was a significant change in a resident’s skin condition, as required by its own skin program policy. The policy stated that when a resident develops a reddened area or wound, the licensed nurse must notify the resident, family, and physician of the reddened area or wound, with physician notification to occur during normal office hours unless a treatment order is needed. Resident #3 had a significant change in skin condition that was not promptly communicated to the physician, despite the facility’s policy and the resident’s risk factors. Resident #3 was admitted on 05/06/2024 and had a significant change MDS dated 01/22/2026 indicating the resident was always incontinent of bowel and bladder, dependent for bed mobility, and had no unhealed pressure ulcers at that time. On 02/14/2026, a CNA working day shift observed three dime-sized, fluid-filled blisters on the resident’s buttocks and reported this finding to the nurse. The LPN on duty acknowledged that it was reported to her that the resident had a skin condition on the buttocks, which she described as reddened and open, and she applied skin prep to the area. The LPN confirmed she did not notify the doctor or the resident’s responsible party and did not recall whether she documented her assessment. There was no documentation of a skin assessment for Resident #3 on 02/14/2026 in the medical record. On 02/18/2026, during a weekly body audit, a treatment nurse discovered a stage 3 pressure ulcer on the resident’s sacrum, measuring 8.1 cm in length, 9.2 cm in width, and 0.1 cm in depth, identified as an in-house acquired, new onset pressure ulcer with full-thickness skin loss. The nurse documented the wound, notified the nurse practitioner and responsible party, and obtained new treatment orders. The wound care nurse practitioner’s assessment on 02/19/2026 confirmed an acute stage 3 pressure injury with exposed adipose tissue and three open areas measured together as one wound. Interviews confirmed that the earlier skin changes reported on 02/14/2026 were not communicated to the physician at that time, resulting in a delay in physician notification until 02/18/2026.
Failure to Follow Enhanced Barrier Precautions for Residents With Wounds and Indwelling Catheters
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain its Enhanced Barrier Precautions (EBP) policy for residents requiring infection prevention measures. The facility’s written policy, dated January 2025, required the use of gown and gloves during high-contact resident care activities for residents with applicable conditions or devices, such as wounds and indwelling urinary catheters, even if multidrug-resistant organism (MDRO) status was unknown. High-contact activities were defined to include dressing, bathing, transferring, providing hygiene, changing linens or briefs, assisting with toileting, urinary catheter care, and wound care. Resident #5 had a physician’s order for EBP related to a stage 3 pressure ulcer of the left buttock, and Resident #R1 had multiple non-pressure chronic ulcers of the left lower extremity, pressure ulcers of the left ankle and heel, and an indwelling urinary catheter documented in the care plan. On multiple observations, staff did not follow the EBP requirements for gown use during direct care of these residents. A treatment nurse provided wound care to Resident #5 wearing gloves but no gown, and there was no EBP signage on the resident’s door at that time. Later, a CNA was observed emptying Resident #R1’s indwelling catheter wearing gloves but no gown, despite EBP signage on the door, and confirmed she had not donned a gown. The same CNA was subsequently observed changing Resident #5’s brief while wearing gloves but no gown and acknowledged she had forgotten to wear a gown, even though an EBP sign was posted above the resident’s bed. The treatment nurse later confirmed she did not wear a gown for Resident #5’s wound care and stated she only used gowns for “big wounds or infections.” The DON stated that residents with infections, PEG tubes, wounds, colostomies, ostomies, urinary catheters, tube feedings, and pressure ulcers should be on EBP and confirmed staff should wear gown and gloves when emptying urinary catheters or providing wound care.
Inaccurate MDS Coding for Medications, PASRR Status, and Restraints
Penalty
Summary
The facility failed to ensure that multiple residents’ MDS assessments accurately reflected their status. For Resident #7, the Quarterly MDS with an ARD of 10/02/2025 coded Section N0415 to indicate antipsychotic use, but review of physician orders from September 2025 through current showed no antipsychotic medication was ordered. The MDS nurse and DON both confirmed the resident had not received an antipsychotic and that the MDS coding was inaccurate. Resident #43’s Quarterly MDS with an ARD of 11/03/2025 coded insulin injections in Section N0350, yet physician orders and the MAR from October 2025 through current showed no insulin injections were ordered or administered. The MDS nurse and DON confirmed the insulin coding was inaccurate. Resident #13’s Annual MDS with an ARD of 06/18/2025 coded A1500 as “No” for current Level II PASRR status, even though the resident had active diagnoses of schizophrenia and depression. The resident’s current PASRR Level II Evaluation Summary and Determination Notice, dated 10/20/2025, showed approval for admission by Level II Authority for a temporary period effective 10/20/2025 through 10/20/2026 due to qualifying diagnoses of paranoid schizophrenia and depression. The resident’s care plan also identified Level II PASRR as a problem. The MDS staff and DON confirmed the MDS did not accurately reflect the resident’s Level II PASRR status. Resident #4 and Resident #21 were both coded on their MDS assessments as having bed rails used daily as restraints in Section P. Review of their records showed both residents had grab bars/bed rails ordered to assist with bed mobility, transfers, repositioning, and safety. For Resident #4, the grab bars were used with bed mobility and slide board transfers and did not restrict movement or access to her body. For Resident #21, the grab bars were used for repositioning in bed and during incontinence care, while transfers required a Hoyer lift and staff assistance. Interviews with CNAs, the NP, MDS staff, and the DON confirmed the devices were used as safety devices to assist mobility and did not restrict either resident’s movement or access to their bodies, and that the MDS coding as restraints was inaccurate.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
Food was not stored in accordance with professional standards for food service safety in the facility kitchen. During an initial tour of the main kitchen and walk-in cooler, surveyors observed multiple food items that were opened, undated, unlabeled, or not sealed, including a clear bag of grits, two clear bags of cornbread mix, five clear bags of seasoning mixes, a box of powdered sugar, large plastic bags of cheddar and parmesan cheese, a tray of liquid-filled drinking cups, and eight bowls of fruit cocktail. The dietary manager confirmed that the opened food items should have been dated and that the drinking cups and fruit cocktail should have been labeled, and also confirmed that the grits and powdered sugar should have been sealed. The facility administrator was later informed of the findings and confirmed that food and drink items should be sealed, dated, and labeled.
Inaccurate medication and colostomy documentation
Penalty
Summary
The facility failed to maintain accurate records in accordance with accepted professional standards for 3 of 19 sampled residents. For Resident #10, who had diagnoses including hypertensive heart disease and peripheral vascular disease and a BIMS score of 15, the MAR documented Lasix 40 mg due at 12:00 p.m. as administered, but the resident was observed later with the tablet still in a medication cup at the bedside and stated she was not going to take it. The LPN confirmed she left the medication at the bedside, did not observe the resident consume it, and documented it as administered anyway. The DON later confirmed nurses should witness residents consume their medications and that the documentation was inaccurate. For Resident #95, who was receiving oxycodone HCl 5 mg as needed for neoplasm-related pain, the MAR and narcotic log did not match for documented administrations of the medication. The DON reviewed the records and confirmed the oxycodone administration was not documented accurately on the MAR and should have been. For Resident #79, who had a colostomy and a BIMS score of 15, the record contained no documentation that the colostomy bag had been changed since admission, despite an order later directing colostomy bag changes every 72 hours and as needed. The resident stated he had concerns with the night shift not changing his colostomy bag, and both the ADON and DON confirmed there was no documentation showing the colostomy bag had been changed.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to coordinate assessments with the resident's PASRR Level II determination and did not incorporate the PASRR Level II recommendations into the resident's transitions of care for Resident #98. The facility policy stated that recommendations from a PASRR Level II determination and/or evaluation report would be incorporated into the resident's assessment, care planning, and transitions of care. Resident #98 was admitted with diagnoses including Bipolar Disorder and Unspecified Psychosis. His Form 142 showed he was approved for admission by Level II authority for a temporary period from 01/09/2025 through 01/08/2026. The PASRR Level II Evaluation Summary and Determination Notice dated 01/09/2025 approved 365 days of nursing facility placement and required Assertive Community Treatment, a Substance Use Disorder assessment by a Licensed Addictions Counselor, and Substance Use Disorder outpatient treatment including individual and group counseling by a Licensed Addictions Counselor, with UHC to assist with referrals. Review of the clinical record showed none of these PASRR Level II recommendations had been implemented or attempted, and the ADM confirmed this during interview.
Invalid Consent for Bed Rails/Grab Bars
Penalty
Summary
The facility failed to obtain valid informed consent before installing bed rails/grab bars for Resident #13. The resident was admitted with diagnoses including severe morbid obesity and was assessed on the quarterly MDS as cognitively intact with a BIMS score of 15. Her physician orders included grab bars x2 to assist with bed mobility, and the care plan identified that she used bed rails/grab bars x2 for bed mobility and repositioning, with an intervention to ensure valid consent was on the chart prior to initiating. Review of the Physical Restraint / Safety Device Consent showed the sections identifying the restraint/device recommended, when and where it would be used, specific target behaviors, medical symptoms, and less restrictive approaches tried were left blank. Although the resident’s signature was present, the date of the signature was blank. The DON confirmed that a valid consent must include the resident’s name/signature, the date signed, and what the resident was specifically consenting to, including the type of safety device, number of devices, and where they would be applied, and confirmed this consent was not valid.
Insulin Pens Left Unlabeled With Opened Dates
Penalty
Summary
Drugs and biologicals were not stored in accordance with currently accepted professional principles because insulin pens in two medication carts were not labeled with an opened date. During observation of one medication cart, Resident #92's Lantus Subcutaneous Solution Pen-Injector was found opened without an opened date, and an LPN confirmed she did not know when it had been opened. During observation of a second medication cart, Resident #80's Lantus Subcutaneous Solution Pen-Injector was also found opened without an opened date, and the LPN confirmed she did not know when the pen was opened. The DON later confirmed nurses were expected to write the date insulin pens were opened when removed from the refrigerator and before being stored in medication carts.
Medication Left at Bedside Without Direct Observation
Penalty
Summary
The facility failed to ensure services provided, as outlined in the comprehensive care plan, met professional standards of quality when nursing staff did not observe and ensure a resident consumed a scheduled medication. Resident #10 was admitted on 02/05/2025 with diagnoses including Hypertensive Heart Disease and Peripheral Vascular Disease. Her quarterly MDS with an ARD of 11/12/2025 showed a BIMS score of 15, indicating intact cognition. Her physician orders included Lasix 40 mg by mouth twice daily at 5:00 a.m. and 12:00 p.m., and the MAR for 12/01/2025 showed Lasix 40 mg at 12:00 p.m. documented as administered by S7LPN. During an observation on 12/01/2025 at 3:55 p.m., Resident #10 had a white tablet in a medication cup on her bedside table and stated it was her Lasix. She said she did not take Lasix if it was after 1:00 p.m. because she would urinate all night, and since she woke up after 1:00 p.m., she decided not to take it. At 4:00 p.m., S7LPN confirmed the tablet in the cup was the resident’s 12:00 p.m. Lasix and stated she had left it at the bedside. S7LPN acknowledged she should have observed the resident consume the medication to ensure it was taken. S3DON later confirmed nurses should witness residents consume their medications and that medications should never be left at the bedside.
Failure to Accurately Document Pressure Ulcer Interventions
Penalty
Summary
The facility failed to maintain accurate and complete medical records in accordance with accepted professional standards for one resident with pressure ulcers. Specifically, for a resident admitted with multiple pressure ulcers, including Stage 3 and Stage 4 wounds, physician orders required that the resident's heels be floated and that the resident be turned and repositioned every two hours. However, a review of the resident's ADL flowsheets revealed missing documentation for these interventions on several shifts. The assigned CNAs did not record whether the required care was provided during these periods. Interviews with staff confirmed that CNAs were responsible for documenting all ADL tasks, including pressure ulcer interventions such as turning and floating heels. One CNA acknowledged that documentation was not completed for the specified dates, citing lack of computer access at times, but stated that care was provided. The Director of Nursing also confirmed that the documentation was incomplete and that the required interventions were not accurately recorded in the resident's medical record.
Medications Left at Bedside Without Physician Order for Self-Administration
Penalty
Summary
The facility failed to ensure that medications were administered safely and in accordance with professional standards of quality. Specifically, a nurse left a cup containing 13 pills and two cups with liquid and supplement medications at the bedside of a resident without a physician's order for self-administration. The facility's policy requires that residents may only self-administer medications if the attending physician and the Interdisciplinary Care Planning Team have determined the resident has the capacity to do so safely. In this case, there was no such order in place for the resident. The resident, who was cognitively intact as indicated by a BIMS score of 15, confirmed that the medications left at her bedside were her morning medications, which she had not yet taken. The nurse admitted to leaving the medications at the bedside because the resident preferred to take them later, and acknowledged that this was not in accordance with facility policy or physician orders. The Director of Nursing also confirmed that there were no orders for self-administration and that medications should not have been left at the bedside without supervision.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as a wanderer, unsafe smoker, and high fall risk. This resident, who was severely cognitively impaired, managed to enter the smoking patio unsupervised and subsequently fell when attempting to maneuver his wheelchair over uneven concrete. The incident occurred over a weekend when the assigned smoking aide was not present on the patio, leaving the resident without necessary supervision. The resident's clinical records indicated a history of cerebral infarction, hemiplegia, hemiparesis, and cognitive communication deficit. He was assessed to have a high fall risk and required frequent monitoring due to his tendency to wander and inability to remember to ask for assistance. Despite these assessments, there was no documented evidence that the required 30-minute checks were performed during the timeframe reviewed. Interviews with staff and other residents confirmed that the smoking aide was not present on the patio during the incident, and the resident was able to self-propel his wheelchair unsupervised. The facility's policies required a smoking aide to be present from 7 a.m. to 7 p.m. to monitor residents, but this was not adhered to, leading to the resident's fall and the immediate jeopardy situation.
Removal Plan
- The outside patio fence gate is to remain closed.
- Administrator/DON/Designee will monitor the smoke patio area by using a monitoring form to ensure adequate supervision provided to residents.
- Disciplinary action up to termination will take place if this occurs again.
- All staff will be in-serviced by Administrator/DON/Designee on providing supervision to resident while out on smoke patio, the smoke monitor will remain outside and must be relieved by other staff to leave that area.
- All staff members will be required to complete the training prior to working their shift.
- No employee will be allowed to begin their shift until the training has been received.
- Audit reports will be submitted to the Administrator and QAPI committee for review and new interventions implemented as needed.
Failure to Notify Physician and Family After Resident Fall
Penalty
Summary
The facility failed to ensure proper notification procedures were followed after a resident experienced a fall. The resident, who had a history of falling and was identified as a high fall risk, experienced an unwitnessed fall over a weekend. Despite the facility's policy requiring the charge nurse to notify the physician and family in the event of a fall, there was no documented evidence that this notification occurred. The resident's clinical record and nursing notes did not show any communication with the physician or family regarding the fall. Interviews with the nursing staff, including the charge nurse and LPN on duty during the incident, confirmed that the required notifications were not made. The charge nurse admitted to not completing an incident report or notifying the necessary parties. The Assistant Director of Nursing and the Director of Nursing both confirmed that the charge nurse should have followed the established protocol, which includes completing an incident report and notifying the family and nurse practitioner. The Director of Nursing was unaware of the fall until the interview, indicating a breakdown in communication and adherence to the facility's policies.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for a resident, identified as R1, who was admitted to the facility. The resident's admission MDS assessment, with an Assessment Reference Date (ARD) of February 12, 2025, was still marked as 'in progress' beyond the required 14-day completion timeframe. Interviews with the MDS coordinator and the Director of Nursing confirmed that the admission MDS for R1 was not completed within the mandated period, indicating a lapse in adhering to regulatory requirements for timely assessments.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plan for a resident at risk for falls. The resident, who was admitted with diagnoses including paraplegia and an unspecified injury at the T7-T10 level of the thoracic spinal cord, was identified as cognitively intact with a BIMS score of 14. The care plan included the use of a fall mat as an intervention to minimize the risk of injury from falls. However, observations on two consecutive days revealed that the fall mat was not present at the resident's bedside as required. Interviews with the resident and staff confirmed the lack of consistent implementation of the fall mat intervention. The resident reported falling out of bed in previous months and stated that no ongoing safety interventions, including the fall mat, were in place post-accidents. Staff interviews revealed inconsistencies in the understanding and application of the fall mat intervention, with one CNA stating it was only used during transfers, contrary to the care plan's requirement for continuous use at the bedside. The MDS coordinator and DON confirmed the expectation for the fall mat to be in place at all times to reduce fall risk, highlighting a failure in adherence to the care plan.
Failure to Develop Timely Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident within the required timeframe of 7 days following the completion of the comprehensive Minimum Data Set (MDS) assessment. The resident was admitted to the facility, and the Admission MDS assessment had an Assessment Reference Date (ARD) of January 10, 2025. However, by February 24, 2025, the resident's care plan only included a baseline care plan with no specific tasks or interventions listed for activities of daily living assistance, fall risk interventions, nutritional services, or skin care measures. Interviews with facility staff confirmed the oversight. The staff member responsible for completing MDS assessments and care plans acknowledged that the comprehensive care plan should have been completed by January 17, 2025, but was not. The Director of Nursing also verified the ARD and confirmed the absence of a comprehensive care plan by the required date, indicating a lapse in adhering to the facility's policy for timely care plan development.
Failure to Document Census Checks for Residents at Risk of Elopement and Wandering
Penalty
Summary
The facility failed to accurately document census checks for two residents identified as being at risk for elopement and wandering. Resident #5, who was admitted with cerebral infarction, hemiplegia, and hemiparesis, had a severe cognitive impairment with a BIMS score of 3. Physician's orders required census checks every 30 minutes due to the resident's risk of elopement. However, a review of the Task log from February 13 to February 15, 2025, showed no documentation of these checks. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the checks were not documented as required. Similarly, Resident #6, admitted with non-traumatic intracerebral hemorrhage and hemiplegia, also had severe cognitive impairment with a BIMS score of 5. The resident's physician's orders required hourly checks due to a history of wandering. However, the Task log from February 13 to February 24, 2025, lacked documentation of these checks. Interviews with the LPN and CNA assigned to Resident #6, as well as the DON, confirmed the absence of required documentation. Both residents' cases highlight a failure in maintaining accurate records of census checks, which are crucial for minimizing risks associated with elopement and wandering.
Insufficient CNA Staffing on Night Shifts
Penalty
Summary
The facility failed to maintain sufficient certified nursing assistant (CNA) staff to meet the needs of its residents, as required by its policy titled 'Sufficient Staff.' The policy mandates a specific staffing ratio of 8 CNAs for both the day and evening shifts, and 4 CNAs for the night shift. However, on multiple occasions, specifically on 12/22/2024, 12/29/2024, 01/11/2025, and 01/12/2025, the night shift was staffed with only 3 CNAs instead of the required 4. Interviews with several CNAs confirmed that the staffing levels on these dates were insufficient to provide adequate care. The facility's administrator acknowledged the staffing shortfall during an interview, confirming the deficiency in meeting the required staffing levels.
Failure to Notify Ombudsman of Emergency Transfers
Penalty
Summary
The facility failed to notify the Ombudsman of facility-initiated emergency transfers for two residents. The facility's policy requires that the Social Services Director or designee provide copies of notices for emergency transfers to the Ombudsman, which can be sent on a monthly basis. However, the facility did not document the emergency transfers of two residents on the Ombudsman Emergency Transfer Log, as required by their policy. Resident #5 was admitted with a history of cerebral infarction, hemiplegia, hemiparesis, history of falling, and cognitive communication deficit. On 12/26/2024, Resident #5 experienced a fall resulting in an emergency transfer to a local hospital for evaluation and treatment, but this transfer was not documented on the Ombudsman Emergency Transfer Log. Similarly, Resident #6, who was admitted with dementia, dysphagia, and cognitive communication deficit, was transferred to a local hospital on 11/05/2024, but this transfer was also not documented on the log. The Social Services Director confirmed the omissions during an interview.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents, leading to deficiencies in their care. Resident #3, who was admitted with hemiplegia and dementia, experienced a fall on January 1, 2025. Despite the care plan being updated to include a physical therapy (PT) screening, the therapy staff was not informed, and the screening was not completed as required. Interviews with the PT director and assistant confirmed that they were unaware of the fall and the need for a PT evaluation, which should have been conducted the day after the fall. Resident #4, who was severely cognitively impaired, exhibited wandering behaviors that were not reflected in his care plan. Although staff members, including CNAs and an LPN, observed the resident wandering into other residents' rooms and different halls, this behavior was not documented in the elopement risk assessment or care plan. The MDS coordinator confirmed that the resident's wandering should have been reported and included in the care plan, but it was not. Resident #5, who had a history of falls and cognitive impairment, had a physician's order for every 30-minute checks due to falls. However, the care plan did not include this order, and staff were unaware of the need for more frequent checks. Interviews with CNAs and an LPN revealed that they were performing checks every two hours instead. The MDS coordinator and DON confirmed the oversight, acknowledging that the order was not documented in the care plan or other records, leading to a failure in implementing the necessary checks.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide necessary care and services to maintain good personal hygiene for a resident who was unable to perform activities of daily living independently. The resident, who was admitted with diagnoses including Morbid Obesity and Functional Quadriplegia, was assessed to require extensive assistance for ADL care and was always incontinent. On a specific day, the resident activated the call light at 7 p.m. requesting incontinent care, but did not receive assistance until the new shift arrived at 10 p.m., leaving her saturated in urine. Interviews with staff revealed that the CNA assigned to the resident's care was not aware of any missed care prior to shift change, despite the resident's report and the confirmation from another CNA who found the resident saturated. The Director of Nursing confirmed that incontinent care should be provided every two hours and before shift changes, indicating a lapse in the facility's adherence to its care protocols.
Failure to Document ADL Care for Two Residents
Penalty
Summary
The facility failed to ensure accurate documentation of Activities of Daily Living (ADL) care for two residents, leading to a deficiency in maintaining proper medical records. Resident #8, who was admitted with unspecified thoracic spinal cord injury and acute pain due to trauma, required extensive assistance for ADL care. However, the bed bath log for Resident #8 showed missing documentation on multiple dates, indicating a lack of recorded care or refusals. Similarly, Resident #9, admitted with chronic obstructive pulmonary disease, morbid obesity, and hypertensive heart disease with heart failure, also required extensive assistance for ADL care. The bed bath log for Resident #9 also revealed several dates with no documentation of bed baths being given or refused. Interviews with facility staff confirmed the absence of documentation for the specified dates. An LPN stated that CNAs are responsible for charting bed baths, including any refusals, and upon review, confirmed the missing entries for Resident #9. Another staff member reviewed the charts for both residents and confirmed the lack of documentation for the mentioned dates. This failure to document ADL care accurately is a breach of the facility's policy on maintaining complete and legal records of resident care.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident diagnosed with Bipolar Disorder. A handwritten telephone order for Ativan 1 mg IM was issued for the resident to address agitation and aggression. However, the medication was not administered as ordered. The nurse, S2RN, confirmed receiving the order but chose not to administer the medication because the resident had calmed down. S2RN did not contact the nurse practitioner to discontinue the order, which was a deviation from the facility's policy that requires medication to be administered in accordance with physician's orders. The Director of Nursing, S1DON, stated that staff are expected to follow physician's orders and should contact the ordering physician if a medication is not administered.
Deficiencies in Staff Competency and Resident Safety
Penalty
Summary
The facility failed to ensure that nursing staff had the appropriate competencies and skills to provide safe care for residents, as evidenced by several incidents. One significant incident involved a resident who required a Hoyer lift and assistance from two staff members for transfers. However, a CNA attempted to transfer the resident independently without the lift, resulting in the resident falling and sustaining a laceration above the left eyebrow. Interviews with staff revealed a lack of knowledge on how to identify and implement residents' assessed transfer needs, indicating a systemic issue in training and competency verification. Another deficiency was observed in the facility's handling of residents who smoked. Several residents identified as unsafe smokers were found smoking unsupervised in non-designated areas, with some possessing smoking paraphernalia despite being assessed as requiring supervision. Staff interviews revealed a lack of awareness and training regarding their roles in implementing safe smoking interventions and monitoring residents' smoking behaviors. The facility did not have an effective system to assess and communicate smoking safety interventions, leading to unsafe conditions for residents who smoked. Additionally, the facility failed to document and verify the competency of its nursing staff. Personnel files reviewed showed no evidence of competency skills check-offs for several CNAs and LPNs. Interviews with staff and administration confirmed that competency checks were not consistently performed upon hire or annually, and there was no documentation to support that staff were competent in their roles. This lack of competency verification contributed to the unsafe practices observed in resident care and smoking interventions.
Deficiencies in Resident Care and Safety Due to Inadequate Training and Oversight
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to several deficiencies in resident care. One significant incident involved a resident who required a Hoyer lift and two staff members for transfers. However, a CNA attempted to transfer the resident independently without the lift, resulting in the resident falling and sustaining a laceration above her left eyebrow. The CNA and other nursing staff were unaware of how to identify and implement the resident's assessed transfer needs, as there was no documentation in the care plan or resident summary regarding the required assistance and devices for transfers. Another deficiency was observed in the facility's handling of residents who smoked. Several residents identified as unsafe smokers were found smoking unsupervised in unapproved areas without protective gear. The facility lacked an effective system to assess and implement safe smoking interventions, and staff were not informed of their roles in ensuring smoking safety. This led to residents possessing smoking paraphernalia and smoking in non-designated areas, posing a risk to their safety. Additionally, the facility failed to ensure that licensed nurses and CNAs were competent in the skills required to meet resident needs. There was no documented evidence of performance evaluations or competency skills check-offs for several staff members. Interviews revealed that competency checks were not conducted, and new hires were allowed to provide direct resident care without demonstrating their competency. This lack of oversight and training contributed to the deficiencies observed in resident care and safety.
Deficiencies in Resident Transfer and Smoking Safety
Penalty
Summary
The facility failed to ensure that residents remained free from accident hazards and received adequate supervision and assistance to prevent accidents. Specifically, the facility did not have an effective system in place for nursing staff to identify and implement a resident's assessed transfer needs. This deficiency was highlighted when a resident, who required a Hoyer lift and two staff members for transfers, was independently transferred by a CNA without the lift, resulting in a fall and injury. Interviews with staff revealed a lack of knowledge on how to identify residents' transfer needs, and documentation did not clearly indicate the required assistance for transfers. Additionally, the facility failed to implement safe smoking interventions for residents identified as unsafe smokers. One resident, assessed as an unsafe smoker, was observed smoking unsupervised in an unapproved area, while another resident, not listed as a smoker, was found smoking unsupervised with smoking paraphernalia. A third resident, also assessed as an unsafe smoker, was observed with smoking materials in his possession at an undesignated time and area. Staff interviews indicated that the facility lacked an effective system to assess and implement interventions for smokers, and there was a reliance on verbal communication rather than documented procedures. The deficiencies in both transfer assistance and smoking safety were compounded by inadequate documentation and communication among staff. The facility's policies on safe lifting and smoking were not effectively implemented, leading to situations where residents were at risk of harm. Staff were often unaware of residents' specific needs and the appropriate interventions required, resulting in unsafe practices and potential harm to residents.
Failure to Submit PASRR Level II Evaluations
Penalty
Summary
The facility failed to ensure that residents with identified mental health diagnoses were referred for a Preadmission Screening and Resident Review (PASRR) Level II evaluation as required. This deficiency was identified for four residents out of six sampled records reviewed for PASRR compliance. Specifically, residents with diagnoses such as Anxiety Disorder, Schizophrenia, Depression, Paranoid Personality Disorder, and Schizoaffective Disorder did not have the necessary PASRR Level II determinations on file. The absence of these determinations indicates a failure to submit the required Resident Review Forms to the appropriate state agency for evaluation. Interviews conducted with facility staff confirmed the oversight. S20SW, responsible for submitting PASRRs, acknowledged that new mental health diagnoses should prompt a submission for a PASRR Level II referral. However, she verified that the necessary forms for the affected residents were not sent. Similarly, S16CON confirmed that residents with approved mental health diagnoses should have had the forms submitted for PASRR Level II determinations, which were not completed for the residents in question.
Failure to Provide Ordered Therapeutic Diet
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident with End Stage Renal Disease by not providing the ordered therapeutic diet. The resident, who was dependent on dialysis, was prescribed a liberal renal diet with a 1000 ml fluid restriction and was not to receive soups or broths. However, the resident reported frequently receiving soup and insufficient food portions that did not satisfy his hunger. An observation confirmed that the lunch tray lacked protein, consisting only of 1/2 cup of California blend vegetables and 1/2 cup of parslied noodles. Interviews with staff members corroborated the resident's claims. A dietary staff member confirmed the contents of the lunch and dinner trays, which included soup that the resident should not have received. The registered dietitian acknowledged that the resident should have received increased protein with his meals and confirmed the error in the meal provided. The Director of Nursing also confirmed that the resident should have been served the liberal renal diet as ordered, indicating a failure in adhering to the prescribed dietary plan.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored according to accepted professional principles, as observed during a survey. Two medication carts, Med Cart A and Med Cart B, were found to contain loose pills, which were confirmed by the LPNs responsible for these carts. Additionally, Med Cart B contained an expired bottle of sterile water, which was also confirmed by the LPN. These findings indicate a lack of adherence to the facility's policy on medication storage, which requires that medication storage areas be maintained in a clean, safe, and sanitary manner, and that discontinued, outdated, or deteriorated drugs or biologicals not be used. Furthermore, the facility failed to maintain proper storage temperatures for medications in Med Frig D. The refrigerator was observed to have a temperature of 29 degrees Fahrenheit, which is below the required range of 36-45 degrees Fahrenheit. This refrigerator contained several insulin pens and vials of antibiotics. The temperature log for the refrigerator showed previous instances of temperatures being out of range, which were not reported or addressed. The DON confirmed that the responsibility for monitoring and reporting temperature logs lies with the nursing staff, and that the observed temperatures were inappropriate.
Failure to Train Dietary Staff on Dishwasher Chlorine Testing
Penalty
Summary
The facility failed to ensure that all dietary staff hired were trained on how to test the chemical dishwasher for chlorine. During an observation, a staff member was seen placing various items through a low temperature dishwasher without testing for chlorine. In an interview, the staff member confirmed that he was not trained on how to test the dishwasher for chlorine. Additionally, a dietary manager confirmed that all kitchen staff should use the chemical rinse method to sanitize dishes and admitted that there was no documentation or proof of training for the five dietary staff hired to operate the dishwasher.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, potentially affecting 81 residents served from the kitchen. During an initial tour of the kitchen, several items were found without proper labeling or dating, including containers of parsley flakes, onion powder, garlic powder, and a ground garlic and ginger mix. These items lacked labels indicating an open date or expiration date, which is against the facility's policy for food safety guidelines. Further observations in the refrigerator revealed additional items without proper labeling, such as sliced American cheese, shredded cheese, boiled eggs, concentrated liquid coffee, and fruit salad deluxe. Some items, like pepperoni, were past their expiration date. In the freezer, opened and unsealed boxes of premade pancakes, French fries, and white sheet cake were found without labels. The dry pantry also contained an opened, unsealed box of fish fry without a label. An interview with S7DEM confirmed that these items should have been labeled with open dates and/or expiration dates, which they were not.
Failure to Ensure Residents Understood Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents understood the binding arbitration agreement they signed upon admission. This deficiency was identified for two residents, who were admitted from the hospital and signed the Optional Binding Arbitration form without understanding its contents. Both residents stated during interviews that they were not aware of what an arbitration agreement was and confirmed that no one explained the agreement to them before they signed it. The staff member responsible for explaining the admissions process, S6CAC, confirmed that she reviewed the admissions packet and contractual agreements with the residents while they were in the hospital. However, she assumed the residents understood the arbitration agreement because they did not ask any questions. This assumption led to the residents signing the agreement without a clear understanding, resulting in the facility's failure to ensure informed consent for the arbitration agreement.
Failure to Implement Effective QAPI Process
Penalty
Summary
The facility failed to develop and implement appropriate plans of action to correct and ensure ongoing compliance with identified quality deficiencies. This deficiency was observed through a review of the facility's Quality Assurance and Performance Improvement (QAPI) Team Meeting Notes, which indicated ongoing monitoring and audits for complaint surveys conducted between June and August 2024. Despite these notes, the facility continued to exhibit noncompliance in areas such as therapeutic diets, food storage, abuse reporting, and enhanced barrier precautions, as identified in both complaint and annual surveys. During an interview, the current administrator, who was not present during the last QAPI meeting, confirmed the lack of additional documentation to support the facility's compliance claims. The administrator acknowledged the ongoing deficiencies identified by the survey team, indicating that the facility's QA/QAPI process was ineffective in addressing and rectifying these issues. The deficiencies had the potential to affect the 88 residents residing in the facility.
Infection Control Deficiencies in PPE Use and Laundry Management
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by two main deficiencies. Firstly, staff did not adhere to the required use of Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). Specifically, an LPN was observed administering medications through a PEG tube to a resident with a gastrostomy infection without wearing a gown, despite the facility's policy requiring gown and gloves for high-contact care activities. Similarly, a CNA provided incontinence care to a resident with a stage 4 pressure ulcer without donning any PPE, contrary to the physician's order for EBP related to wounds. Secondly, the facility failed to maintain a sanitary environment by not promptly removing urine-soiled laundry from a resident's room. Observations revealed that urine-soiled laundry remained on the floor of a resident's room for an extended period, despite the responsibility of CNAs to remove such items. Interviews with staff confirmed that the laundry should have been picked up after each shift, and it was acknowledged that leaving urine-soiled laundry on the floor posed an infection control risk.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as observed in multiple rooms and hallways. In Room A, issues included uncovered and broken fluorescent light fixtures with dead bugs, scuffed walls and baseboards, stained floor tiles, missing window blinds, dusty serving carts, rusted air conditioner vents, and deteriorating sheetrock on the ceiling. Similar conditions were noted in other areas, such as Room B, where a missing threshold transition piece and scuffed doors were observed, and Room C, which had scuffed walls with dried brown substances and rusted air conditioner vents. Room D had rotten sections of wood around the waterfall area, non-functioning recessed lights, and rusted air conditioner vents. Hallways E and F had scuffed walls, handrails, and baseboards, with broken blinds in resident rooms. In Room G, scuff marks, indentations, and missing paint were noted on the walls, while Room H had similar wall damage, a hole in the bathroom sheetrock, and broken blinds. Room I presented a safety hazard with a windowsill board propped up with exposed nails, which had been in this condition for about a month according to a resident. Interviews with staff confirmed the presence of these environmental concerns and acknowledged that the facility should be maintained in a safe and homelike manner, which it was not. The issues observed had the potential to affect the entire census of 88 residents residing in the facility.
Inaccurate MDS Assessments for PASRR and Hospice Status
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their Minimum Data Set (MDS) coding. For one resident, who had been diagnosed with Anxiety Disorder, Major Depressive Disorder, and Schizoaffective Disorder, the facility did not accurately code the annual MDS assessment regarding the Pre-Admission Screening and Resident Review (PASRR) Level II status. The resident's clinical record showed an approved Level II PASRR, but the MDS assessment did not reflect this, as it was incorrectly marked as 'no' for PASRR evaluation and left blank for serious mental illness. This discrepancy was confirmed during an interview with a staff member. Another resident, who had been diagnosed with Chronic Diastolic Congestive Heart Failure and had a cardiac pacemaker, was admitted to a hospice agency. However, the resident's quarterly MDS assessment did not indicate hospice care, as the relevant section was left unchecked. This oversight was confirmed by a staff member during an interview, who acknowledged that the resident was indeed receiving hospice services. The facility's policy on conducting accurate resident assessments was not effectively implemented, as evidenced by these inaccuracies in the MDS assessments.
Deficiencies in Care Plan Implementation
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, leading to deficiencies in care. Resident #4's care plan did not reflect their hospice status, despite being admitted to a hospice agency. This oversight was confirmed by the MDS coordinator, who acknowledged the care plan should have included this information. Resident #14's ostomy care was not provided according to physician orders, as observed when an LPN failed to clean the ostomy site before applying a new bag, which was confirmed by the LPN and the Assistant Director of Nursing. Resident #32 missed a scheduled nephrology appointment due to a lack of staff available to accompany her, despite being ready and waiting for transportation. The facility's appointment log incorrectly indicated that she attended the appointment, which was later confirmed as a no-show by the nephrologist's office. Interviews with staff revealed a breakdown in communication and scheduling, resulting in the missed appointment. Resident #54's care plan did not document the necessary assistance and devices required for transfers, despite being dependent on staff and requiring a Hoyer lift. This was confirmed by an LPN. Additionally, Resident #75's care plan failed to address his smoking status, even though staff were aware of his smoking habits. The MDS coordinator confirmed that smoking status should be included in care plans, identifying residents as safe or non-safe smokers with appropriate interventions.
Failure to Provide Scheduled Baths for a Resident
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out Activities of Daily Living (ADLs) without assistance received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #32, who was cognitively intact with a BIMS score of 15 and had a diagnosis of Type 2 Diabetes Mellitus with a foot ulcer, did not receive scheduled baths on several Saturdays over a four-month period. The facility's policy required residents to be assisted with bathing at least three times weekly, but there was no documentation of completed baths for Resident #32 on specified dates. Interviews with Resident #32 and staff confirmed the lack of documentation and the failure to provide the scheduled baths. Resident #32 stated she was supposed to receive baths on Tuesdays, Thursdays, and Saturdays but had not received them on Saturdays for the past four months, and she had never refused a bath. Staff interviews corroborated the resident's account, and it was acknowledged that there should have been documentation of the baths being performed or refused, which was not available.
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 101 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Baton Rouge
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Landmark Of Baton Rouge | 1.6 mi | ★★★★★ | 8 | 0 |
| Heritage Manor Of Baton Rouge Ii | 1.6 mi | ★★★★★ | 5 | 0 |
| Jefferson Manor Nursing And Rehab Ctr, Llc | 1.6 mi | ★★★★★ | 4 | 0 |
| Capitol House Nursing And Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
| The Guest House Care Center | 2.4 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.