Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at White Oak Post Acute Care during CMS and state inspections, most recent first.
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.
A resident experienced a significant delay in receiving assistance after activating the call light, with staff failing to respond in a timely manner. Despite the call light being visibly lit, multiple staff members passed by without providing care. Interviews revealed inconsistencies in the facility's call light response protocol, with staff acknowledging that a 30-minute wait is unacceptable.
A resident with moderate cognitive impairment was given a bottle containing a blue liquid resembling a cleaning agent, leading to stomach upset and burning sensations. The resident also alleged a CNA used her food stamp card for personal use. Despite attempts to contact the DON, ADON, and administrator, the facility failed to report these allegations of physical and financial abuse to the state survey agency within the required timeframe.
A resident with a history of Cerebral Vascular Infarction, Aphasia, and Dysphagia did not receive continuous enteral feeding as ordered by the physician. Observations showed the feeding tube was not running for several hours, and the pump displayed error messages. Staff interviews confirmed the deficiency, as the resident's feeding was not administered as prescribed.
The facility did not post daily nurse staffing information in a location accessible to residents and visitors. An observation revealed no staffing data sheets were displayed, and interviews with staff confirmed the last sheet was completed the previous day.
A paraplegic resident in a LTC facility developed a Deep Tissue Injury (DTI) on the left heel due to the facility's failure to follow physician orders to float the heels. Despite being at risk for pressure ulcers, the resident's heels were observed resting on the footboard multiple times without heel boots, leading to new pressure-related injuries. Staff interviews confirmed the resident required assistance with repositioning, and the Director of Nursing acknowledged the deficiency.
The facility failed to maintain an effective infection prevention and control program, as staff did not adhere to Enhanced Barrier Precautions for two residents with wounds and indwelling devices. Staff were observed not wearing gowns during high-contact activities and improperly handling a urinary drainage bag, risking infection. Additionally, staff did not perform proper hand hygiene, failing to wash hands after removing soiled gloves and before applying new ones.
A resident with intact cognition and dependent on transfers requested to be moved out of bed around 6:20 a.m. but was not transferred until after 9:45 a.m. The CNA acknowledged the request but delayed the transfer, requiring a two-person assist. Both the ADON and DON confirmed the delay was unacceptable, indicating a failure to accommodate the resident's needs.
A resident with cerebral infarction and muscle disorders, dependent on staff for toileting, was left in a wet gown and pillow due to delayed incontinence care. Despite the facility's policy for two-hourly checks, staff failed to change the resident's brief on time, as confirmed by observations and interviews with the resident and staff.
A facility failed to maintain accurate medical records for a diabetic resident, as insulin was documented as administered even when blood glucose levels were below the prescribed threshold. Interviews with LPNs confirmed these were documentation errors, and the DON verified that insulin should not have been documented as given if not administered.
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.
Delayed Response to Call Light
Penalty
Summary
The facility failed to ensure timely response to call lights, which is a critical aspect of accommodating resident needs and preferences. Specifically, Resident #192 experienced a significant delay in receiving assistance after activating the call light. On the morning of September 17, 2024, Resident #192, who was wet and needed changing, pressed the call light for help. Despite the call light being visibly lit in the hallway, multiple staff members passed by without entering the room to provide care. It was not until 9:42 a.m., nearly 43 minutes after the initial activation, that CNA staff entered the room to assist the resident. Interviews with staff revealed inconsistencies in the facility's call light response protocol. The ward clerk, S22WC, stated that the front desk is alerted when a call light is pressed, and after five minutes, a CNA is paged overhead. However, it was noted that a resident should not wait 30 minutes for a response. Both S3ADN and S2DON confirmed that any staff in the hallway should respond to a call light within 3-5 minutes, and acknowledged that a 30-minute wait is unacceptable. This incident highlights a breakdown in the facility's policy for timely call light response, resulting in a deficiency in accommodating resident needs effectively.
Failure to Timely Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of physical abuse and misappropriation of resident property to the facility administrator and the state survey agency in a timely manner. The incident involved a resident who was moderately cognitively impaired and had been given a bottle by a CNA, which was later found to contain a blue liquid with a strong smell resembling a cleaning agent. The resident experienced stomach upset and burning sensations after consuming a sip from the bottle. Despite attempts to contact the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the administrator, the incident was not reported to the state survey agency within the required timeframe. The resident also alleged that the same CNA had used her food stamp card for personal use, leaving only 12 cents on it. This was reported to a social worker, who confirmed that the administrator conducted an investigation into the allegations. However, the allegations of both physical and financial abuse were not reported to the state survey agency as required by the facility's policy, which mandates reporting within two hours for abuse allegations. Interviews with staff members revealed that the CNA who discovered the blue liquid reported the incident to an LPN, who then attempted to notify the DON and ADON via text messages. The ADON confirmed receiving a text about the incident the following morning and assessed the liquid as detergent. The administrator acknowledged being informed of the allegations the morning after the incident and admitted that the allegations should have been reported to the state survey agency within the required timeframe.
Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that a resident received enteral feedings as ordered by the physician. The resident, who had a history of Cerebral Vascular Infarction, Aphasia, and Dysphagia, was assessed with a BIMS of 0, indicating they were rarely or never understood. The physician's orders specified that the resident should receive continuous enteral feeding of Glucerna 1.2 at 70ml/hour for 22 hours daily, with a 2-hour break for routine care. However, observations on a specific day revealed that the resident's feeding tube was not running at multiple times throughout the day, and the pump displayed error messages indicating issues such as an empty bag, clog in line, and valve not loaded. Interviews with staff confirmed the deficiency. An LPN was observed attempting to restart the pump and hang a new bottle of Glucerna, acknowledging that the pump should have alarmed when empty. A registered dietitian and a consultant confirmed that the resident did not receive the continuous enteral feeding as ordered, as the feeding was not running from 8:45 a.m. to 4:00 p.m. on the day in question. This failure to administer the feeding as prescribed constituted a deficiency in the care provided to the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily in a prominent location accessible to residents and visitors. On 09/19/2024, an observation at 9:45 a.m. revealed that no staffing data sheets were displayed. During an interview at 9:50 a.m., S3ADN, who was responsible for posting the staffing data, confirmed that the last staffing data sheet was completed on 09/18/2024. Another interview at 9:55 a.m. with S1ADM corroborated that the last daily staffing data sheet was completed on 09/18/2024.
Failure to Prevent Pressure Ulcers in Paraplegic Resident
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development of new pressure ulcers for a resident, resulting in actual harm. The resident, who is paraplegic with no sensation in the lower extremities, was observed multiple times with his feet resting directly on the footboard of the bed, contrary to the physician's order to float the heels. This oversight led to the development of new areas of discoloration on both heels, which were later assessed as a Deep Tissue Injury (DTI) on the left heel. The resident's clinical records indicated a history of spinal cord injury and osteomyelitis, with a Braden Scale assessment showing a risk for pressure ulcers. Despite this, the resident's care plan, which included floating the heels, was not followed. Observations and interviews revealed that the resident's heel boots were not applied, and his heels were not floated as required, leading to the development of pressure-related injuries. Interviews with staff, including CNAs and LPNs, confirmed that the resident required assistance with repositioning and that the responsibility for floating the heels and applying heel boots was not adequately fulfilled. The Director of Nursing acknowledged the deficiency, confirming that the resident's feet should not have been on the footboard and that the heels should have been floated at all times while in bed.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not adhering to Enhanced Barrier Precautions for residents with wounds and indwelling medical devices. Specifically, staff members were observed not wearing gowns while providing care to two residents who were on Enhanced Barrier Precautions. This included activities such as transferring a resident and performing wound care, which are considered high-contact activities requiring the use of gowns and gloves. Additionally, the facility did not ensure proper handling of a urinary drainage bag for one of the residents. During a transfer, a staff member placed the urinary drainage bag above the level of the resident's bladder, which could potentially lead to backflow and increase the risk of infection. This action was confirmed by the staff involved, who acknowledged the mistake and the requirement to keep the drainage bag below the bladder level. Furthermore, the facility's staff failed to perform proper hand hygiene during the care of a resident. Observations revealed that staff members did not wash their hands after removing soiled gloves and before applying new ones, which is a critical step in preventing the spread of infection. Interviews with the staff confirmed their awareness of the hand hygiene policy, yet they did not adhere to it during the care of the resident.
Failure to Timely Transfer Resident Out of Bed
Penalty
Summary
The facility failed to accommodate the needs of a resident who requested to be transferred out of bed in a timely manner. The resident, who was admitted with diagnoses including Cerebral Infarction and Primary Disorders of Muscles, had a BIMS score of 15, indicating intact cognition, and was dependent on transfers. According to the resident's care plan, she required assistance with activities of daily living (ADLs) due to impaired mobility and needed a mechanical lift for transfers. On the morning of the incident, the resident requested to be transferred out of bed around 6:20 a.m., but the request was not fulfilled until after 9:45 a.m. Interviews conducted with the staff revealed that the CNA acknowledged the resident's request but did not transfer her until much later, citing the need for a two-person assist. The Assistant Director of Nursing (ADON) and the Director of Nursing (DON) both confirmed that the delay in transferring the resident was unacceptable. The incident highlights a failure in the facility's ability to reasonably accommodate the resident's needs and preferences, as the resident was left in bed for an extended period despite her request to get up.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident who was unable to perform activities of daily living independently. The resident, who had diagnoses including Cerebral Infarction and Primary Disorders of Muscles, was dependent on staff for toileting hygiene and required substantial assistance with mobility in bed. Despite having intact cognition, the resident expressed frustration over being left in a wet gown and pillow, indicating a lack of timely care. Observations confirmed that the resident's under pad and brief were wet with urine, and staff acknowledged the delay in providing necessary care. Interviews with staff revealed that incontinence checks and care were not performed according to the facility's policy, which required checks every two hours and changes as needed. A CNA admitted to not changing the resident's brief within the required timeframe, and both the Assistant Director of Nursing and the Director of Nursing confirmed the expectation for two-hourly checks and care. The deficiency was identified through observations and interviews, highlighting a failure in adhering to the facility's incontinence care policy.
Inaccurate Insulin Administration Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for a resident with diabetes, as required by professional standards. The resident, who was moderately cognitively impaired, had specific physician orders for insulin administration based on blood glucose levels. However, the Medication Administration Record (MAR) for July 2024 showed that insulin was documented as administered even when the resident's blood glucose levels were below the threshold of 200, contrary to the physician's orders. This discrepancy was confirmed by interviews with the Licensed Practical Nurses (LPNs) involved, who admitted to documentation errors, stating that insulin was not actually administered when the blood glucose levels were below 200. The Director of Nursing (DON) also reviewed the MAR and confirmed the findings, acknowledging that insulin should not have been documented as given if it was not administered. The resident himself confirmed that insulin was only supposed to be administered when his blood glucose was 200 or higher, aligning with the physician's orders. This documentation error indicates a failure in maintaining accurate medical records, which is a critical aspect of resident care management, especially for those with conditions like diabetes that require precise medication administration.
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 123 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 | ★★★★★ | 5 | 0 |
| Capitol House Nursing And Rehab Center | 2.3 mi | ★★★★★ | 0 | 0 |
| The Guest House Care Center | 2.4 mi | ★★★★★ | 0 | 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 July 2026) and official state health department websites.