Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Champion Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Unsafe smoking practices and incomplete fall investigations were identified. A cognitively intact resident was allowed to light cigarettes for other residents while staff did not stop the activity, two residents who were supposed to use smoking aprons were observed smoking without them, and another resident smoked before a required smoking evaluation was completed. In addition, three residents with significant cognitive or mobility impairment had repeated falls with incomplete investigations, missing witness statements or root-cause analysis, and no effective new care plan interventions; one resident’s fall mat was also observed in the wrong location or absent.
A resident with ESRD, anemia, diabetes, and malnutrition did not have the facility Dietitian review monthly dialysis lab report cards or coordinate with the dialysis dietitian. The resident remained on a regular diet without renal vitamins, while the dialysis reports showed abnormal Hgb, albumin, and phosphorus values with dietary guidance that was not addressed by the facility Dietitian.
Failure to offer pneumococcal vaccines to eligible residents. Three residents had prior pneumococcal immunization histories that were not reassessed against current CDC guidance, and the IP stated they were overdue for PCV20 or PCV21 but were not offered the vaccine. The IP also could not locate vaccine consents for two residents and stated residents with prior pneumococcal vaccines were not being reassessed or offered the pneumonia vaccine.
Failure to notify MD/RD of severe weight loss: A resident with dementia, diabetes, and mobility impairment had a confirmed significant weight loss after a re-weigh, but the record did not show immediate notification to the MD/NP or RD. The NP later saw the resident for recent falls, yet the note did not address the weight loss, and there was no documentation that the weight loss had been evaluated by the MD/NP or RD for 14 days.
Failure to Address Significant Weight Loss: A resident with dementia, diabetes, and dysphagia had a severe unplanned weight loss, but the record showed no timely RD or MD/NP evaluation, no additional weight monitoring, and no documented interventions after the loss was confirmed. Staff and the DON said the weight loss should have been rechecked and communicated, yet the RD had been waiting for a reweight and had not seen the resident, while meal observations showed the resident was eating less than half of meals.
The facility failed to create comprehensive care plans for three residents, neglecting to address specific needs such as smoking supervision, epilepsy management, and monitoring for suicidal ideation. One resident required supervision while smoking, another had frequent seizures without a care plan for triggers, and a third had a history of suicidal ideation without a mental health care plan. Staff were unaware of these needs, and the DON acknowledged the oversights.
The facility failed to provide trauma-informed care to three residents, each with PTSD or a history of trauma. A resident admitted with PTSD did not receive a trauma assessment, and staff were unaware of their trauma history. Another resident, newly diagnosed with PTSD, lacked a completed Trauma Questionnaire and specific care plan triggers. A third resident with a history of abuse did not have a trauma assessment or care plan addressing their PTSD. Staff interviews revealed a lack of awareness and completion of necessary assessments.
The facility failed to ensure proper hand hygiene during meal service, as observed by surveyors on two units. Nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents, despite the facility's policy requiring it to prevent infection spread. The Food Service Manager confirmed the oversight during an interview.
A resident with epilepsy experienced frequent seizures, but the LTC facility failed to schedule recommended Neurology and Epilepsy Center appointments. Despite initial refusal, the resident later agreed to an inpatient evaluation, yet the facility did not follow through. Interviews revealed staff were unaware of the appointment status, and the facility did not contact the Epilepsy Center to confirm insurance acceptance.
A resident with dementia and on hospice care developed a stage 3 pressure ulcer on the sacrum, and the facility failed to implement the ordered treatments. Communication lapses and incorrect wound care practices, including the use of wrong supplies and poor hand hygiene, contributed to the deficiency. The DON acknowledged that treatment orders were not updated timely, leading to missed treatments.
A resident with muscular dystrophy and cognitive intactness was not provided with adequate supervision and safety measures while smoking, as required by their care plan. The facility failed to conduct quarterly smoking evaluations and did not ensure the use of an adaptive ashtray, leading to unsafe smoking practices. Staff supervision was inadequate, with the resident being observed smoking unsafely and other residents assisting them, contrary to facility policy.
A resident with moderate cognitive impairment and epilepsy returned from a hospital stay with a Foley catheter due to urinary retention. The facility failed to assess the catheter for removal or schedule a recommended urology follow-up and voiding trial. The resident experienced catheter issues, and staff were unaware of the missed appointment, indicating a lapse in care coordination.
A resident with anoxic brain damage, dysphagia, and dementia experienced a 9.68% weight loss over six months due to the facility's failure to monitor their nutritional status. Despite a care plan goal to maintain a specific weight, weekly weights were not consistently obtained as ordered. The RD had not completed a quarterly assessment since March, and the resident was not on the list for weekly weights. The physician's notes did not acknowledge the weight loss, contributing to the oversight.
A resident was administered Azithromycin for an excessive duration of one year without adequate indication. Despite being discharged from the hospital with a 5-day antibiotic course for pneumonia, the resident continued to receive Azithromycin three times a week for COPD without documented justification. Facility staff could not provide documentation from the pulmonologist or PCP supporting the prolonged use.
A resident with severe cognitive impairment and dysphagia was observed consuming crackers, contrary to their physician-ordered pureed diet. Staff interviews revealed no documentation or physician's order allowing this deviation, highlighting a failure to adhere to the therapeutic diet, posing a risk for choking and aspiration.
A nurse failed to follow infection control protocols during wound care for a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not perform hand hygiene between glove changes and applied ointments directly from tubes onto the wound, contrary to facility policy. Interviews confirmed these lapses in infection prevention practices.
Unsafe Smoking Practices and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure safe smoking practices were followed for multiple residents. Resident #27, who was cognitively intact and had COPD, was observed in the designated smoking area lighting cigarettes for other residents while staff remained inside or otherwise did not stop the activity. The resident was seen lighting multiple cigarettes for other residents during two separate smoking breaks, and both the resident and CNA reported that staff provided the lighter and allowed the resident to light cigarettes for others. The DON stated the resident should not have been lighting any cigarettes and that staff should have been supervising and preventing this activity. Resident #55, who was cognitively intact and had paraplegia, was observed smoking without the smoking apron that was documented in the care plan as required. On another observation, cigarette ash was seen blowing onto a hole in the resident’s shirt. Resident #81, who was also cognitively intact, was observed smoking without the smoking apron required by the care plan, and ash was seen on the resident’s clothing during smoking. The resident reported trouble using the ashtray and stated that cigarette ash had burned holes in clothing. Staff told the surveyor that the resident did not require a smoking apron, while the DON stated the resident should have been using one and that the holes in the shirts showed the need for it. The facility also failed to complete a smoking evaluation before Resident #8 smoked on facility property. Although the resident signed the smoking agreement and was observed smoking, the medical record contained smoking evaluations indicating the resident did not smoke, and a later evaluation was left incomplete with the smoking section blank. Nursing staff and the unit manager stated that a smoking assessment should have been completed before the resident was allowed to smoke, and the DON stated the resident should have been evaluated for safety after signing the smoking agreement. The facility further failed to thoroughly investigate falls and implement effective interventions for Residents #30, #98, and #15. Resident #30, who had dementia, muscle weakness, abnormal gait, and a history of falls, sustained multiple falls with injuries, but the investigations were incomplete, did not identify root causes, and did not result in new interventions; the fall mat was also observed on the wrong side of the bed. Resident #98, who had severe cognitive impairment and a history of falls, also had multiple falls with incomplete investigations, missing statements, and no new interventions, and the resident’s care-planned fall mat was not present in the room during observations. Resident #15, who had severe cognitive impairment, had 10 falls over several months, including falls involving lying on the floor, wandering, balance loss, and pulling on a mechanical lift, yet the records repeatedly lacked investigations, witness statements, and updated care plan interventions.
Failure to Coordinate Dialysis Nutrition Monitoring
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required dialysis, specifically by not collaborating with the dialysis center on the resident’s care and services. The resident was admitted with end stage renal disease (ESRD), anemia, diabetes, and malnutrition, and was cognitively intact. The resident stated that the facility Dietitian rarely spoke with him/her, did not review the dialysis center report cards, and had never made dietary recommendations based on the dialysis lab results. Record review showed the resident was not on a renal diet and was not taking renal vitamins. The most recent blood labs in the facility record were dated January 2, 2025. The dialysis communication binder contained monthly lab report cards showing abnormal results, including low hemoglobin values in multiple months, low albumin values, and one report with high phosphorus and another with low phosphorus. The report cards included dietary guidance such as increasing protein intake, talking with the dietitian, taking renal vitamins, and limiting phosphorus-containing foods when indicated. The facility’s nutritional risk evaluations documented that lab values were not entered for review, while the resident continued on a regular diet with Nepro twice daily. The Dietitian stated she followed the resident quarterly, did not review the monthly dialysis lab report cards, was not aware of the recommendations on the report cards, and did not communicate regularly with the dialysis dietitian. She also stated she did not review the resident’s dialysis lab results because they were done at dialysis and not sent over.
Failure to Offer Pneumococcal Vaccines to Eligible Residents
Penalty
Summary
The facility failed to provide pneumococcal immunizations for three eligible residents out of a sample of five. The facility policy titled Pneumococcal Vaccine, last revised March 2023, stated that all residents are to be offered pneumococcal vaccines, that residents are to be assessed for eligibility prior to or upon admission, and that when indicated the vaccine series is to be offered within 30 days of admission unless medically contraindicated or already vaccinated. CDC guidance reviewed by surveyors indicated current adult pneumococcal vaccine timing recommendations, including shared clinical decision-making for adults who had previously completed PCV13 and PPSV23. Resident #7, admitted in April 2025 and currently [AGE] years old, had a documented immunization history showing Prevnar13 on 9/18/15 and PPSV23 on 12/19/16. The Infection Preventionist stated on 9/15/25 that Resident #7 was not up to date, was overdue for PCV20 or PCV21, and should have been offered the vaccine but was not. Resident #15, admitted in January 2025 and currently [AGE] years old, had PPSV23 on 10/17/13, and Resident #30, admitted in December 2024 and currently [AGE] years old, had PPSV23 on 9/1/11. The Infection Preventionist stated both residents were not up to date, were overdue for PCV20 or PCV21, and should have received it. On 9/16/25, the Infection Preventionist said she could not locate pneumonia vaccine consents for Residents #15 and #30 and stated residents who had received the pneumococcal vaccine in the past were not reassessed for current CDC guidance and had not been offered the pneumonia vaccine.
Failure to Notify MD/RD of Severe Weight Loss
Penalty
Summary
The facility failed to immediately notify the physician and/or registered dietitian of a significant weight loss for one resident, who had diagnoses including muscle weakness, difficulty walking, diabetes mellitus, and dementia. The resident’s MDS assessment showed severe cognitive impairment with a BIMS score of 1 out of 15 and no weight loss noted at that time. The weight record showed the resident’s weight decreased from 156.6 lbs. on 8/2/25 to 139.2 lbs. on 9/1/25 and 138.4 lbs. on 9/2/25, reflecting an 18.2 lb. loss in one month and a 13.61% loss over six months. The facility policy required that a weight change of 5% or more be reweighed the next day for confirmation and, if verified, nursing immediately notify the dietitian in writing, with significant unplanned weight loss evaluated by the treatment team. The record review found no documentation that the physician and RD were notified on 9/2/25 after the severe weight loss was confirmed by re-weigh. The resident was seen by the NP on 9/3/25 for recent falls, but the note did not address the severe weight loss, and the record did not show that the RD or MD/NP had addressed or evaluated the weight loss for 14 days after it was confirmed.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for one resident who had an unplanned significant weight loss. The resident had diagnoses including muscle weakness, difficulty walking, diabetes mellitus, and dementia, and the MDS showed severe cognitive impairment. The care plan identified a potential nutritional problem related to dysphagia, diabetes, and dementia, with goals for weight maintenance and adequate intake, and the resident was ordered a regular diet with mechanical soft texture, thin liquids, Lactaid milk, and a nutritional treat three times daily. The resident’s weight record showed 160.2 lbs. on 3/10/25, 156.6 lbs. on 8/2/25, 139.2 lbs. on 9/1/25, and 138.4 lbs. on 9/2/25, reflecting an 18.2 lb. loss in one month and a 13.61% loss in six months. The facility policy required confirmation of a 5% or greater weight change, immediate notification of the dietitian, and evaluation by the treatment team, but the record did not show additional weight monitoring after the confirmed loss, nor did it show that the RD or MD/NP addressed the severe weight loss for 14 days. The quarterly RD review in July documented no weight loss, and the 9/3/25 NP note related to falls did not address the weight loss. Survey observations showed the resident ate meals in the day room and consistently consumed less than half of meals. During interviews, nursing staff and the DON stated that significant weight loss should be confirmed, reported to the MD/NP and RD, and monitored more frequently, but the DON found the resident’s risk meeting worksheet only noted weight loss and to monitor, with no interventions documented. The RD stated she had not seen or spoken with the resident since the last quarterly review, had been waiting for a reweight, and had not taken action after the weight loss was identified. A later weight obtained during the survey showed the resident had lost an additional 4 lbs., bringing the loss to 16.10% over six months.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan for three residents, leading to deficiencies in addressing their specific needs. For one resident, the facility did not create a care plan for smoking needs, despite a smoking assessment indicating the resident required supervision while smoking. The resident was observed smoking without any special instructions noted in their care plan, and the unit manager and DON acknowledged the oversight. Another resident with epilepsy did not have a care plan addressing their condition, even though they had been hospitalized multiple times due to seizures. The resident's medical record included physician orders for seizure monitoring and medication, but no care plan was developed to manage triggers and interventions. The nurse and DON confirmed the absence of a care plan, which was supposed to include known triggers like door alarms. A third resident with a history of suicidal ideation and recent psychiatric hospitalization did not have a care plan addressing their mental health needs. The CNA and unit manager were unaware of the resident's suicidal history, and the social worker admitted to not reviewing the hospital discharge summary. The DON confirmed that a care plan should have been developed to monitor for signs of worsening depression and suicidal ideation.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care to three residents, as identified in a survey. Resident #36, admitted with diagnoses including dementia and PTSD, did not receive a trauma-informed care assessment upon admission. The medical record lacked information on PTSD symptoms and triggers, and staff, including a CNA and a social worker, were unaware of the resident's trauma history. The Director of Nurses acknowledged that a trauma assessment should have been completed but was not. Resident #51, who was admitted with muscular dystrophy, depression, and anxiety, received a new PTSD diagnosis after a traumatic event in July 2024. Despite this, the facility did not complete a Trauma Questionnaire, and the care plan lacked specific triggers to prevent re-traumatization. Interviews with staff revealed a lack of awareness and completion of necessary assessments, with the DON admitting that the care plan was generic and not tailored to the resident's needs. Resident #89, with a history of suicidal ideation and major depressive disorder, also did not receive a trauma assessment. The care plan did not address the resident's history of trauma, despite documentation indicating a history of sexual and physical abuse. The social worker admitted to missing information in the resident's PASARR and hospital discharge summary, resulting in a lack of a comprehensive care plan to address the resident's PTSD and associated triggers.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to adhere to professional standards of practice for food safety and sanitation, specifically in the area of hand hygiene during meal service. Observations by the surveyor on two separate occasions revealed that nurses and CNAs did not consistently perform hand hygiene when delivering food trays to residents. On the first occasion, some hand hygiene was observed, but it was not consistent. On the second occasion, no hand hygiene was observed at all. This lack of adherence to hand hygiene protocols occurred during meal service on two of the three units observed. The facility's policy on hand washing and hygiene, revised in August 2019, clearly states that hand hygiene is the primary means to prevent the spread of infections. It requires personnel to perform hand hygiene before and after direct contact with residents, contact with objects in the immediate vicinity of the resident, and before and after assisting a resident with meals. Despite this policy, the CNAs and nurses failed to consistently follow these procedures, as confirmed by the Food Service Manager during an interview. The FSM acknowledged the lack of hand hygiene during meal service, which is a critical step in preventing the spread of infections among high-risk residents.
Failure to Schedule Specialist Appointments for Resident with Epilepsy
Penalty
Summary
The facility failed to ensure that a resident with epilepsy had their recommended specialist appointments scheduled. The resident, who had moderate cognitive impairment, was experiencing frequent seizures and had been hospitalized recently. Despite recommendations for follow-up appointments with a Neurology office and an Epilepsy Center, the facility did not schedule these appointments. The resident initially refused an inpatient evaluation at the Epilepsy Center but later agreed, yet the facility did not follow through with scheduling. The facility's records, including the Appointment Communication Form and nursing progress notes, showed a lack of documentation and follow-up regarding the scheduling of these critical appointments. The resident continued to experience frequent seizures, and there was no evidence that the facility staff had reached out to the Epilepsy Center or Neurology office to arrange the necessary evaluations. The facility's Appointment book and nursing notes failed to indicate any progress in scheduling these appointments, despite the resident's ongoing health issues. Interviews with facility staff revealed a lack of awareness and follow-up on the resident's care plan. Nurse #4 and the Director of Nurses admitted to not knowing the status of the appointments and acknowledged that the process had been mishandled. The facility did not know that the Epilepsy Center would not accept the resident's insurance because they had not contacted the office. The Director of Nurses confirmed that the resident's condition had worsened, with more frequent seizures, and that the necessary appointments had not been made in a timely manner.
Deficiency in Pressure Ulcer Care and Treatment
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident with a pressure ulcer, leading to a deficiency in wound management. The resident, who was admitted with dementia and on hospice care, developed a deep tissue injury on the sacrum, which progressed to a stage 3 pressure ulcer. Despite specific treatment recommendations from both hospice and a wound consultant physician, the facility did not implement the treatments as ordered. The Treatment Administration Record (TAR) showed inconsistencies in treatment application, including missed dressing changes and incorrect implementation of wound care protocols. The deficiency was further compounded by communication lapses between the facility staff and the primary physician, as well as between the facility and hospice services. The primary physician could not recall approving changes to the treatment plan, and the hospice staff did not perform dressing changes on specified dates. Additionally, the Director of Nurses (DON) acknowledged that the treatment orders were not updated in a timely manner, resulting in a missed treatment. The wound consultant physician emphasized that the dressing should not have been left unchanged for an extended period, especially on a necrotic wound. During an observation, a nurse failed to follow proper wound care procedures, using incorrect supplies and not adhering to hand hygiene protocols. The nurse used the wrong strength of Dakins solution, incorrect calcium alginate, and ointments belonging to another resident. Furthermore, the nurse applied ointments directly from the tubes onto the wound, contrary to infection control practices. The DON and Infection Preventionist confirmed that the nurse did not follow the treatment order and failed to perform hand hygiene with each glove change, as required.
Failure to Ensure Safe Smoking Practices for Resident
Penalty
Summary
The facility failed to ensure a safe environment for Resident #51, who was cognitively intact and had a history of muscular dystrophy, ambulatory dysfunction, and generalized weakness. The resident was known to smoke and required supervision and specific safety interventions, such as using an adaptive ashtray and wearing a smoking apron. However, the facility did not complete the required quarterly smoking evaluations, with the last evaluation being conducted in March 2023. This evaluation indicated that Resident #51 was unable to safely light, use an ashtray, or extinguish a cigarette, necessitating staff supervision and the use of a smoking apron. Observations revealed that Resident #51 was not using the adaptive ashtray as outlined in the care plan. On multiple occasions, the resident was seen smoking with a cigarette hanging from their mouth, without the use of the adaptive ashtray, and with ashes falling onto the smoking apron. Staff supervision was inadequate, as the supervising nurse was inside the building, and other residents were observed assisting Resident #51 by picking up dropped cigarettes. This lack of direct supervision and failure to use the adaptive ashtray posed a safety risk to the resident. Interviews with staff, including the Director of Nurses and the Staff Development Coordinator, confirmed that Resident #51 did not use the adaptive ashtray and preferred to smoke with the cigarette hanging from their mouth. The Director of Nurses acknowledged that the care plan was not being followed and that Resident #51's practice of keeping cigarettes in their room was against policy. The staff also recognized that Resident #51 required one-on-one supervision while smoking, which was not being provided, leading to the deficiency in ensuring a safe environment for the resident.
Failure in Foley Catheter Management and Follow-Up Care
Penalty
Summary
The facility failed to provide appropriate care and management for a resident with an indwelling Foley catheter, which was not assessed for removal after the resident returned from a hospital stay. The resident, who had moderate cognitive impairment and a history of epilepsy, was hospitalized for seizures and returned with a Foley catheter due to acute urinary retention and urethral trauma. Despite discharge recommendations for a urology follow-up and a voiding trial, the facility did not document any attempts or discussions regarding these recommendations. The facility's records did not show a scheduled urology appointment, and the resident missed an appointment due to it not being logged or transportation arranged. Nursing staff were unaware of the appointment status, and the Director of Nurses acknowledged the oversight, indicating a need for process improvement. The resident experienced issues with the catheter, including leakage and discomfort, but there was no evidence of staff contacting the physician to discuss the voiding trial or follow-up care.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to adequately monitor the nutritional status of a resident who experienced an unplanned gradual weight loss of 9.68% over six months. The resident, who was admitted with diagnoses including anoxic brain damage, dysphagia, and dementia, was identified as nutritionally at risk. Despite a care plan goal to maintain a weight of 185 pounds plus or minus 5 pounds, the resident's weight decreased from 169.4 pounds to 153 pounds over the specified period. The facility's Weight Management policy required residents to be weighed at least monthly, with more frequent weights as necessary, but the resident's weekly weights were not consistently obtained as ordered by the physician on 3/5/24. Interviews and record reviews revealed that the resident was not included on the list of those needing weekly weights, and the Registered Dietitian (RD) had not completed a quarterly assessment since March 2024. The RD, who began covering the facility in June 2024, was unaware of the resident's insidious weight loss until the week of the survey. The RD acknowledged the lack of a quarterly assessment and the failure to ensure weekly weights were obtained, which contributed to the oversight in monitoring the resident's nutritional status. The physician's progress notes also failed to recognize the significant weight loss, despite the resident's good meal intake.
Unnecessary Prolonged Use of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically Azithromycin, which was administered without an adequate indication for use for an excessive duration of one year. The resident, who was admitted with chronic respiratory failure, COPD, and pneumonia, was discharged from the hospital with a 5-day course of antibiotics for pneumonia. However, the discharge summary did not recommend long-term prophylactic antibiotic treatment. Despite this, the resident continued to receive Azithromycin three times a week for COPD without a documented indication for its prolonged use. The medical records lacked documentation from the pulmonologist or primary care physician justifying the need for long-term antibiotic use. Interviews with facility staff, including a nurse and the Director of Nurses, revealed that there was no clear documentation or rationale for the continued use of Azithromycin. The Director of Nurses attempted to contact the pulmonologist for clarification but was unable to provide additional documentation by the conclusion of the survey.
Failure to Adhere to Therapeutic Diet for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered therapeutic diet was followed for a resident with significant medical conditions, including dysphagia, pneumonitis, and hemiplegia. The resident was assessed to be severely cognitively impaired and required a pureed diet with thin liquids for safe swallowing. Despite these orders, the surveyor observed the resident consuming crackers, which were not part of the prescribed diet. The resident's care plan indicated the need for tube feedings and pureed diet for pleasure foods, with supervision required during oral intake. Interviews with facility staff, including the Unit Manager, Director of Nursing, and Rehabilitation Director, revealed a lack of awareness and documentation regarding any exceptions to the resident's therapeutic diet. The Unit Manager acknowledged that staff would have had to assist the resident with the crackers, and the Rehabilitation Director confirmed that there was no documentation supporting the resident's ability to safely consume crackers unsupervised. The failure to adhere to the therapeutic diet was recognized as a risk for choking and aspiration, with no physician's order allowing for deviations from the prescribed diet.
Inadequate Infection Control During Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control measures for a resident, leading to potential cross-contamination. The deficiency was observed during a wound care procedure performed by a nurse on a resident with severe cognitive impairment and an unhealed pressure ulcer. The nurse did not follow the facility's hand hygiene policy, which requires hand hygiene before and after glove changes and after contact with potentially contaminated surfaces. During the wound care procedure, the nurse removed soiled dressings and changed gloves multiple times without performing hand hygiene. The nurse also handled incorrect ointment tubes, touched the treatment cart, and continued the procedure without changing gloves or performing hand hygiene. Additionally, the nurse applied ointments directly from the tubes onto the resident's wound, which is against infection control practices. Interviews with the nurse and the Director of Nursing (DON) and Infection Preventionist/Staff Development (IP/SDC) confirmed the failure to adhere to hand hygiene protocols. The nurse admitted to not performing hand hygiene with every glove change and acknowledged the improper application of ointments. The DON and IP/SDC emphasized that hand hygiene should be performed with every glove change and that ointments should be applied to a clean surface before being used on wounds.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Brockton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Joseph Manor Health Care Inc | 0.8 mi | ★★★★★ | 4 | 0 |
| Colony Center For Health And Rehabilitation | 2.2 mi | ★★★★★ | 1 | 0 |
| The Guardian Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Brockton Post Acute Care | 2.7 mi | ★★★★★ | 0 | 0 |
| Alliance Health At West Acres | 3.3 mi | ★★★★★ | 6 | 0 |
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