Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lanessa Extended Care during CMS and state inspections, most recent first.
Medication Given Outside BP Parameters and Neuro Checks Not Completed After Falls: A resident with HTN and dementia received Lisinopril even when BP readings were below the provider's hold parameters, and after two unwitnessed falls with head injuries, nursing did not document the required neurological checks. The MAR showed multiple administrations despite low BP readings, and the record contained no evidence that neuro monitoring was started after either fall, although the DON stated it should have been.
Failure to notify the provider and rehab staff of major changes in condition affected two residents. One resident with dementia, dysphagia, and severe cognitive impairment had significant unanticipated weight loss, but nursing did not promptly report the decline to the provider or RD. Another resident with left-hand contractures and severe cognitive impairment could not tolerate an ordered palm guard, yet nursing did not notify the provider or OT when the device could not be applied and therapy goals were not being met.
Failure to Provide Ordered Foot Care: A resident with dementia, right foot drop, and gait impairment had HCP consent for podiatry services, but staff did not arrange consultant podiatry care and the resident's toenails were observed to be markedly overgrown, thick, yellow, and curling toward the toes. The DON stated staff should have noticed the condition during skin checks, and the physician later trimmed the nails after noting they were long and ingrown.
Failure to apply an ordered palm guard for a resident with left-hand contractures led to worsening ROM limitation and pain. The resident had severe cognitive impairment, required max assist with ADLs, and was supposed to wear a left-hand orthotic at A.M. care and have it removed at P.M. care. Staff reported the device was difficult to apply, that the resident became agitated, and that it had not been used for about two weeks; the OT stated the hand contracture had worsened and the resident now expressed pain when the palm guard was attempted.
Failure to Address Significant Weight Loss and Malnutrition: A resident with dementia and dysphagia had a severe, unaddressed weight loss with delayed nutrition interventions. The RD identified significant weight loss and variable PO intake, but weekly weights were not started and supplements such as Ensure and Prosource were not implemented until later. The resident was ultimately documented with PCM after losing 30 lbs. over a short period.
Improper dish machine temperatures and food labeling/storage practices were observed in the kitchen. The dish machine wash cycle was running below the required temp, with readings as low as 130 to 132 degrees F, and the FSD said the lower wash temp was acceptable even though he acknowledged dishes may not be as clean as they should be. Surveyors also found multiple unlabeled and undated refrigerated foods, dated items beyond the expected storage period, and expired or undated dry goods on the bread shelf and in dry storage.
Failure to obtain valid HCP signature on MOLST: A resident with dementia and severe cognitive impairment was permanently incapacitated, had an invoked HCP, and had DNR/DNI orders on a MOLST that was not signed or dated by the HCP. Staff stated the MOLST was not valid without the HCP signature, and there was no evidence the resident’s life-sustaining treatment wishes were reviewed with the HCP after admission.
Failure to timely investigate and resolve grievances for two residents involving missing money and missing clothing. One cognitively intact resident with HF, HTN, and dysphagia reported missing money, but the grievance was left unreviewed in the SW’s paperwork. Another cognitively intact resident with dementia-related diagnoses reported missing clothing, but the SW marked the grievance complete without fully investigating the complaint or confirming the facts.
A medication storage room had opened kits with missing documentation and no evidence of pharmacy reorder, while the unit refrigerator repeatedly ran above the required 36 to 46 degrees F range and contained refrigerated meds including insulin and other biologics. The room door was also found slightly ajar on multiple observations, allowing access beyond nursing staff. The DON and ADON stated the meds in the refrigerator needed to be discarded and reordered, and staff said the room should always be locked.
Food was not served in an appetizing or easy-to-chew manner on one unit and in the main dining room. Test trays showed boneless chicken breast that was discolored, rubbery, hard to cut, and difficult to chew, and banana slices in fruit cocktail that did not taste like banana and were stringy. Residents also reported cold meals, small portions, and poor food quality, and the MDS nurse confirmed the chicken was hard to cut and chew.
Meals were not consistently served as ordered for several cognitively intact residents. Residents reported not receiving requested items, and one resident was observed receiving pork instead of chicken at lunch; the tray was later replaced, but the soup requested was still missing. Resident council and food committee notes also reflected ongoing kitchen staffing and meal service problems.
A resident with a history of ESBL in urine was on EBP, but a CNA provided incontinent care, changed and dressed the resident, and handled used linen without wearing a gown. The CNA and an RN initially said the resident was not on precautions and removed the EBP sign, while another RN and the IP nurse confirmed the resident required EBP and that gown use was needed for high-contact care.
Failure to Administer Consented Pneumococcal Vaccine: A resident with COPD, DM, lung cancer, and dementia was eligible for a pneumococcal conjugate vaccine and the health care proxy consented after receiving the VIS, but the immunization record showed no evidence the vaccine was administered. The IP reported no record of a pneumococcal vaccine, and the DON stated the vaccine was not ordered until after the surveyor asked about the resident’s vaccination status.
Failure to Timely Offer and Administer Updated COVID-19 Vaccine: The facility did not timely offer and administer the updated COVID-19 vaccine to a resident with COPD, diabetes, cancer, and dementia after consent was obtained for COVID-19 immunization. The record lacked evidence that the 2025/2026 vaccine was offered, administered, or refused, and the IP was unsure whether the updated vaccine had been given before the surveyor’s inquiry.
Daily Nurse Staffing Posting Missing Required Information. The facility posted nurse staffing information on a wipe off board at the reception area, but the posting did not include the total hours worked per shift by RN, LPN/LVN, and CNA staff directly responsible for resident care. The Scheduler said the Receptionist updated the board daily from information provided the day before, but the facility did not maintain the daily staffing records for 18 months as required. The Administrator stated she was unaware of the full posting requirement and confirmed the records had not been retained for the required period.
A resident with vascular dementia, generalized anxiety disorder, moderate cognitive impairment (BIMS 9), and documented wandering and exit‑seeking behaviors, who lived on a secured unit with alarmed exits and was assessed as at risk for elopement, exited the unit through an alarmed exterior door during the night shift. Staff heard an alarm but initially assumed it was triggered by a nurse leaving through an interior lobby door, and one CNA did not hear it at first due to a loud TV near his documentation area. After realizing the alarm was from the exterior door, staff searched the unit, found the resident missing, activated the missing resident protocol, and contacted 911. The resident was found by police at the end of the block, evaluated in the ED with no hypothermia, and returned. The DON later stated that the secured unit is for exit‑seeking residents, that staff had mistaken the alarm source, and that the exterior door alarm was not loud enough and shared the same sound as the lobby door alarm.
A resident with multiple health conditions developed a stage 3 pressure injury on the wrist after being admitted with a right arm immobilizer. Although wound treatment orders were obtained, nursing staff did not create or update a care plan with interventions, goals, or outcomes to address the new wound, as required by facility policy. Interviews confirmed that the care plan was not amended following the change in condition.
A resident with multiple comorbidities and a recent right humerus fracture experienced significant delays in follow-up care due to the facility's failure to arrange appropriate wheelchair-accessible transportation. Multiple scheduled appointments with an orthopedic surgeon were missed or canceled because transportation requests did not specify the need for a wheelchair van, resulting in the resident not being evaluated for over a month after hospital discharge.
The facility failed to maintain accurate records of controlled substance medications on the Elmwood and Windsor Units. Controlled substances were removed from medication carts and stored in the DON's office without proper documentation of destruction. The DON and CNS confirmed that medications had not been destroyed for six months, and there was no disposal record in place. Observations revealed five large bags containing 80 different controlled substances, including opioids and antianxiety medications, stored in the DON's office.
The facility failed to maintain an effective pest control program, resulting in the presence of pests in the Windsor Unit and Main Dining Room. The facility's agreement required 12 pest control services per year, but only 11 were provided in 2024. Observations revealed small, winged insects in various areas, including a resident's room and the Main Kitchen. Despite identifying fruit flies in November, no follow-up actions were taken, and no pest control services were obtained after October.
The facility failed to accurately complete MDS assessments for several residents, leading to deficiencies in documenting their care. A resident was not coded for hospice services, while others were not accurately coded for receiving various medications, including opioids, psychotropics, and antidepressants. These inaccuracies were acknowledged by the MDS nurses, highlighting the need for accurate coding to ensure proper care planning.
A resident with gout experienced increased pain due to a transcription error that resulted in receiving Allopurinol once daily instead of the prescribed twice daily. The error occurred because the new order was not accurately transcribed to the January MAR, and the double-check system failed.
The facility failed to provide pureed chicken to residents with a physician's order for a pureed diet. Observations revealed that the chicken served was ground instead of pureed, which is unsuitable for residents with dysphagia. Staff interviews confirmed the oversight, as the chicken's consistency was not checked before serving. This affected residents requiring pureed textured foods, indicating a lapse in following dietary guidelines.
The facility failed to maintain sanitary conditions and proper food safety practices in the kitchen and dining areas. A container of Thick-It was found contaminated, and meat lasagna was served at unsafe temperatures. Additionally, the kitchen and dining areas were unsanitary, with unclean equipment and improper temperature maintenance in refrigerators, posing foodborne illness risks.
A facility failed to obtain informed consent from a resident's Health Care Proxy before administering Ativan, a psychotropic medication, for anxiety. Despite the facility's policy requiring consent, the medication was given without it, as confirmed by staff interviews. The resident had diagnoses including Idiopathic Gout, Chronic Kidney Disease Stage 3B, and Major Depressive Disorder.
A facility failed to assess a resident for the appropriateness of self-administering Benadryl cream, as required by their policy. Despite the resident being cognitively intact, no evaluation was conducted before the medication was left at the bedside. The oversight was confirmed by staff interviews, highlighting a lapse in following the facility's procedures for self-medication assessments.
The facility failed to address and document responses to Resident Council grievances about insufficient staffing on the 11:00 P.M. to 7:00 A.M. shift. Despite concerns being raised in meetings, there was no evidence of a formal response or rationale provided by the administration. Staffing records confirmed shortages, affecting resident care, with delays in assistance reported.
The facility failed to accurately execute Advance Directives for two residents, leading to deficiencies in the handling of MOLST forms. One resident's MOLST form was signed by the HCP before the resident was deemed incapacitated, and another resident's MOLST form lacked validation of the HCP's authority. These oversights were identified during a surveyor's review.
The facility failed to properly issue the Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for three residents. The NOMNCs lacked provider contact information and were not delivered in the required timeframe. Additionally, the SNF ABN forms were not signed by the responsible parties, indicating a failure to confirm receipt and understanding of the notices.
A resident's wheelchair was found visibly soiled on multiple occasions, with staff acknowledging the lack of cleaning due to staff illness and absence of a specific cleaning policy. The resident, who was severely cognitively impaired and dependent on the wheelchair, did not receive the necessary maintenance to ensure a clean and homelike environment.
The facility failed to schedule a urology appointment for a resident with a kidney stone and did not implement a pulmonary consultation for another resident with COPD symptoms. Additionally, the facility did not follow physician orders for weight monitoring for the latter resident, leading to non-compliance with the care plan.
A resident with nicotine dependence and dementia was left unsupervised during smoking activities, despite requiring routine supervision for safety. The facility's policy required staff supervision during smoking, but observations showed the resident was left alone on multiple occasions, contrary to the facility's expectations.
A facility failed to reassess and update the care plan for a resident with an indwelling urinary catheter upon re-admission from the hospital. The resident, with severe cognitive impairment and multiple diagnoses, returned with a size 24 Fr catheter, but the physician's order indicated a size 16 Fr. No re-admission or catheter assessment was completed, leading to a deficiency in care.
The facility failed to maintain sufficient nursing staff on the Elmwood unit during the night shift, leading to unmet resident needs. Despite the facility's assessment indicating a need for 3.58 hours of direct care per patient per day, staffing levels were inadequate, particularly for residents with advanced cognitive loss. Residents reported delays in receiving assistance, and staff confirmed frequent no-call/no-shows and difficulties in finding replacements, resulting in only one CNA being available on certain shifts.
The facility failed to ensure that a CNA demonstrated the necessary competencies for resident care, as CNA #3 did not complete the required annual competency evaluation for 2024. The Facility Assessment Tool outlined the need for in-service training, but the CNA's record lacked evidence of a completed evaluation. The Administrator could not provide documentation or a policy on CNA competency evaluations.
Two residents with depression and anxiety diagnoses did not receive necessary follow-up behavioral health services as recommended by healthcare providers. Despite being cognitively intact and exhibiting symptoms such as verbal outbursts and rejection of care, the facility failed to ensure timely psychiatric consultations, leading to deficiencies in their mental and psychosocial well-being.
A facility failed to obtain proper consent for psychotropic medications for a resident with cognitive impairment and multiple diagnoses, including PTSD and bipolar disorder. The consent for Trazodone and Buspirone was signed by another resident's HCP, not the appropriate one, contrary to facility policy. This was confirmed during interviews with staff.
A resident at risk for weight loss experienced significant weight fluctuations due to incomplete meal intake documentation by CNAs. Despite the facility's policy requiring accurate documentation, many meal entries were left blank over several months. Interviews confirmed that CNAs were expected to document meal intakes, but this was not consistently done, leading to a lack of accurate records to support care decisions.
The facility failed to maintain infection control practices for three residents, leading to potential contamination and infection risks. A resident's urinary drainage bags were improperly managed, another resident was not assisted with hand hygiene before eating, and Enhanced Barrier Precautions were not followed during a bolus feeding procedure. These deficiencies were observed and confirmed through staff interviews.
The facility did not post complete daily nursing staff data, omitting the total number and actual hours worked by RNs, LPNs, and CNAs, as well as the resident census. The Receptionist and Scheduler were unaware of the requirement to include this information.
A resident with ESRD and Dementia was admitted to hospice, necessitating a Significant Change in Status Assessment (SCSA). The facility failed to complete the SCSA within the required 14-day period, finalizing it 20 days after the significant change was determined. The MDS Nurse confirmed the delay, highlighting the need for timely assessments to meet resident needs.
The facility failed to protect two residents from involuntary seclusion when a CNA tied their room door shut with a plastic bag to prevent one resident from wandering. The incident occurred during a short-staffed evening shift, leaving the residents confined to their room for approximately two hours. The facility's investigation confirmed the CNA's actions and the violation of the facility's policy on abuse, neglect, and exploitation.
The facility failed to ensure staff followed their Abuse Policy by not immediately reporting an incident where a bedroom door was tied shut, involuntarily confining two residents. The incident was discovered two days later by the DON, placing other residents at risk for abuse.
The Facility failed to report an allegation of involuntary seclusion to the DPH within the required two-hour timeframe. The incident, where a door was tied shut to keep a resident safe, was discovered on 01/15/24 but not reported until more than ten hours later. The Facility's policy mandates that any incident involving abuse must be reported within two hours.
A resident with dementia and known exit-seeking behaviors eloped from the Facility without staff knowledge. The resident was found by police four miles away and was transported to the hospital for cold exposure. Staff failed to provide adequate supervision and did not follow the Facility's elopement policy.
The facility failed to provide sufficient nursing staff, resulting in a resident wandering off a locked unit and another resident being involuntarily secluded. The incidents occurred due to understaffing, with only two CNAs and one nurse available to care for 40 residents, leading to inadequate supervision and safety measures.
Medication Given Outside BP Parameters and Neurological Monitoring Not Completed After Falls
Penalty
Summary
The facility failed to follow professional standards of practice when nursing staff administered Lisinopril to a resident despite blood pressure readings that were below the physician-ordered hold parameters. Resident #1 had diagnoses including hypertension and dementia with agitation, and the MAR showed an order for Lisinopril 10 mg daily with instructions to hold the medication for systolic blood pressure less than 110 and diastolic blood pressure less than 70. The MAR documented administration of the medication on multiple dates when the resident's blood pressure readings were 104/62, 101/62, 108/64, 104/65, 106/62, and 105/65. During interview, Nurse #1 stated she administered the medication on those dates and did not know how it happened that she gave it when it should have been held, and the DON stated nursing should not have administered it outside the ordered parameters. The facility also failed to monitor the resident for neurological changes after two unwitnessed falls with head injuries. On the morning of 05/16/26, the resident had an unwitnessed fall and was found on the bathroom floor with a bruise and swelling on the back of the head, and later that day had another unwitnessed fall in the room with bleeding from the back of the head. The resident was transferred to the hospital after each fall, and hospital summaries showed no intracranial bleeding or fractures. The facility record contained no documentation that neurological checks were initiated or completed after either fall, despite the facility policy requiring neurological monitoring after any head injury or suspected head injury. Nurse #1 stated neurological checks should have been initiated, and the DON stated they were to be initiated following every unwitnessed fall or fall with a head injury.
Failure to Notify Provider of Significant Weight Loss and Inability to Tolerate Ordered Splint
Penalty
Summary
The facility failed to notify the provider when a resident experienced an unanticipated and significant weight loss. The resident was admitted with diagnoses including vascular dementia with agitation and mood disturbance, a history of TIA and cerebral infarction without residual deficits, and dysphagia. The resident was severely cognitively impaired, required setup assistance for eating, and had no weight loss or gain on the MDS dated 4/24/26. Facility weight records showed a decline from 181.6 lbs. on 2/1/26 to 161.4 lbs. on 3/1/26, then to 151.6 lbs. on 4/15/26, reflecting a 30 lb. loss over 73 days. The March 2026 progress notes did not show that the provider had been notified of the 20.2 lb. weight loss identified on 3/1/26. The RD documented the significant weight loss after reviewing the weekly weight report in the EMR and noted the resident had significant weight loss in 30 days and 180 days. During interview, the RD stated she was unsure whether the provider had been notified and said nursing was responsible for contacting the provider. The UM stated it was the nurse’s responsibility to enter weights into the EMR and notify the provider and RD of any weight loss or gain, and that the provider and RD should have been notified right away when the loss was identified. The DON stated the weight loss was not reported to the provider until 4/17/26, although it should have been reported on 3/1/26. The physician stated that if he or the NP had been updated, they would have documented the change and re-evaluated food intake, supplements, and medical status. The facility also failed to notify the provider and OT when a resident could not tolerate a left-hand palm guard ordered for contracture management. The resident was admitted with adult failure to thrive, altered mental status, and left-hand contractures, and was severely cognitively impaired with maximum assistance needed for ADLs. OT had established a goal for the resident to tolerate a left-hand orthotic for 8 hours without redness, irritation, or discomfort. Nursing documentation and observations showed the palm guard was ordered to be applied in the morning and removed at night as tolerated, with skin checks each shift, but staff repeatedly found the resident’s left hand closed in a fist and the splint not in use. Nurses reported difficulty applying the device, agitation when attempting to open the hand, and that they had switched to using a folded towel because it was better tolerated. Staff stated they had not alerted therapy or the physician, and the OT confirmed the therapy department had not been notified that the resident was unable to tolerate the splint application. The physician and NP both stated they had not been informed that the treatment could not be performed as ordered.
Failure to Provide Ordered Foot Care
Penalty
Summary
The facility failed to ensure that one resident received foot care and treatment in accordance with professional standards of practice. The resident was admitted with diagnoses including dementia, right foot drop, and abnormalities of gait and mobility, and the record showed that the resident's invoked HCP consented to podiatry services. The facility policy stated that consultant services would be identified and facilitated to meet resident needs, and that for podiatry the family would sign a release form and staff would call the consultant after permission was given. The resident's care plan included skin integrity monitoring and daily foot inspection, and physician orders included podiatry care as needed, weekly skin checks, and skin checks related to the right ankle-foot orthosis and brace use. On observation, the resident was seen walking with a brace on the right lower leg, and the right great toenail was about one inch beyond the tip of the toe, thick, yellowish, and the other right toenails were also long, thick, yellowish, and angled toward the great toe, with one curled under toward the toe. The left foot also had thick, yellowish toenails grown out approximately three-quarters of an inch to one inch from the tips of the toes, with one nail angled toward an adjacent toe. The Regional Clinical Specialist could not find evidence that the resident had ever been seen by the consultant podiatry provider since admission, and the podiatry provider had no record that the resident was enrolled for services. The DON stated that the toenails were overgrown and curling under, that nurses should have observed the condition during skin checks, and that the resident should have been enrolled in consultant podiatry services as consented by the HCP. The physician later trimmed the resident's toenails and stated that the nails had been long, grown out, and ingrown toward the resident's skin, and that staff should have noticed the need for toenail care and communicated with podiatry or with him.
Failure to Apply Ordered Palm Guard for Resident With Worsening Hand Contracture
Penalty
Summary
The facility failed to ensure that ordered services to maintain or improve range of motion were carried out for a resident with left-hand contractures. The resident was admitted with diagnoses including left-hand contractures, had severe cognitive impairment, impairment of ROM on one upper side, and required maximum assistance with ADLs. The care plan and OT plan of treatment included use of a left-hand palm guard/orthotic, with the goal of keeping the hand open enough to allow skin integrity, bathing, and nail care, and the order summary directed staff to apply the left palm guard at A.M. care and remove it at P.M. care, as tolerated, while checking skin integrity every shift. During observation, the resident was found sitting with the left hand closed in a fist and the palm guard not in place. Nursing staff stated the resident did not like the hand opened, that the palm guard was difficult to apply, and that two staff members were now required because the resident became agitated and aggressive. One nurse said she preferred to place a folded facecloth in the resident’s hand because it was better tolerated. Another nurse stated the palm guard had not been applied for about two weeks and that the resident showed increased pain when staff attempted to apply it. The OT/rehabilitation manager stated the resident’s left hand had been very tight on admission, but when the palm guard was first ordered staff could open the hand about one-half to three-quarters of an inch. The OT said the hand was now tighter, that the contracture had worsened, and that if staff had applied the palm guard as ordered during the prior weeks, the contracture would not have worsened. The OT also stated therapy had not been notified that the resident was unable to tolerate the palm guard, and nursing should have alerted therapy right away. When the OT reviewed the resident again, the palm guard no longer fit as it had in February and the resident expressed pain.
Failure to Address Significant Weight Loss and Malnutrition
Penalty
Summary
The facility failed to adequately provide nutritional services for one resident who experienced a severe weight loss of 16.52% (30 pounds) between 2/1/26 and 4/15/26, resulting in protein calorie malnutrition. The resident was admitted in October 2025 with vascular dementia with agitation and mood disturbance, a history of TIA and stroke without residual deficits, and dysphagia. The MDS dated 4/24/26 showed the resident was severely cognitively impaired, required setup for eating, and had significant weight loss. The resident’s weights showed 181.6 lbs. on 2/1/26, 161.4 lbs. on 3/1/26, and 151.6 lbs. on 4/15/26. The RD documented significant weight loss on 3/6/26 and noted variable PO intake, but the record did not show new interventions for the weight loss at that time, and weekly weights were not ordered per facility policy. The RD also noted the resident refused a cup of Ensure offered during the assessment. The clinical record did not show timely implementation of interventions after the 3/1/26 weight loss was identified. Ensure Plus, Prosource, and an evening snack were not initiated until 4/17/26, and the weight loss care plan was also initiated on 4/17/26. The malnutrition care plan was initiated on 4/24/26 and documented protein calorie malnutrition related to inadequate calorie/protein intake. Interviews with the RD, UM, DON, and physician indicated the weight loss should have been reported earlier, weekly weights should have been started when the loss was identified, and supplements should have been attempted sooner, but these actions were not implemented until later.
Improper Dish Machine Temperatures and Food Labeling/Storage
Penalty
Summary
The facility failed to maintain proper sanitation, food handling, and food storage practices in the main kitchen. During observation of the dish machine in operation, the wash temperatures fluctuated and did not rise above 150 degrees F, with temperatures observed at 130 to 132 degrees F. A Dietary Aide said she could not get the machine temperature above 140 degrees F and would finish washing dishes and notify the Administrator when this occurred. The Food Service Director stated that washing and rinsing dishes at 132 degrees F was acceptable because the rinse cycle was not affected, although he acknowledged that dishes washed below 150 degrees F may not be as clean as they should be. The Administrator stated the plates should not be used to serve resident meals because the dish machine did not reach the manufacturer recommended temperature and said residents needed disposable plates until the machine was repaired or the plates were re-washed by hand. During a kitchen walkthrough, multiple food items in the refrigerator were observed without labels or dates, including sliced ham, two seafood sandwiches, tortilla wraps, lettuce, and a container of scrambled eggs. A container of hard-boiled eggs was dated 4/28/26, and a cooked ham in the walk-in refrigerator was dated 4/30/26. On the bread shelf, several tortilla packages were found with use-by dates of 12/30/25, 2/1/26, and 4/13/26, along with three undated packages of rolls. In dry storage, an open bag of green split peas and an open bag of pasta were both undated. The Regional Food Service Director said he was unsure how long the undated refrigerated items had been stored and stated that all food items in the refrigerator should be dated when placed there and discarded within three days if not used.
Failure to Obtain Valid HCP Signature on MOLST
Penalty
Summary
The facility failed to afford Resident #5 the opportunity to formulate an advance directive relative to orders for life sustaining treatment. Resident #5 was admitted with diagnoses including atrial fibrillation and dementia, had a BIMS score of 0, and was determined permanently incapacitated prior to admission. The resident’s HCP was invoked, and the clinical record showed advance directives of DNR and DNI, but the MOLST form was not signed or dated by the invoked HCP; instead, the representative signature line reflected verbal consent via telephone. The facility’s records showed that advance directives were reviewed at IDT care plan meetings, but there was no evidence that Resident #5’s wishes regarding life sustaining treatment were reviewed with the HCP between admission and the survey period. During interview, nursing staff stated the MOLST was not valid without the HCP signature and that, without a valid MOLST, the resident would be treated as full code in the event of cardiac or respiratory arrest. The DON later stated she spoke with the HCP, who said DNR and DNI had been elected, and the RCS stated the facility should have provided the HCP with information relative to MOLST and obtained the required signature.
Failure to Timely Investigate and Resolve Resident Grievances
Penalty
Summary
The facility failed to resolve grievances timely for two residents regarding missing personal property. The facility’s grievance policy required prompt efforts to resolve grievances, immediate notification of the grievance officer, initiation of an investigation, completion of review within seven days when possible, and documentation of the findings and any corrective action. For one resident, who was admitted in February 2025 and had diagnoses including heart failure, hypertension, and dysphagia, the resident was cognitively intact with a BIMS score of 13/15 and reported missing money to nursing staff. A nurse documented the concern and said she filed a grievance on the resident’s behalf, but the grievance was later found in a pile of paperwork on the social worker’s desk and had not been reviewed, investigated, or communicated back to the resident. For the second resident, who was admitted in March 2026 and had diagnoses including dementia with mild behavioral disturbance and psychoactive substance dependence, the resident was also cognitively intact with a BIMS score of 14/15 and reported missing clothing that had been sent to laundry. The grievance binder showed the resident’s complaint that the facility had repeatedly failed to return the clothing, and the social worker signed off that the grievance was complete after reviewing the admission clothing inventory sheet. However, the social worker stated she did not actually investigate when the resident received the clothing, who brought it in, or follow through with resolution before marking it complete. The administrator confirmed there was no evidence the grievance had been investigated before it was resolved.
Medication Storage Room Not Secured and Refrigerator Out of Range
Penalty
Summary
The facility failed to ensure medications and biologicals were stored securely and in accordance with accepted storage requirements in the Windsor Unit medication storage room. Surveyors observed an IV kit opened with no paper documentation showing what was removed or for which resident, an emergency Super Kit lying on the floor with no documentation of the resident, date, or nurse associated with removed medication, and no evidence that the kit had been reordered from the pharmacy. An antibiotic had also been opened with no evidence that the kit had been reordered from the pharmacy. The Windsor Unit medication room refrigerator was repeatedly documented outside the required 36 to 46 degrees Fahrenheit range. The temperature log showed multiple out-of-range readings in February, March, April, and early May 2026, including readings as high as 51 degrees. When the surveyor and UM #1 checked the refrigerator, the gauge read 50 degrees and the refrigerator felt warm. Medications observed inside included Acidophilus, Omeprazole liquid, unopened Humalog, Trulicity pens, Tresiba, Lantus, Mounjaro, Insulin Lispro, and Xalatan. UM #1 and the ADON stated the refrigerator appeared to have been broken for a while and that the medications needed to be discarded and reordered because they were not good to be administered to residents. The medication storage room on the Windsor Unit was also observed unsecured on multiple occasions. The door was slightly ajar and able to be opened by the surveyor, with residents ambulating in the hallway nearby. Staff stated the room should always be locked and only accessible to nurses on the unit, and the DON stated that if the door was not completely closed, anyone including unauthorized staff, residents, or visitors could enter the room. The DON also stated she was not aware the door was not completely closing all the way.
Food Not Served in an Appetizing or Easy-to-Chew Manner
Penalty
Summary
The facility failed to serve food that was palatable, attractive, and appetizing on the Elmwood Unit and in the Main Dining Room. During lunch meal test tray observations, the boneless chicken breast on the Elmwood Unit was discolored on one side with grey and pink patches, was difficult to cut and chew, and had a rubbery texture. The fruit cocktail on the same tray contained banana slices that did not taste like bananas, were stringy, and tasted like fruit cocktail syrup. In the Main Dining Room, the boneless chicken breast on the test tray was difficult to cut and hard to chew, and the MDS Nurse who tasted it said the chicken was hard to cut and chew. Resident and committee feedback documented ongoing concerns about food quality before the observations. Food Committee minutes noted residents said food was served cold, especially on weekends and nights, and portions were too small. During a screening interview, one resident said the food was "[expletive]." At the Resident Council Meeting, residents reported not receiving requested food items, described meatloaf as like a hockey puck, said the food was not good, and stated that most meals were cold and not edible. The Administrator stated she had been made aware of resident complaints about food and said food served to residents should look appetizing and should not be difficult to cut and chew.
Meals Not Served as Ordered
Penalty
Summary
The facility failed to ensure that meals provided matched resident allergies, intolerances, and food preferences for three cognitively intact residents. The facility policy stated residents would receive nourishing, attractive meals that met individual nutritional and special needs and supported a positive dining experience. Resident council and food committee minutes documented ongoing kitchen staffing shortages and multiple kitchen issues. The Minimum Data Set assessments showed that Residents #49, #57, and #70 were cognitively intact, with BIMS scores of 15/15, 13/15, and 14/15, respectively. Resident interviews and meal observations showed repeated problems with ordered meals not being served as requested. Resident #70 stated the food was not edible and said he/she would eat whatever was brought because he/she did not want to wait. Resident #49 said he/she often did not receive requested meals, especially at dinner. During a resident council meeting, multiple residents reported not receiving what they ordered. Resident #57 stated kitchen staff did not read the ticket and that he/she rarely received requested food; during lunch observation, pork was on the tray even though chicken had been requested, and the resident was upset. Later, the resident said the tray was replaced with chicken but the soup requested was missing. The Food Service Director stated chicken was the main meal, pork was the alternate, and Resident #57 was not on the alternate meal list, so the resident should have received chicken initially.
Failure to Use EBP PPE for Resident with ESBL History
Penalty
Summary
The facility failed to follow infection control standards of practice to prevent contamination and the spread of infections for one resident on Enhanced Barrier Precautions (EBP). Resident #61 had diagnoses including ESBL in urine, basal cell carcinoma, adult failure to thrive, and dementia, and physician orders indicated EBP related to a history of ESBL starting 10/27/25. CDC guidance and the facility’s EBP policy both described that gowns and gloves are required during high-contact care activities for residents on EBP, including bathing, hygiene, dressing, transferring, linen changes, toileting, device care, and wound care. During observation, CNA #1 provided incontinent care, changed and dressed the resident, and handled used linen without wearing a gown, despite EBP signage posted at the resident’s door stating staff must wear gloves and a gown for high-contact care activities. The resident’s door was open and the curtain was partially pulled. CNA #1 later told the surveyor the resident was not on precautions and removed the EBP sign from the door. Nurse #1 also stated the resident was not on precautions and said the sign was not supposed to be posted, while Nurse #2 stated the resident had a history of ESBL in the urine and required EBP. The Infection Prevention Nurse confirmed the resident was on EBP for ESBL in the urine and stated CNA #1 should have worn a gown and should not have removed the sign.
Failure to Administer Consented Pneumococcal Vaccine
Penalty
Summary
The facility failed to administer the pneumococcal immunization to one resident who was eligible to receive it and had consented to the vaccine. The facility’s policy stated that all eligible residents would be offered the pneumococcal vaccine unless medically contraindicated, and that adults 50 years and older who had not previously received a pneumococcal conjugate vaccine or whose vaccination history was unknown should receive PCV15, PCV20, or PCV21. Resident #11 was admitted with diagnoses including COPD, diabetes, malignant neoplasm of the right bronchus or lung, and dementia, and was 50 years of age or older. The admission vaccination education form, signed by the resident’s health care proxy, indicated that PCV20 or PCV21 was recommended, that the VIS had been provided, and that the resident/representative agreed to receive the pneumococcal conjugate vaccine. However, the immunization record did not show that the vaccine had been administered, and the resident immunization log indicated the resident was not up to date. The IP stated there was no record of the resident ever having a pneumococcal vaccine and was unsure whether it had been given, while the DON stated the vaccine should have been ordered when consent was obtained and that it was not ordered until after the surveyor’s inquiry.
Failure to Timely Offer and Administer Updated COVID-19 Vaccine
Penalty
Summary
The facility failed to offer and administer the 2025/2026 COVID-19 vaccine to one resident in a timely manner after the resident became eligible to receive it. The resident was admitted in March 2026 with diagnoses including COPD, diabetes, malignant neoplasm of the right bronchus or lung, and dementia, and was between the ages of 12 and 64. The resident’s record showed the most recent COVID-19 vaccine had been given on 4/12/21, and the resident’s representative agreed to receive the 2024/2025 COVID-19 vaccine on 3/25/26. Record review did not show evidence that the facility offered the 2025/2026 COVID-19 vaccine to the resident or the representative, or that the resident received or did not receive the vaccine due to medical contraindication or refusal. The facility’s immunization log listed the resident’s most recent COVID-19 vaccine as 4/21/21. During interviews, the IP said he was unsure whether the updated vaccine had been administered after consent was obtained, and the DON said the facility offers updated COVID-19 vaccines when residents are admitted and that the 2025/2026 vaccine was not offered and administered to the resident until after the surveyor asked about the resident’s vaccination status.
Daily Nurse Staffing Posting Missing Required Information
Penalty
Summary
The facility failed to ensure the daily required nurse staffing information was posted as required. On 5/5/26 at 7:18 A.M., the surveyor observed that the nurse staffing information was handwritten with an erasable marker on a wipe off board at the entrance of the reception area, but it did not include the total hours worked by staff directly responsible for resident care per shift, including RN, LPN/LVN, and CNA hours. During an interview on 5/5/26 at 9:26 A.M., the Scheduler said she left the information for the Receptionist the day before and the Receptionist wrote it on the board daily, and she did not have a record of the daily staff posting for 18 months as required. During an interview on 5/5/26 at 10:28 A.M., the Receptionist said she was responsible for updating the daily staff posting using the information provided by the Scheduler. During an interview on 5/6/26 at 7:51 A.M., the Administrator said she was unaware that the total number of hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift needed to be on the posting, and said the facility had not maintained the posted daily staffing for 18 months as required.
Elopement of High-Risk Resident Due to Inadequate Response to Door Alarm
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and maintain a safe, hazard‑free environment for a resident with known elopement risk, resulting in an elopement from a secured unit. The resident, who had vascular dementia, generalized anxiety disorder, and was moderately cognitively impaired with a BIMS score of 9, had documented behaviors of wandering, exit seeking, and occasional resistance to care. The resident resided on a secured unit with alarms on all exit doors and had been assessed as at risk for elopement and wandering on formal Elopement and Wandering Risk Assessments, as well as on the MDS, which documented wandering behavior on four to six days during the seven‑day look‑back period. The facility’s own elopement policy defined elopement as a resident who is not capable of protecting themselves from harm leaving the facility unsupervised and unnoticed. On the night of the incident, during the 11:00 P.M. to 7:00 A.M. shift, the resident exited the secured unit through an alarmed exterior door at approximately 2:10 A.M. Staff on duty, including a nurse and two CNAs, heard an alarm but initially assumed it was triggered by the nurse leaving the unit through the interior door to the lobby to obtain supplies, rather than the exterior exit door. One CNA reported that he did not initially hear the alarm because a loud television was on near where he was documenting, and only heard it once he moved closer to the nurses’ station. The other CNA stated she heard an alarm around that time and believed it was the lobby door alarm associated with the nurse’s departure, and only upon leaving a resident room did she realize the alarm was coming from the exterior exit door. After staff recognized that the alarm was from the exterior door, they conducted a search of the unit and discovered the resident was missing. A facility‑wide missing resident protocol (Dr. Hunt) was initiated, 911 was called, and staff searched outside and in the parking lot. The resident was ultimately located off facility premises at the end of the block by police, with a staff member present. The resident was transported to the hospital ED, where evaluation determined there were no signs of hypothermia, and the resident was later returned to the facility. The DON stated that the secured unit is intended for residents with exit‑seeking behaviors and acknowledged that staff had mistaken the alarm for the lobby door alarm and that the exterior door alarm was not loud enough to be heard throughout the unit, while both doors shared the same alarm sound.
Failure to Develop and Implement Care Plan for Pressure Injury
Penalty
Summary
Nursing staff failed to develop and implement a comprehensive, person-centered care plan to address a new pressure injury for a resident with multiple medical conditions, including dementia, chronic kidney disease, anemia, and a recent right humerus fracture. The resident was admitted with a right arm immobilizer following a fall and subsequently developed a stage 3 pressure injury on the right wrist, as documented in the medical record and confirmed by an orthopedic consult. Although treatment orders for the pressure injury were obtained, there was no evidence in the medical record that a care plan with specific interventions, treatment goals, and outcomes was created or implemented to address the wound care needs. Facility policy requires individualized care plans based on comprehensive assessments and mandates updates to care plans following significant changes in a resident's condition. Despite these requirements, interviews with facility staff, including the Unit Manager and DON, confirmed that the care plan was not updated to reflect the new pressure injury. The lack of documentation and failure to amend the care plan after the development of the pressure injury constituted a deficiency in meeting the resident's wound care needs.
Failure to Arrange Timely Transportation for Post-Fracture Follow-Up
Penalty
Summary
A resident with dementia, chronic kidney disease, anemia, and a recent right distal humerus fracture was admitted to the facility and required a follow-up appointment with an orthopedic surgeon one week after discharge from the hospital. The hospital discharge summary specified the need for this timely follow-up to evaluate the resident's candidacy for open reduction surgery. However, the facility failed to ensure the resident was transported to the scheduled appointments due to repeated transportation issues, including the transportation company sending an inappropriate vehicle and late arrivals, resulting in multiple cancellations. Review of transportation request forms revealed that the facility did not specify the need for a wheelchair van, which contributed to the transportation problems. As a result, the resident experienced a delay of over a month before being evaluated by the orthopedic surgeon, contrary to the discharge instructions and medical needs. Interviews with facility staff confirmed ongoing transportation issues and acknowledged that the resident was not provided with the necessary services to attend critical follow-up appointments.
Failure to Maintain Accurate Records of Controlled Substance Medications
Penalty
Summary
The facility failed to maintain accurate records of controlled substance medications management and reconciliation for four locked medication carts on the Elmwood and Windsor Units. The facility's policy requires that controlled substances be handled, stored, disposed of, and recorded in accordance with federal and state laws. However, the surveyor found discrepancies in the documentation of controlled substances that had been removed from the medication carts and stored in the Director of Nursing's (DON) office awaiting destruction. The records did not indicate that these medications had been destroyed, despite being signed out by staff members. During observations, the surveyor noted that narcotic medications had been removed from the controlled substance medication books on both units, with no documentation of their destruction. The DON confirmed that the medications had been removed for destruction and were kept under double lock and key in her office, but she was unsure of how long they had been there. The Clinical Nurse Specialist (CNS) also acknowledged that the medications had not been destroyed for six months, and there was no record of the medications that had been removed from the nurses' medication carts. Further investigation revealed that five large bags containing a total of 80 different controlled substance medications were stored in the DON's office. These included various opioid pain medications, antianxiety medications, and sedatives for multiple residents. The CNS admitted that the facility did not have a controlled substance medication disposal record in place, which should have included details such as the dates of removal, the amount of medication removed per resident, the resident's name, and the type of medication removed.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of pests in the Windsor Unit and the Main Dining Room. The facility's Pest Control Services Agreement required inspection and treatment for pests at least 12 times per year, but only 11 services were provided in 2024. Additionally, the facility did not obtain pest control services when staff and residents identified fruit flies in the Main Dining Room and Windsor Unit. The last pest control service was conducted on 10/29/24, specifically for fruit fly prevention in the kitchen and dishwasher areas. Observations by surveyors revealed the presence of small, winged insects in various areas, including Resident #25's room and the Main Kitchen. Interviews with the Food Service Director and Cook indicated a previous issue with fruit flies, but no current problems were noted by the staff. However, the Administrator acknowledged observing fruit flies in November 2024 and recorded these observations in the Pest Control Log. Despite this, no follow-up actions were taken to address the sightings, and no pest control services were obtained after the last visit in October 2024.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to accurately complete Minimum Data Set (MDS) assessments for several residents, leading to deficiencies in the documentation of their care. Resident #82, who was admitted with dementia and end-stage renal disease, was not coded for receiving hospice services on their Significant Change in Status Assessment (SCSA), despite being admitted to hospice services prior to the assessment date. This oversight was acknowledged by MDS Nurse #1, who confirmed that the assessment should have reflected the hospice services provided. Resident #235, admitted with conditions including delirium and traumatic brain injury, was not accurately coded for receiving multiple medications, including anticoagulants, antidepressants, antipsychotics, and antianxiety medications, during the observation period for the MDS assessment. MDS Nurse #2 confirmed the inaccuracy, noting that the resident's medication administration records indicated the use of these medications, which should have been reflected in the assessment. Additional inaccuracies were found in the MDS assessments for Residents #38, #54, and #51. Resident #38 was not coded for receiving opioid medication, despite being administered Tramadol as prescribed. Resident #54's assessment failed to indicate the use of psychotropic medications, which were part of the resident's treatment plan. Similarly, Resident #51's assessment did not reflect the use of antidepressant medication, despite the resident being prescribed and administered Cymbalta. These errors were acknowledged by the respective MDS nurses, who noted the need for accurate coding to ensure proper care planning.
Medication Transcription Error Leads to Inadequate Gout Management
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when an order for Allopurinol, a medication used to prevent gout pain, was not accurately transcribed to a new monthly Medication Administration Record (MAR). The resident, who was admitted with diagnoses including Idiopathic Gout and Major Depressive Disorder, had a physician's order to increase Allopurinol to 100 mg twice a day due to increased gout pain. However, this order was not accurately transcribed to the January 2025 MAR, resulting in the resident receiving the medication only once a day. The error was identified during an interview with the resident, who reported experiencing gout pain. The Unit Manager acknowledged that the new order was posted on the December 2024 MAR but not on the January 2025 MAR due to a failure in the double-check system for editing. The Clinical Nurse Specialist confirmed that the error occurred because of a transcription mistake during the end-of-month editing process. The responsibility for double-checking the accuracy of the transcription was not fulfilled, leading to the medication error.
Failure to Provide Pureed Diet as Ordered
Penalty
Summary
The facility failed to provide pureed chicken to four residents who had a physician's order for a pureed texture diet. The deficiency was identified during a survey when it was observed that the chicken served at lunch was not of the required pureed consistency. Instead, the chicken was ground, which is not suitable for residents with moderate to severe dysphagia who require a smooth, pudding-like consistency to safely consume their meals. The facility's US Foods Diet Guide and job descriptions for dining services staff clearly outlined the need to follow therapeutic diet cards and prepare food according to specific dietary requirements, which was not adhered to in this instance. During interviews, the Dietary Aide and Food Service Director (FSD) acknowledged that the chicken was not prepared correctly and should have been checked before being served. The Cook admitted to not verifying the consistency of the pureed chicken before it was delivered to the residents. The Speech Therapist confirmed that the pureed food should have been of a moist, baby food-like consistency, which was not achieved. This oversight affected four residents who required pureed textured foods, highlighting a lapse in the facility's adherence to dietary guidelines and procedures.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and dining areas, leading to potential foodborne illness risks. During an inspection, a large container of Thick-It, a thickening agent used for residents with swallowing difficulties, was found uncovered and contaminated with cardboard debris. The Food Service Director (FSD) acknowledged the contamination but had not yet discarded the product, indicating a lapse in immediate corrective action. Additionally, the facility did not ensure that food was stored and served at safe temperatures. The meat lasagna served as the main entree for lunch was recorded at 134°F, below the required 135-140°F range. Despite this, the lasagna was served to residents, and the FSD admitted that the dietary aide should have returned it for reheating. This oversight posed a concern for food safety, as serving food at improper temperatures can lead to foodborne illnesses. The facility's kitchen and dining areas were also found to be in unsanitary conditions. Observations included crumbs and dried substances in the freezer and refrigerator, unclean movable carts, a broken ice machine vent with dust accumulation, and a walk-in refrigerator with standing liquid. The FSD admitted to the lack of a cleaning schedule or logs, which contributed to the unsanitary conditions. Furthermore, the dishwasher was not reaching the required temperature for sanitization, and the refrigerator in the Windsor Unit was not maintaining the correct temperature, leading to potential spoilage of stored food items.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain informed consent from the invoked Health Care Proxy (HCP) for the administration of psychotropic medication to a resident. The resident, who was admitted with diagnoses including Idiopathic Gout, Chronic Kidney Disease Stage 3B, and Major Depressive Disorder, was prescribed Ativan for anxiety or agitation. Despite the facility's policy requiring informed written consent from the resident's HCP before administering psychotropic medications, the consent was not obtained prior to administering Ativan on November 9, 2024. Interviews with facility staff, including a Unit Manager and the Director of Nursing, confirmed that the necessary consent was not present in the resident's medical record. The facility's policy mandates that informed consent should include details about the purpose, dosage, and potential effects of the medication, and should be documented in the resident's medical record. However, this procedure was not followed, resulting in the administration of Ativan without the required consent from the resident's HCP.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for the clinical appropriateness to self-administer medications, specifically Benadryl cream, which was ordered to be left at the resident's bedside. The facility's policy requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications, along with documentation of the assessment and communication with the resident or responsible party. However, no such evaluation was completed for the resident, despite the resident being cognitively intact as indicated by a perfect score on the Brief Interview of Mental Status (BIMS). The deficiency was identified during a review of the resident's clinical record, which lacked evidence of an assessment for self-administration of the Benadryl cream. Interviews with the Unit Manager and Clinical Nurse Specialist confirmed that an evaluation should have been conducted before the medication was left at the resident's bedside, but this step was overlooked. The oversight occurred even though the facility's policy clearly outlines the need for such assessments to ensure the safety and appropriateness of self-medication.
Failure to Address Resident Council Grievances on Staffing Levels
Penalty
Summary
The facility failed to adequately address and document responses to grievances related to staffing levels on the 11:00 P.M. to 7:00 A.M. shift, as reported by the Resident Council. On two occasions, the Resident Council raised concerns about insufficient staffing during this shift, which affected the timeliness of care, such as changing and cleaning residents. Despite these grievances being documented in Resident Council meetings, there was no evidence of a formal response or rationale provided by the facility administration, as required by their grievance policy. The facility's grievance policy mandates prompt efforts to resolve grievances, including appointing a grievance officer to oversee the process and issuing written decisions if requested. However, the facility did not adhere to these procedures. The Activities Director recalled completing a Resident Council Concern Form regarding the staffing issue on December 18, 2024, but was unable to locate it. Additionally, the facility's response to the January 21, 2025, grievance was incomplete, lacking a documented rationale for the response. Interviews with residents and staff revealed ongoing issues with staffing during the night shift, with residents experiencing delays in receiving assistance. The facility's staffing records confirmed that staffing levels were below the planned number of CNAs for the 11:00 P.M. to 7:00 A.M. shift on several occasions. The Clinical Nurse Specialist acknowledged the staffing shortages and the need for more CNAs, particularly on the Elmwood unit, which has residents with more acute needs. Despite these acknowledgments, the facility did not provide evidence of addressing the staffing concerns raised by the Resident Council.
Failure to Accurately Execute Advance Directives
Penalty
Summary
The facility failed to accurately execute Advance Directives for two residents, leading to deficiencies in the handling of MOLST forms. For one resident, the MOLST form was signed by the Health Care Proxy (HCP) before the resident was deemed incapacitated by a physician, rendering the form invalid. The facility did not re-address the MOLST form with the HCP after the resident's admission, and this oversight was only identified when brought to the facility's attention by a surveyor. The resident had been admitted with diagnoses including toxic encephalopathy and seizure disorder. For another resident, the MOLST form was signed by the HCP prior to the resident's admission, without evidence of a HCP activation form or a physician's order to validate the HCP's authority. The facility failed to complete a new MOLST form with the resident, who maintained the capacity for informed medical decision-making. This deficiency was also identified during the surveyor's review, highlighting a lapse in the facility's adherence to its policy for managing MOLST forms.
Failure to Properly Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to properly issue the Notice of Medicare Non-Coverage (NOMNC) and the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) for three residents. For Resident #483, the facility did not provide the NOMNC with the required provider contact information above the title of the form and failed to deliver the notice two days prior to the resident's discharge. The resident signed the NOMNC on the same day as discharge, which was not in compliance with the guidelines. For Resident #63, the facility did not include provider contact information on the NOMNC and failed to provide a paper copy to the responsible party. The NOMNC was emailed, but not mailed, and the SNF ABN form was not signed by the responsible party, indicating a lack of confirmation that the notice was received and understood. Similarly, for Resident #34, the NOMNC lacked provider contact information, and the form was emailed but not mailed to the responsible party. The SNF ABN form also remained unsigned, failing to confirm receipt and understanding by the responsible party. The social worker acknowledged the oversight in completing the provider information on the NOMNC forms and the failure to provide paper copies to the responsible parties. The social worker also admitted to not obtaining signatures on the SNF ABN forms, which are necessary to confirm that the notices were received and understood. These deficiencies indicate a failure to adhere to the CMS guidelines for issuing NOMNC and SNF ABN forms, resulting in non-compliance with the required procedures.
Failure to Maintain Clean Wheelchair for Resident
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for a resident who was dependent on a wheelchair for mobility. The resident's wheelchair was observed on multiple occasions to be visibly soiled with a white splattered substance and dried brown debris on the armrests. Despite the resident's severe cognitive impairment and reliance on the wheelchair, the necessary cleaning was not performed, compromising the resident's environment. Interviews with staff revealed that the cleaning of wheelchairs was supposed to be conducted weekly by housekeeping, but this was not done due to staff illness and lack of replacement staff. The Certified Nurses Aide (CNA) assigned to the resident acknowledged the wheelchair was dirty and admitted to not contacting housekeeping for cleaning during his shift. The Housekeeping Director confirmed the lapse in cleaning and was unable to provide evidence of the wheelchair being cleaned in the past 30 days. The facility lacked a specific policy for wheelchair cleaning, although the Administrator stated it should occur every two weeks or as needed.
Failure to Schedule Appointments and Monitor Weights
Penalty
Summary
The facility failed to provide care and services that met professional standards of practice for two residents. For one resident, who was admitted with a diagnosis of a kidney stone and related infection, the facility did not schedule a necessary follow-up appointment with a urologist as recommended in the hospital discharge summary. Despite the nurse's admission progress notes indicating the need for this appointment, it was not scheduled, and the oversight was confirmed during an interview with a nurse. Another resident, who was cognitively intact and had a history of chronic conditions including COPD, did not receive a pulmonary consultation as ordered by the nurse practitioner. The resident had been experiencing a chronic cough, and the nurse practitioner had recommended a pulmonary consult to evaluate the possibility of COPD. However, there was no evidence in the clinical record that this consultation was ever scheduled or completed. Additionally, the facility failed to implement physician orders for weight monitoring for the same resident. Despite orders for weekly weights in December and daily weights in January, the resident's weights were not consistently recorded in the medical record. Interviews with the Director of Nursing and the Clinical Nurse Specialist revealed a lack of awareness and follow-through regarding the physician's orders for weight monitoring, resulting in non-compliance with the prescribed care plan.
Failure to Supervise Resident During Smoking Activities
Penalty
Summary
The facility failed to provide a smoking environment free of accidental hazards for a resident who required supervision during smoking activities. The resident, diagnosed with nicotine dependence and dementia, was assessed as needing routine supervision during scheduled smoking times to ensure safety. The facility's policy mandated that residents who smoke be evaluated for their ability to do so safely and that smoking occur under staff supervision. However, observations revealed that the resident was left unsupervised while smoking on multiple occasions. On one occasion, the smoking supervisor left the designated smoking area to assist another resident, leaving the resident unsupervised while smoking. On another occasion, the resident was observed smoking without any staff present, despite the smoking supervisor being assigned to supervise at that time. Interviews with the smoking supervisor and facility administrators confirmed that the expectation was for residents to be supervised at all times during smoking to prevent accidents, which was not adhered to in these instances.
Failure to Reassess and Update Catheter Care Plan
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling urinary catheter, leading to a deficiency. Upon the resident's re-admission from the hospital, where they were treated for catheter-associated complications, the facility did not reassess the resident's catheter status. There was no physician order obtained for the current catheter size, and the resident's care plan was not updated to reflect the correct catheter size. The resident, who was severely cognitively impaired and required assistance for perineal hygiene, had a history of dementia, obstructive and reflux uropathy, benign prostatic hypertrophy, other hydronephrosis, and stage four chronic kidney disease. The facility's failure to reassess the catheter status and update the care plan resulted in a discrepancy between the catheter size used and the physician's order. The resident was observed with a size 24 French catheter, while the physician's order indicated a size 16 French catheter. This discrepancy was not addressed, and no re-admission assessment or catheter assessment was completed. The clinical nurse specialist confirmed the lack of appropriate orders and assessments, highlighting the importance of ensuring the correct catheter size to prevent complications.
Staffing Deficiency on Elmwood Unit During Night Shift
Penalty
Summary
The facility failed to maintain sufficient nursing staff to provide care to residents on the Elmwood unit during the night shift from 11:00 P.M. to 7:00 A.M. This deficiency was identified through interviews and record reviews, revealing that the facility did not have staffing waivers in place and was unable to fill positions timely when staff called out. The facility assessment indicated a need for 3.58 hours of direct care per patient per day, but the actual staffing levels fell short of this requirement, particularly on the Elmwood unit, which houses residents with advanced cognitive loss and high care needs. Residents reported that during the night shift, they often did not receive assistance with basic needs such as changing and toileting until the end of the shift. The Resident Council minutes highlighted concerns about late medication administration and insufficient CNA staffing. Interviews with CNAs and nurses confirmed that staffing shortages were a recurring issue, with frequent no-call/no-shows and difficulties in finding replacement staff. This resulted in only one CNA being available on the Elmwood unit during certain shifts, which was insufficient to meet the needs of residents who required total care for activities of daily living. The facility's scheduler and clinical nurse specialist acknowledged the staffing issues, noting that the Elmwood unit required a higher level of care due to resident acuity. Despite attempts to adjust staffing models and cover shifts, the facility was unable to consistently maintain the required staffing levels. The administrator was unaware of the specific staffing shortages on the identified dates, and the facility did not provide evidence of meeting the required hours of direct care per patient per day during the survey period.
Failure to Ensure CNA Competency Evaluation
Penalty
Summary
The facility failed to ensure that a Certified Nurses Aide (CNA) demonstrated the necessary competencies to provide resident care, as required by regulations. Specifically, CNA #3 did not complete the annual competency evaluation for 2024, which is mandated to ensure continuing competence in skills and techniques necessary for resident care. The Facility Assessment Tool, dated July 2024, outlined the requirements for staff training and competencies, including a minimum of 12 hours of in-service training per year, dementia management training, and resident abuse prevention training. However, a review of CNA #3's employee record showed no evidence of a completed competency evaluation for the year. During an interview, the Administrator was unable to provide documentation of the completed evaluation or a facility policy regarding CNA competency evaluations.
Failure to Provide Follow-Up Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to two residents, leading to deficiencies in their mental and psychosocial well-being. Resident #51, admitted with diagnoses including Major Depressive Disorder and Generalized Anxiety Disorder, did not receive follow-up psychiatric services after an initial evaluation in March 2024. Despite recommendations for three-month follow-up visits, there was no evidence of further psychiatric consultations until January 2025, when the resident declined services. The social worker confirmed the lack of follow-up and acknowledged that the resident should have been offered additional psychiatric services before January 2025. Resident #23, admitted with Major Depressive Disorder and Congestive Heart Failure, also did not receive the recommended psychiatric follow-up. The resident's care plan included interventions for psychiatric consultation, and a physician's note in December 2024 recommended follow-up by the in-house psychiatric team. However, there was no documented evidence that the resident was seen by the psychiatric team following these recommendations. The social worker confirmed that the resident had not been referred for behavioral health follow-up despite the documented need. Both residents were cognitively intact and exhibited symptoms of depression and anxiety, with documented behavioral issues such as verbal outbursts and rejection of care. The facility's failure to ensure timely follow-up with psychiatric services, as recommended by healthcare providers, resulted in a deficiency in meeting the residents' behavioral health needs.
Improper Consent for Psychotropic Medication Administration
Penalty
Summary
The facility failed to ensure that psychotropic medications administered were necessary for a resident, as evidenced by the lack of proper consent from the resident's Health Care Proxy (HCP). The resident, who was admitted with diagnoses including PTSD, cirrhosis, hallucinations, and altered mental status, was moderately cognitively impaired and had a diagnosis of delusional disorder and bipolar disorder. The resident's incapacity to make medication decisions was documented as indefinite due to progressive dementia. Despite this, the informed consent for the administration of Trazodone and Buspirone was signed by an individual other than the resident's HCP. The facility's policy on psychotropic medication management requires that each resident's drug regimen be free from unnecessary drugs and that consent for psychoactive medication be obtained from the resident or responsible party. However, the consent for the resident's psychotropic medications was signed by another resident's HCP, not the appropriate HCP. This oversight was confirmed during interviews with the Unit Manager and Clinical Nurse Specialist, who acknowledged that the consents should have been signed by the correct HCP but were not.
Incomplete Meal Intake Documentation for At-Risk Resident
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident identified as being at risk for weight loss. Specifically, the Certified Nurse Aides (CNAs) did not consistently document meal intake percentages for the resident, who was admitted with diagnoses including Alcohol Dependence, Traumatic Fracture, COPD, and Muscle Weakness. The resident experienced significant weight fluctuations, with a noted weight loss of 18.1 pounds from September to December 2024. Despite being identified as at risk for weight loss, the meal intake documentation was incomplete, with numerous instances of missing entries over several months. The facility's policy on nursing documentation requires nursing personnel to document information related to the resident's condition and care in the medical record. However, a review of the CNA flowsheets revealed that many opportunities for meal documentation were left blank, with 39 out of 90 in November, 35 out of 93 in December, and 25 out of 90 in January. Interviews with the Unit Manager and Dietician confirmed that CNAs are expected to document meal intakes after every meal, but this was not consistently done. The Dietician noted that he would not rely solely on the incomplete meal intake documentation for interventions, indicating a lack of accurate records to support resident care decisions.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility staff failed to maintain proper infection control practices for three residents, leading to potential contamination and infection risks. For Resident #7, the staff did not appropriately manage the urinary drainage bags used for daytime and nighttime, which were observed hanging in the bathroom and making contact with the wall without being secured in a storage bag. The bags contained residual urine, and the staff did not follow a standard procedure for cleaning and storing these bags, as confirmed by interviews with the CNA, Nurse, and Infection Preventionist. Resident #47, who was severely cognitively impaired and dependent on staff for personal hygiene, was not assisted with hand hygiene before eating. The resident participated in a group activity with visibly soiled hands and was served a meal without handwashing, despite the presence of a dried brown substance on the hands. The Activity Aide admitted that hand hygiene was not performed before meals, which was against the expectations of the Director of Nursing, who emphasized the importance of hand hygiene in preventing infections. For Resident #11, the facility did not adhere to Enhanced Barrier Precautions (EBP) during a bolus feeding procedure. The nurse involved did not wear a gown or gloves as required by the EBP signage posted outside the resident's room. The Unit Manager confirmed that all staff should follow EBP protocols, including wearing appropriate personal protective equipment during high-contact care activities. The lack of compliance with EBP protocols placed the resident at risk for transmission of organisms.
Incomplete Daily Nursing Staff Data Posting
Penalty
Summary
The facility failed to comply with regulatory requirements by not posting complete daily nursing staff data at the start of each shift. The posted information on the dry-erase board, accessible to residents and visitors, included only the number of Registered Nurses (RNs), Licensed Practical Nurses (LPNs), and Certified Nurse Aides (CNAs) scheduled for each shift. However, it did not include the total number and actual hours worked by these staff members, nor did it provide the facility's resident census. During interviews, the Receptionist and Scheduler confirmed that the staffing information was updated daily based on the schedule provided, but they were unaware of the requirement to include hours worked and resident census in the postings.
Delayed MDS Assessment for Hospice-Enrolled Resident
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Assessment in a timely manner for a resident who experienced a significant change in status. The resident, who was admitted to the facility with End Stage Renal Disease (ESRD) and Dementia, was enrolled in a hospice program, which required a Significant Change in Status Assessment (SCSA) to be performed. According to the Centers for Medicare and Medicaid Services (CMS) guidelines, the SCSA should have been completed within 14 days of the determination of the significant change, which occurred when the resident was admitted to hospice. However, the SCSA for the resident was not completed until 20 days after the determination of the significant change in status. The Assessment Reference Date (ARD) was set for two days after the resident's enrollment in hospice, but the assessment itself was not finalized until much later, resulting in a delay. During an interview, the MDS Nurse acknowledged that the assessment was completed late and emphasized the importance of timely completion to ensure that the services provided met the resident's needs.
Involuntary Seclusion of Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from involuntary seclusion when a Certified Nurse Aide (CNA) tied a plastic bag from the door handle of their room to the hallway handrail. This action was taken to prevent one resident, who had a history of exit-seeking and wandering behaviors, from leaving the room while the CNA attended to another resident. The incident occurred during an evening shift when the unit was short-staffed, and the CNA was left alone to care for over 40 residents. The door remained tied shut for approximately two hours, confining both residents to their room against their will. Resident #1, who was severely cognitively impaired and had a history of wandering and exit-seeking behaviors, was found standing behind the door when it was eventually untied. Resident #4, who shared the room and was also severely cognitively impaired, was asleep during the incident. The facility's policy on abuse, neglect, and exploitation clearly defines involuntary seclusion as the separation of a resident from other residents or confinement to their room against their will. The CNA admitted to tying the door shut for safety reasons due to being overwhelmed by the staffing situation. The facility's investigation substantiated the allegation of involuntary seclusion based on staff statements and the CNA's admission. The Director of Nurses (DON) and other staff members confirmed the details of the incident, including the CNA's actions and the subsequent discovery of the tied door. The facility's policy was not followed, leading to the confinement of the residents and a failure to protect them from involuntary seclusion.
Failure to Report Involuntary Seclusion Incident
Penalty
Summary
The facility failed to ensure staff implemented and followed their Abuse Policy related to the immediate reporting of an allegation of involuntary seclusion. On 01/13/24, Nurse #1 and Nurse #2 became aware that the door to a bedroom occupied by two ambulatory residents was tied shut with a plastic bag, preventing them from exiting the room at will. Despite being aware of the incident, both nurses did not report it to the Facility Administration until 01/15/24, when the Director of Nurses (DON) discovered a progress note about the incident. This delay in reporting violated the facility's policy, which requires immediate reporting of such allegations to the administrator or designee. The incident involved two residents, one of whom typically wandered the unit during the evening and overnight shifts, while the other usually stayed in bed during the night. The door was tied shut by a Certified Nurse Aide (CNA) who claimed it was done to keep one resident safe while attending to another. However, this action resulted in involuntary seclusion of both residents. The failure to report the incident immediately as required by the facility's policy placed other residents at risk for abuse. The deficiency was identified when the DON reviewed clinical notes and sought clarification from the involved nurses, who admitted to not reporting the incident to the administration as required.
Failure to Timely Report Allegation of Involuntary Seclusion
Penalty
Summary
The Facility failed to report an allegation of involuntary seclusion to the Department of Public Health (DPH) within the required two-hour timeframe. On 01/15/24 at approximately 7:30 A.M., the Director of Nurses (DON) #1 became aware of an incident that occurred on 01/12/24, where the door to the bedroom occupied by Resident #1 and Resident #4 was found to be tied shut. The incident was not reported to DPH until 6:07 P.M. on 01/15/24, more than ten hours after DON #1 learned of the incident. The Facility's policy mandates that any incident involving abuse must be reported to DPH within two hours. The incident was first noted in a Nurse Progress Note dated 01/13/24, which indicated that a plastic bag was found around the door of Resident #1's room at 11:30 P.M. on 01/12/24. Upon further investigation, it was revealed that CNA #1 had tied the door shut to keep Resident #1 safe while attending to another resident. Despite this, the incident was not reported immediately as required. The Administrator confirmed that the former DON was responsible for reporting the incident but failed to do so within the mandated timeframe.
Failure to Prevent Resident Elopement
Penalty
Summary
The Facility failed to ensure adequate supervision for Resident #2, who had dementia and was known to wander and exhibit exit-seeking behaviors. On 03/11/2024, Resident #2 exited the Facility without staff knowledge. The staff only became aware of the elopement after noticing that Resident #2's lunch tray was untouched and they could not locate him/her. Resident #2 was found later that day by the police, seated on the side of a road, four miles from the Facility, and was transported to the hospital for evaluation due to cold exposure but was stable and returned to the Facility. Resident #2 had been admitted to the secured unit of the Facility in December 2023, with diagnoses including dementia, anxiety disorder, and a history of traumatic brain injury. The Facility's policy on elopement indicated that residents at risk should be identified and preventative strategies implemented. Despite this, Resident #2's history of exit-seeking behavior was well-documented, with multiple instances of attempting to leave the unit and being redirected by staff. On the day of the incident, a Physical Therapy Assistant observed Resident #2 pushing the handle on an exit door but did not notify the nursing staff or redirect the resident. Interviews with staff revealed that Resident #2 was known to frequently attempt to exit the unit and that the exit doors did not shut quickly enough, allowing opportunities for elopement. The Facility's investigation suggested that Resident #2 might have exited through the main door, as visitors knew the code to enter and exit the unit. The Administrator confirmed that only staff members should have the code and that staff were expected to notify nursing staff if they observed a resident exit-seeking. The failure to provide adequate supervision and follow the Facility's elopement policy led to Resident #2's elopement and subsequent exposure to cold weather.
Insufficient Staffing Leads to Resident Safety Issues
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, leading to two significant incidents involving Resident #1 and Resident #2. On the evening shift of 01/12/24, Resident #2, who was moderately cognitively impaired and at risk for wandering, managed to leave the locked unit and was found on another unit. This occurred while the unit was understaffed, with only two CNAs and one nurse available to care for 40 residents. Additionally, CNA #1 admitted to securing Resident #1's door with a plastic bag to prevent him/her from wandering while she attended to another resident, as she was overwhelmed by the lack of staff support. Resident #1, who was severely cognitively impaired and had a history of wandering, was effectively placed in involuntary seclusion due to the staffing shortage. The facility's policy on abuse, neglect, and exploitation emphasizes the need for sufficient and qualified staff to meet residents' needs and prevent situations that could lead to abuse or neglect. However, the facility's staffing on 01/12/24 was significantly below the assessed need of 3.58 PPD for both nurses and CNAs, with actual staffing levels at 1.836 PPD. This shortfall directly contributed to the incidents involving Resident #1 and Resident #2. The facility's assessment indicated that the Elmwood unit housed residents with mid to late-stage dementia, requiring frequent staff interactions to maintain safety, which was not adequately provided on the night in question. Interviews with staff and the facility's investigation confirmed that the incidents were a result of insufficient staffing. CNA #1 reported feeling overwhelmed and unable to manage the residents' needs effectively, leading to the decision to secure Resident #1's door. The administrator acknowledged the staffing challenges and confirmed that the facility had not been able to meet its assessed staffing needs. The investigation substantiated the incident involving CNA #1 as involuntary seclusion and identified insufficient staffing as a contributing factor.
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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.
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Nursing homes near Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster Manor Rehabilitation & Health Care Center | 0 mi | ★★★★★ | 3 | 0 |
| Brookside Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 1 | 0 |
| Matulaitis Rehabilitation & Skilled Care | 7.7 mi | ★★★★★ | 4 | 0 |
| Southbridge Rehabilitation & Health Care Center | 8.3 mi | ★★★★★ | 8 | 0 |
| Overlook Masonic Health Center | 8.7 mi | ★★★★★ | 0 | 0 |
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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 October 2026) and official state health department websites.