Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pine Knoll Nursing Center during CMS and state inspections, most recent first.
Failure to Manage Contractures and ROM Decline: The facility did not provide timely OT, ordered orthotic support, or physician-recommended botox for a resident whose left hand contracture progressed and ended in amputation of the fifth finger. Another resident was observed with bilateral hand contractures without splints, including a left hand splint issue tied to a stage four pressure wound and an untreated new right hand contracture. A third resident did not receive ordered bilateral hand grips for contracture management.
The facility failed to notify the physician and, for one resident, the legal guardian, of significant changes in condition. One resident’s worsening hand contracture, delayed OT eval, missed OT frequency, and orthotic intolerance were not reported, and the contracture progressed to finger amputation. Another resident’s worsening bilateral hand contractures and stage 4 pressure ulcer were not reported. Two residents with COPD had empty O2 tanks and low SpO2 readings, but the NP was not notified of the respiratory decline.
A facility failed to protect two residents from abuse and neglectful supervision. One cognitively intact resident with paraplegia and depression repeatedly reported sexually explicit comments and exposure by another resident, but the concern was not documented in the care plan or progress notes and key clinical staff were not informed. Another cognitively intact resident with mobility dependence was repeatedly entered by a wandering resident who attempted to get into bed, exposed buttocks, and touched the resident and belongings while staff provided only intermittent redirection and no resident-specific interventions were in place.
Failure to provide behavioral health services for two residents distressed by another resident’s intrusive and sexually inappropriate behaviors. One resident reported ongoing sexual harassment and fear after repeated vulgar threats, while another resident experienced repeated room intrusions, attempted bed entry, exposure, and unwanted touching that caused fear and sleep disturbance. The chart lacked behavioral health referrals or therapy, and the DON, SW, and psychiatrist acknowledged the residents were distressed and that talk therapy was not available.
Two residents did not receive ordered rehab services. One resident developed a left-hand contracture, had a delayed OT eval, and then did not receive OT at the ordered frequency; the contracture worsened and the fifth finger was later amputated. Another resident had a PT eval ordered for pain and decline, but the record did not show the eval was completed, and the resident reported ongoing shoulder pain and no recent PT.
Failure to Timely Report Abuse and Resident-to-Resident Altercations: The facility did not timely report multiple allegations of sexual abuse, physical abuse, and resident-to-resident altercations to HCFRS. Residents with varying cognitive impairment levels reported or were documented as involved in sexual misconduct, physical aggression, and other altercations, and the DON and NHA acknowledged several incidents should have been reported within the required timeframe but were not.
Failure to Investigate Abuse Allegations and Resident Altercations: The facility did not investigate multiple allegations involving sexual abuse, physical abuse by staff, and resident-to-resident altercations. Residents with cognitive impairment and behavioral issues reported sexually explicit conduct, rough handling by staff, and altercations with peers, but the DON and NHA acknowledged that required investigations were not completed and, in one case, the event was not reported to the state agency.
Medication storage and security failures were observed in the LTC facility. An unopened insulin pen that required refrigeration was left at room temperature, multiple opened meds with shortened expiry dates were undated, and loose unlabeled pills and medications touching a sticky brown substance were found in medication carts. Staff also left a med cart and med room unsecured when unattended, gave keys to an off-duty nurse who entered the med room, and stored lorazepam with non-controlled meds instead of in a separately locked compartment.
Improper food storage and unsafe meal handling were observed in the kitchen and [NAME] Unit dining room. Surveyors found spoiled and undated foods in the walk-in and reach-in refrigerators, including produce with mold-like growth, opened dairy and deli items without dates, and raw fish stored above ready-to-eat ham. During meals, the COD, CNAs, and a nurse handled ready-to-eat foods with bare hands, opened a milk container by placing a finger inside the spout, and a resident ate food from another resident’s plate while the nurse did not stop it.
Failure to maintain resident privacy during personal care. A resident who was dependent on staff for all ADLs and had dementia, dysphagia, and seizures was observed naked in bed receiving morning care with the privacy curtain open, allowing two roommates to see the resident. The CNA acknowledged residents should have privacy during care, and the DON stated privacy curtains should be pulled during personal care.
Failure to Include Estimated Private-Pay Costs on SNF ABN Notices: The facility failed to provide two residents, who had exhausted Medicare Part A skilled coverage but still had benefit days remaining, with SNF ABN forms that included estimated costs for privately paid skilled services. The SW said she left the cost sections blank because she did not know the individual costs, and the Ops Director said the cost breakdown should have been listed on the SNF ABN.
Persistent urine odors were observed on the [NAME] Wing, with surveyors noting a strong stale urine smell in the hallway on multiple occasions. Residents reported unpleasant odors, and staff said deodorizing spray was used frequently to cover the smell. The housekeeper reported urine had soaked into flooring in two resident rooms and that cleaning only masked the odor, while the Administrator and DOF confirmed the odor was linked to urine in the flooring and had not been fixed promptly.
A resident’s quarterly MDS assessment was not completed in a timely manner. The MDS Coordinator said the assessment was missed and overdue, and the DON stated he expected all MDS assessments to be completed according to the RAI manual instructions.
Failure to develop a care plan for suicidal ideation for a resident with schizoaffective disorder and schizophrenia. The resident had documented suicidal ideation, including a report of a plan and placement on 1:1 monitoring, but the interdisciplinary care plan did not include a suicidal ideation focus. The DON and SW stated that any resident with present or past suicidal ideation should have such a care plan.
Care plans were not revised after quarterly MDS reviews for two residents. One resident with dementia, wandering, and TBI still had 15-minute checks listed even though they were not being done, and staff said the intervention was outdated. Another resident with Alzheimer’s dementia and a Swahili language barrier had a communication care plan that did not include expected supports such as a communication board or translator services, despite staff confirming they could not communicate with the resident without Swahili-speaking staff.
Physician order for padded side rails was not followed for a resident with seizure and epilepsy diagnoses. Surveyors observed the resident in bed on multiple occasions with two quarter side rails up, but the rails were not padded as ordered. A nurse confirmed the order called for padded side rails, a CNA said he had not seen them in place, and the DON stated the order should have been followed.
Failure to Provide ADL Assistance: Two residents who were dependent on staff for toileting and incontinent of bowel and bladder were left for more than four hours at a time without being checked or assisted to the bathroom, and when toileting was finally provided their briefs were saturated with urine. Another resident with severe cognitive impairment and a care plan for grooming assistance was observed with significant chin hair and stated a desire for it to be removed, but staff did not provide the requested grooming assistance.
Failure to provide activities on the [NAME] Unit. Surveyors observed that scheduled morning activities did not occur on multiple days, with most residents lined up in front of the TV, several sleeping, and CNAs not engaging them. Only three residents received individual activities, and no activity staff member was present. The Activity Director said she was the only activity staff member, the assistant was on medical leave, and CNAs had not been trained to run activities while supervising the room.
A resident with bilateral hearing loss and severe cognitive impairment was repeatedly observed without hearing aids, and the record showed no evidence of audiology follow-up or documented refusal of devices. The HCP said the resident had hearing aids on admission, they later went missing, and staff did not notify her or arrange audiology services. Nursing, the DON, and the SW acknowledged the resident was hard of hearing, had no current hearing devices, and should have been referred to audiology, but no appointment had been scheduled.
Failure to Follow Fall Care Plan Supervision Intervention: A resident with dementia, severe cognitive impairment, and hemiplegia was identified as high risk for falls, and the care plan directed staff not to leave the resident unattended in the room. Surveyors observed the resident in bed without staff present on multiple occasions, and staff interviews showed the CNA and an RN were unaware of the specific intervention, while the DON stated the intervention should have been implemented.
Failure to address significant weight loss: A resident with dementia, FTT, and schizoaffective disorder had a marked decline in weight while refusing meals and stating the food was poisoned. Although staff and the NP were aware of the loss, the record did not show an RD referral, a completed nutritional assessment, or added nutritional interventions such as supplements or other diet changes.
Failure to Provide Ordered Oxygen to Two Residents: Two residents with COPD and severe cognitive impairment were observed with empty portable O2 tanks while wearing nasal cannulas, and staff did not ensure oxygen was being delivered at the ordered rate. One resident’s O2 sat was documented at 85%, then 74% and 80% on repeat checks; the other resident’s O2 sat was 74% and later 80%. The nurse stated he had not assessed the residents’ oxygen needs that day, and the CNA said tank checks were the nurse’s responsibility.
A resident with osteoarthritis, shoulder pain, and major depressive disorder reported ongoing severe pain that limited arm movement and was not relieved by the current regimen. The NP ordered a pain management consult and orthopedic follow-up for multiple joint pain, but the consult was not completed and the DON acknowledged a two-month delay in sending the referral to the pain doctor. The resident’s HCP also reported worsening pain, decline, and reduced ability to eat or drink independently.
Failure to update a trauma care plan after a resident reported sexual abuse by another resident. The resident, who had anxiety, depression, and paraplegia, said the other resident repeatedly made vulgar sexual threats and that the issue had been reported to the DON and NHA and even involved police. The trauma plan remained focused on an older trauma history and loud-noise triggers, and staff interviews confirmed the plan was not updated to address the resident’s fear and the ongoing peer abuse.
A resident with dementia, TBI, wandering, and behavioral disturbance repeatedly wandered into other residents’ rooms, disrobed in common areas, and made sexually inappropriate comments and gestures toward peers. Nursing notes showed the resident was difficult to redirect and continued the behaviors, while the care plans were not reviewed or revised after a sexual incident with a peer and after interventions proved ineffective. Staff interviews confirmed the resident was not appropriate for the facility and that the behaviors were ongoing.
Failure to provide social services support after sexual threats: A cognitively intact resident with anxiety, depression, and paraplegia reported repeated sexually explicit threats and inappropriate behavior by another resident, including an incident that led to police involvement. The resident said the SW did not meet in person or provide emotional support, and the record did not show the abuse was addressed in the care plan or by social services. Interviews with the DON, NHA, psychiatrist, and medical director confirmed the resident should have received SW follow-up and support.
A resident with glaucoma, dementia, and bipolar disorder had orders for multiple eye drops, and the Consultant Pharmacist repeatedly recommended separating the drops by at least 5 minutes during administration. The record did not show that the provider reviewed or responded to the recommendation in a timely manner, and the DON stated that a two-month delay in implementing pharmacist recommendations would be considered a delay in care.
Unnecessary Psychotropic Medication Use and Missing AIMS Monitoring: The facility failed to ensure a resident’s antipsychotic dose was reduced as recommended by the psychiatrist, and it also failed to complete AIMS assessments for several residents receiving antipsychotic medications. Records showed ongoing orders for Seroquel, ziprasidone, clozapine, and risperidone without the expected monitoring documentation, while staff interviews showed confusion about who was responsible for AIMS completion and follow-through on psychotropic medication recommendations.
Failure to provide dental services and replace missing dentures. A resident with severe cognitive impairment and dependence on staff was observed eating without dentures, while the resident’s daughter reported the dentures had been missing for about a year. The record showed a dental consult order and consent for dental services, but no evidence the resident was ever seen by a dentist or dental hygienist. Staff, including the unit manager, CNA, social worker, and DON, were unaware of the missing dentures and the lack of dental follow-up; only the lower dentures were found in a labeled container, and the upper dentures could not be located.
QAPI failed to address the full range of care and services and did not use a systematic, data-driven process to identify root causes, develop corrective actions, or monitor effectiveness. Surveyors found systemic concerns in rehab services, contracture management, and abuse reporting/investigation/prevention, but the QAPI plan did not show projects for those areas. The Administrator said recent QAPI work focused on environmental and dietary issues, while the DON said clinical issues were identified informally and no QAPI projects were developed for the known concerns.
A facility failed to follow EBP for two residents on the North Unit. A CNA provided morning care to a resident with a G-tube without wearing a gown despite EBP signage and PPE available outside the room, and later said he did not know the resident was on precautions. For another resident with a stage 4 heel wound, an RN brought the entire treatment cart into the room and was observed changing gloves without performing hand hygiene between glove changes.
COVID-19 vaccine was administered to a resident with severe cognitive impairment without consent from the resident or health care proxy. The resident’s daughter had told the facility she did not want the vaccine, and the record still showed an order and MAR/nursing documentation indicating the vaccine was given. The DON later acknowledged the vaccine must have been administered without proxy consent.
A resident’s MDS incorrectly coded restraint use even though staff and records showed no restraints and the facility was restraint free. Another resident who spoke Swahili was coded as rarely/never understood, and the BIMS and mood interviews were not completed in the resident’s preferred language. A third resident’s discharge and annual MDS failed to identify an unstageable pressure ulcer on the left hand despite skin assessments, treatment records, and hospital documentation confirming the wound.
A resident with intact cognition and no documented financial incapacity was denied timely access to personal funds despite having money in a PNA, because the NHA believed the resident had previously misplaced cash and spent money on takeout. The facility also kept pooled resident funds in a non-interest-bearing account, and PNA records for multiple residents showed no accrued interest even though the facility was the rep-payee and its policy called for an interest-bearing account.
Failure to Document and Administer Influenza and Pneumococcal Vaccinations: The facility did not have documentation that three residents received the annual influenza vaccine and did not have documentation that two residents received pneumococcal vaccination. Records showed consents and physician orders allowing the vaccines, but the immunization tabs and paper charts lacked evidence of administration. The Administrator, DS, and DON were unable to locate the missing vaccine documentation and were unsure why the pneumococcal vaccines were not given.
Care Plan Not Revised After Fall-Related Wrist Fracture: A resident with dementia, DM, and RA had a severe cognitive impairment and required total assistance with care and mobility. After an unwitnessed fall caused an undisplaced distal radial fracture of the left wrist, the resident’s care plan was not updated to include the fracture, related treatment, precautions, or fall-prevention interventions, despite staff stating care plans should be revised after MDS assessments and after return from the hospital.
Two residents had physician-ordered protective devices that were not actually in use despite charting that they were being applied. One resident with dementia and a history of a pressure ulcer was ordered heel protectors while in bed, but surveyors repeatedly observed bare heels on the mattress and staff said the resident had not worn the boots in a long time. Another resident with dementia, AFib, and anticoagulant use was ordered bilateral geri sleeves, but surveyors repeatedly observed the arms without sleeves and staff said the resident had not worn them in a long time.
Air Mattress Set Incorrectly for Resident With Pressure Ulcer: A resident with a stage 4 sacral/coccyx pressure ulcer, dementia, malnutrition, and total dependence on staff had an air mattress that was observed operating at the 320-400 setting instead of the ordered weight line of 120. The physician order and care plan directed the mattress to be set by weight with the static function off, but staff observations and interviews confirmed the setting remained incorrect while the resident was in bed.
A resident with a Foley catheter and diagnoses including UTI, urinary retention, acute kidney failure, and heart failure had catheter care that did not match physician orders. Staff observed the drainage bag dated outside the ordered schedule, and records showed the catheter was documented as changed, but the resident was later observed with a 16 Fr 30 ml balloon catheter instead of the ordered 16 Fr 5 ml balloon catheter. Nursing and the DON stated catheter and bag changes should follow the physician's orders.
The facility failed to designate a qualified FSD. The FSD said he had attended college but did not complete a degree and only had food safety and allergen awareness training. The RD was not employed full-time and came to the facility two to three days a week. The FSD and Executive Director both acknowledged that the FSD did not meet the regulatory requirements for the role.
Pureed Diets Not Served Per Posted Menu: The FSD and cook served pureed meals that did not match the posted menu during multiple observed meals. Instead of the listed entrees and sides, residents on pureed diets were given items such as beef in tomato, ground beef in tomato, mashed potatoes, spinach, and mixed vegetables. The Dietitian stated that residents requiring a pureed diet should receive the same entree as the regular textured diets, and the FSD said he did not understand that the pureed diets should be served based on the menu breakdown.
A resident with dementia and diabetes, ordered a pureed diet with nectar-thickened liquids for dysphagia, was observed receiving gelatin for dessert even though it returns to a thin liquid consistency. Nurse believed the gelatin was allowed, while the Dietitian stated it should not be served to residents on nectar-thickened liquids and reported that multiple residents received it because kitchen staff and the FSD were unaware of the restriction. The DON agreed the resident should not have received gelatin, and the FSD later stated pudding should have been served instead.
A resident with dysphagia, malnutrition, and severe cognitive impairment was ordered adaptive eating utensils and a two-handled cup/sippy cup to support self-feeding, but repeated meal observations showed these items were missing from the tray. Instead, the resident was served regular cups with straws at times and was observed having shaking hands and difficulty managing utensils. Staff interviews confirmed the meal slip called for the adaptive equipment, but it was not available on the tray.
Inaccurate skin check documentation affected three residents with significant cognitive impairment and wound histories. Nursing records for one resident showed a left foot discoloration that staff and the DON said was not present, another resident’s skin checks continued to list healed buttock and finger wounds despite staff stating those areas were resolved, and a third resident’s skin checks and wound documentation were inconsistent with staff reports of the resident’s actual wounds and current skin condition. The DON and unit staff stated skin checks should reflect the resident’s actual skin integrity.
The facility failed to complete quarterly MDS assessments on time for two residents. One resident’s quarterly MDS was completed late and another resident’s quarterly MDS was also completed after the required timeframe. The MDS Nurse said the delays were oversights on her part, and the DON stated MDSs should be completed timely according to the RAI manual.
Late Transmission of MDS Assessments: The facility failed to transmit MDS assessments within the required timeframe for three residents. An MDS Nurse said quarterly MDSs should be submitted within 14 days of completion, but she was still being trained on submission and relied on the prior MDS Nurse, and the DON stated he expected MDSs to be completed and submitted per the RAI manual.
A facility failed to code several MDS assessments accurately. One resident was incorrectly coded for antianxiety medication when the MAR and orders did not support it, another was miscoded for antianxiety, hypoglycemic, and anticonvulsant medications, a third was incorrectly coded for antianxiety medication, and a fourth was incorrectly listed with schizophrenia after a physician note was entered in the wrong chart. The MDS Nurse stated she was not aware medications should be coded by classification rather than the reason for use, and the DON expected the MDS to reflect accurate active diagnoses.
The facility failed to protect three residents from neglect by not implementing wound care treatments as recommended by the Consultant Wound Physician. One resident's pressure injury deteriorated to a Stage 4 due to lack of treatment, while another resident's stage two pressure wound was not treated as recommended. A third resident's multiple pressure ulcers were not managed according to the wound physician's plans. Staff interviews revealed a lack of awareness and communication regarding wound care needs.
The facility failed to implement wound care recommendations for three residents, leading to the worsening of pressure injuries. One resident's unstageable pressure wound deteriorated to a Stage 4 injury due to the facility's failure to follow the Consultant Wound Physician's orders and use an air mattress. Another resident did not receive the recommended wound care treatments. The facility's lack of communication, documentation, and oversight contributed to these deficiencies.
The facility failed to ensure nursing staff were trained and competent in wound care, leading to a resident's pressure injury worsening from an unstageable DTI to a Stage 4 wound. Personnel files lacked documentation of necessary competencies, and interviews revealed inadequate training. Observations showed improper infection control during wound care, highlighting the facility's lack of structured training and competency evaluations.
Failure to Manage Contractures and ROM Decline
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion for multiple residents. Resident #24, who was cognitively intact and admitted with diagnoses including osteoarthritis, heart failure, and hypertension, developed a left hand contracture after admission. The record showed no contracture on admission or on hospital paperwork after a January 2025 hospitalization, but later notes documented increasing tightness in the left hand and fingers. The resident’s health care proxy and staff reported that the contracture worsened over time, the resident had pain, and the left fifth finger was ultimately amputated after the contracture progressed. For Resident #24, OT evaluation was delayed after the need for OT was first documented, and once OT began, the resident did not receive therapy at the frequency ordered. OT notes repeatedly recommended orthotic devices such as a rolled towel, hand carrot, and later a palm guard, but the record did not show written orders for these devices or nursing documentation showing consistent use. OT documented that the resident’s hand improved after treatment but regressed between visits, and OT also noted nursing lack of follow-through with the hand carrot. The DON stated he had not been monitoring whether therapy referrals or treatments were completed. The record also showed multiple physician recommendations for botox injections for the left hand contracture, but appointments were cancelled by the facility and never rescheduled, and the resident never received the injections. Resident #6, who had dementia and severe cognitive impairment, was observed with both hands contracted and without splints. The left hand was in a fist and the right hand had fingers bent toward the palm. The record indicated the resident had no documented neurological disorder causing contracture, yet the facility failed to implement a splint for the left hand, and the deficiency report states this resulted in a stage four pressure wound. The report also states the facility failed to identify and treat a new contracture of the right hand. Resident #11 was also included in the deficiency for failure to implement a physician’s order for bilateral hand grips for contracture management. The report states the facility did not carry out the ordered hand grips. Facility policies required residents to receive care to prevent progression of contractures, physician notification when contractures were assessed, and monitoring of splint compliance, but the findings showed these interventions were not consistently implemented for the affected residents.
Failure to Notify Providers and Representative of Significant Changes in Condition
Penalty
Summary
The facility failed to notify physicians and a legal guardian of significant changes in condition for four residents. The report states that the facility did not notify the physician or resident representative when Resident #24’s left-hand contracture worsened, when OT evaluation was delayed, when ordered OT treatment was not being completed at the prescribed frequency, or when the resident could not tolerate the hand orthotic because of increased pain and decreased range of motion. The resident was cognitively intact, had no left-hand contracture on admission/readmission assessments, and later developed a worsening left-hand contracture that ultimately resulted in amputation of the left fifth finger. For Resident #24, the medical record showed NP notes in July and August 2025 documenting stiffness and pain with OT evaluation pending, but the OT evaluation was not completed until 49 days after the first documented need. The OT plan called for 10 visits per 30-day period, but the resident received only 13 visits during the treatment period from September through December 2025. OT notes documented that the hand carrot was not being worn consistently, nursing staff were educated on its use, and later the OT discontinued the hand carrot because of nursing lack of follow-through and increased pain; the resident then refused a palm guard due to pain. The record did not show the physician was notified of the delayed evaluation, missed treatment frequency, orthotic intolerance, or worsening contracture. The resident was later hospitalized, and hospital paperwork described severe finger contractures and pain, followed by amputation of the left fifth finger. For Resident #6, who had severe cognitive impairment and was dependent on staff for all ADLs, the facility failed to notify the legal guardian of worsening left-hand contracture with a stage 4 pressure ulcer and a new right-hand contracture, and failed to notify the physician of the worsening left-hand contracture and new right-hand contracture. The resident was observed with both hands contracted, without a splint in either hand, and staff reported the left-hand splint had not been seen for a long time. The resident had pain when staff attempted to open the fingers. A wound was observed on the left third finger, and the wound care specialist later documented a new stage 4 wound with pressure etiology. The record did not show notification to the guardian or physician about the worsening contractures or the new wound. For Residents #21 and #9, both with COPD and severe cognitive impairment, the facility failed to notify the physician of a change in respiratory status when oxygen saturation dropped below the ordered parameters. On the survey date, both residents were observed with empty portable oxygen tanks while oxygen was ordered continuously at 2 liters via nasal cannula. Nurse #9 stated he did not know the ordered oxygen level and initially did not assess the residents’ oxygen status. When oximetry was obtained, Resident #21’s oxygen saturation was documented as low as 74% and Resident #9’s as low as 74% to 80%. The nurse stated that provider notification was required when oxygen saturation was below 90%, and the NP later stated he was never notified of the lowered oxygen saturation levels or the change in respiratory status.
Failure to Protect Residents from Sexual Abuse and Resident-to-Resident Intrusions
Penalty
Summary
The facility failed to protect two residents from abuse and neglectful supervision. Resident #36, admitted in April 2025 with anxiety disorder, paraplegia, and depression, had intact cognition on the most recent MDS and was dependent on staff for self-care and transfers. Despite repeated emails to the Administrator, DON, and SW describing sexually explicit comments and exposure by another resident, the facility did not document a care plan specific to the abuse, did not address the incident in progress notes, and did not show that the concern was communicated to the Psychiatrist, NP, or behavioral services. Resident #36 stated he/she lived in fear of the other resident and could not protect himself/herself or get up and run. Resident #36 reported that another resident approached him/her in the hallway, made vulgar sexual statements, and exposed his/her genitals. The resident emailed the NHA and DON about the incident and later called the police. The DON later acknowledged that the abuse should have been addressed and a plan made to prevent recurrence, but it had not been. The SW stated she was not informed of the incident at the time and said communication in the building was lacking. CNA #1 said Resident #36 would stop care when hearing the accused resident in the hallway because he/she was scared and uncomfortable, but this was not reported because it was treated as a regular occurrence. The facility also failed to protect Resident #24, who was admitted in December 2024 with osteoarthritis, heart failure, and hypertension and was cognitively intact with a BIMS score of 14. During observation, another resident repeatedly entered Resident #24’s room, attempted to climb into the bed, exposed buttocks, and touched the resident and belongings while staff did not intervene until the surveyor alerted them. Resident #24 said the other resident entered the room daily, made him/her feel afraid and unsafe, and that staff only told him/her to press the call light. The care plan did not reflect the repeated room intrusions or any interventions to deter them, and staff interviews showed they were aware of the wandering but had not implemented resident-specific measures. The DON, SW, NP, and Administrator each stated they were unaware of the full extent of Resident #24’s distress or that interventions specific to the resident had not been put in place.
Failure to Provide Behavioral Health Services for Residents Distressed by Peer Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health services to two cognitively intact residents who were experiencing fear and emotional distress related to repeated intrusive and sexually inappropriate behavior by another resident. Resident #36, who had diagnoses including anxiety disorder, paraplegia, and depression, reported ongoing sexual harassment and threats from a peer, including an incident in which the peer made vulgar sexual comments while the resident was seated in the hall. Resident #36 stated that the behavior continued afterward, that he/she lived in fear of being hurt or touched, and that he/she did not receive talk therapy despite being willing to accept it. Resident #36 provided emails sent to the NHA, DON, and SW describing the abuse and pleading for help. The record showed no behavioral health intervention in the care plan after the incident, and the medical record did not show evaluation or treatment by behavioral health services. The psychiatrist stated he had not been told about the abuse, had not been asked to see the resident, and said the resident would benefit from talk therapy. The SW and DON acknowledged that the resident was distressed, that the facility had been without a psychotherapist since December 2024, and that no formal therapy was available. Resident #24, who had diagnoses including osteoarthritis, heart failure, and hypertension and was cognitively intact, was repeatedly exposed to another resident entering the room, attempting to get into bed, exposing buttocks, and touching belongings. During survey observation, the resident appeared frightened while the other resident attempted to get into the bed and expose himself/herself. Resident #24 stated that the other resident entered the room daily, made him/her feel unsafe, and caused fear and sleep disturbance. The care plan did not address the repeated intrusions, and the medical record did not show referral to or evaluation for behavioral health services. Staff, including the SW, DON, and psychiatrist, acknowledged that the resident’s fear and distress should have prompted behavioral health referral, but no such referral had been made.
Failure to Provide Ordered Therapy Evaluations and Treatments
Penalty
Summary
The facility failed to provide specialized rehabilitative services for two residents. For one resident with a new left-hand contracture, the record showed that an OT evaluation was not completed until 49 days after the need for OT was first documented, and the resident did not receive OT at the frequency ordered after the evaluation. The resident was admitted without contractures, later developed a left-hand contracture in July 2025, and the contracture progressed over time. The resident’s NP documented stiffness and an OT evaluation pending in multiple progress notes, but those notes were later described by the NP as inaccurate because they referenced the right hand instead of the left. An OT order was written, the evaluation was eventually completed, and OT recommended 10 visits per certification period. However, the resident was seen only 13 times from the initial evaluation through discharge from services, despite repeated recertifications continuing to order 10 visits per period. The record did not show a reason for the delay in the initial OT evaluation or for the missed treatment frequency. The resident was later hospitalized, and discharge paperwork described severe left-hand contractures with the fifth finger swollen and pink, inability to visualize the nailbed, and the fifth finger was amputated. The resident and the health care proxy both stated the contracture worsened over months and that more therapy was desired but not available. For the second resident, the physician ordered a PT evaluation, but the clinical record did not show that the evaluation was completed. The resident had dementia, osteoarthritis, left shoulder pain, fatigue, major depressive disorder, and required moderate to maximum assistance with ADLs. The resident reported pain in both shoulders and difficulty lifting the arms, and later said no PT had been received recently. The NP stated PT was ordered because pain medication alone was not enough and that the evaluation was still pending. Nursing staff and the DON stated consults were to be communicated and tracked, while the DOR stated she never received the referral for the PT evaluation.
Failure to Timely Report Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to report multiple allegations of abuse and resident-to-resident altercations to the Health Care Facility Reporting System within the required time frame. The report identified failures involving residents #36, #47, #25, #55, #10, and #45, including allegations of sexual abuse, physical abuse by staff, and resident-to-resident abuse or altercations. The facility policy stated that all allegations of abuse are to be reported to the Department of Public Health within 2 hours after the allegation is made, and that suspected sexual assault, physical abuse, neglect, and resident-to-resident altercations are to be reported immediately or within the required reporting window. Resident #36, who had intact cognition on the most recent MDS and required staff assistance for care and transfers, reported that another resident repeatedly made sexually explicit comments and exposed his genitals in the hallway. The resident emailed the DON and NHA about the incident and later called the police. The DON acknowledged that the allegation should have been reported to HCFRS within 2 hours, but the report was not filed. Resident #47, who had severely impaired cognition and wandering behaviors, was documented in progress notes as exposing himself to peers and using sexually explicit language toward them. The DON and NHA both stated that this resident-to-resident sexual abuse and altercation should have been reported, but the HCFRS record did not show that it was. Resident #25, who had severely impaired cognition and daily physical behaviors toward others, was documented as having a brief altercation with another resident and as being found soaked in water after a screaming incident. The DON stated that resident-to-resident altercations, whether verbal or physical, should be reported within 2 hours, but no HCFRS report was found. Resident #55, who had intact cognition, reported that another resident had jumped into bed and grabbed her breast on multiple occasions; the DON later acknowledged the allegation should have been reported, but the HCFRS report was initiated about 14 hours after the allegation was brought to the DON's attention. Resident #10, who had moderately impaired cognition and daily verbal behaviors toward others, was documented as throwing water on a roommate after alleging the roommate was trying to climb into the bed; the DON said this was a resident-to-resident altercation that should have been investigated and reported, but it was not reported to the state agency. Resident #45, who had severe cognitive impairment, alleged that a staff member grabbed and handled her roughly, causing bruising to her arm; the DON did not report the allegation because he felt it could not be substantiated, and the HCFRS record did not show a report within the required 2-hour time frame.
Failure to Investigate Allegations of Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to investigate multiple allegations of abuse involving five residents. The report states that allegations included sexual abuse, resident-to-resident altercations, and physical abuse by staff, and that the facility did not complete the required investigations for these events. Facility leadership, including the DON and NHA, acknowledged during interviews that these allegations should have been investigated but were not. Resident #36, who was admitted in April 2025 and had diagnoses including anxiety disorder, paraplegia, and depression, had intact cognition on the most recent MDS and was dependent on staff for care and transfers. The resident reported that another resident repeatedly made sexually explicit comments, exposed genitals, and engaged in ongoing inappropriate behavior. The resident stated that the incident was reported to the DON and NHA by email and that police were called. The report notes that the allegation was not reported in the HCFRS as required, and the DON and NHA both stated that the sexual abuse allegation and the related resident-to-resident altercation should have been investigated but were not. Resident #47, who had dementia with behavioral disturbance, wandering, and traumatic brain injury, had severely impaired cognition on the most recent MDS. Clinical notes described provocative hypersexual behavior toward peers, including exposing self and making sexually explicit statements. Other residents also reported that this resident approached them with vulgar sexual comments and exposed genitals. The DON later stated that the allegation of sexual abuse involving Resident #47 should have been investigated but had not. The report also states that the NHA agreed the event should have been investigated and that a thorough investigation would include interviews with the residents involved and staff who may have witnessed the event. Resident #25, who had bipolar disorder and Alzheimer’s disease and was assessed as severely cognitively impaired, had progress notes documenting a resident altercation on multiple dates in January 2026. Notes described the resident as confused, unable to explain what happened, and involved in a brief altercation with another resident. The DON stated he was unaware of the notes at the time and that no investigation had been completed, although one should have been. Resident #45, who had Alzheimer’s disease and schizophrenia and severe cognitive impairment, reported being grabbed roughly by a staff member and having bruises on an arm. The DON’s incident report documented the resident’s statement but did not show further investigation such as staff interviews, resident interviews, skin checks, or other assessments. The DON stated that the incident report was the only investigation completed and that no further investigation was done because no bruises were visible and the resident could not recall full details. Resident #10, who had Alzheimer’s disease with late onset and anxiety disorder and was moderately cognitively impaired, was involved in an incident in which water was spilled on a roommate and the resident reported that the roommate was trying to climb into the resident’s bed. The social work note documented the incident as a resident-to-resident altercation and noted that the DON and physician were notified. The health care reporting system did not show that the facility reported the altercation to the state agency. The DON later stated that the incident should have been investigated and reported, and the Administrator stated that it should have been investigated and filed with the state agency.
Medication Storage and Security Failures
Penalty
Summary
The facility failed to store drugs and biologicals in accordance with State and Federal requirements. In the [NAME] Wing medication room, an unopened Lantus Solostar insulin pen was found at room temperature even though the manufacturer’s label indicated it should be refrigerated until opened. In the [NAME] Wing medication cart, multiple opened medications with shortened expiry dates were undated, including fluticasone propionate and salmeterol inhalers, an Airsupra inhaler, a Symbicort inhaler, latanoprost eye drops, and artificial tears. The surveyor also observed loose, unlabeled pills, one bottle of artificial tears not labeled with a resident name and stored outside its box, and medications stored touching a sticky brown substance in a drawer. Similar findings were observed in the Central Wing medication cart, including undated latanoprost eye drops, inhalers, liquid protein, artificial tears, loose unlabeled pills, and medications stored in contact with a sticky brown substance. The facility also failed to keep medication carts and the medication room secured when unattended. On one unit, the medication cart was observed unlocked and unattended in the hallway, with the nurse not within sight of it. On another occasion, the same cart was again observed unlocked and unattended in the hallway, and the assigned nurse could not be located. The medication room on the [NAME] Wing was observed ajar with no nurse in view, while two residents were wandering around the desk in front of the open room. Staff interviews confirmed that carts should be locked when unattended and that the medication room should never be left unlocked when unattended. The facility further failed to restrict access to the medication room and to separately secure a controlled drug. A nurse gave keys to a person who was not wearing a facility badge or uniform, and that person used the keys to enter the medication room out of the nurse’s sight. Staff identified the person as an off-duty nurse retrieving personal belongings. In the North/Central medication room, two bottles of lorazepam were stored in the shared medication refrigerator with non-controlled medications rather than in a separately locked, permanently affixed compartment for controlled drugs. Staff stated the facility did not have such a compartment, and the DON confirmed lorazepam should always be locked separately.
Improper Food Storage and Unsafe Meal Handling
Penalty
Summary
The facility failed to store and prepare food in accordance with professional standards for food service safety. During an initial kitchen walkthrough on 2/5/26, the surveyor observed a case of acorn squash with significant signs of decomposition, a case of sweet potatoes with textural changes and a blueish-white wispy growth, an undated bag of shredded cabbage with brown discoloration and textural changes, and a container of oranges with color changes, textural changes, and a blueish-white wispy growth. The surveyor also observed black wispy growth on shelving in the walk-in refrigerator, two undated bags of shredded mozzarella cheese with irregular blue coloring consistent with mold, a container of salsa dated opened 8/26 with blueish-white wispy growth on the outside and a slimy white substance inside, raw fish fillets stored above opened ready-to-eat ham, a box of chicken stored directly on the freezer floor, two bottles of juice opened but undated, sliced deli turkey opened but undated, salami dated 1/10/26, a fan covered in brownish stringy debris with food stored below it, and undated brownies in the reach-in refrigerator. During interview, the FSD stated he had noticed the acorn squash the day before and should have thrown it out, that kitchen staff were supposed to label and date all prepared and opened foods and discard them after seven days, and that the shredded cabbage should have been dated. He also stated the sweet potatoes should have been gone through and the ones showing signs of decomposition discarded, the black wispy growth on the shelving could be mold and food should not be stored on top of or below it, raw fish should not have been stored above opened ready-to-eat ham, the salsa should have been thrown away, the chicken should not have been stored on the freezer floor, the open juice should have been dated when opened, the deli turkey and salami should have been discarded, and food should not be stored below the fan because debris could fall and contaminate the food. The facility also failed to practice proper food handling during meals in the [NAME] Unit dining room. Staff were observed touching toast, muffins, dinner rolls, and bananas with bare hands while serving residents, including spreading jelly and buttering rolls without gloves and without washing hands between tasks. The COD was observed putting a finger inside a milk container spout to open it without gloves, and multiple CNAs and a nurse handled ready-to-eat food with bare hands. One resident took a glass of juice from a tablemate’s tray and drank it, then took food from another resident’s plate with her bare hands and ate it, and the nurse did not stop the resident from eating the food from another resident’s plate. The DON stated that food should not be touched by staff and that staff assisting with meals should wear gloves when touching food.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to provide a dignified existence for one resident when staff did not pull the privacy curtain during morning bathing care, leaving the resident naked in bed and visible to two roommates. The resident was dependent on staff for all activities of daily living, had diagnoses including dysphagia, unspecified dementia, and seizures, and had a BIMS score of 8 out of 15 indicating moderate cognitive impairment. The resident’s care plan directed staff to assist with bathing, dressing, and grooming, and the facility policy stated that staff shall promote, maintain, and protect resident privacy, including bodily privacy during personal care and treatment. During observation, CNA #4 provided care with the curtain open, and both roommates were able to see the resident receiving personal care. The CNA stated that residents should be provided privacy during care, and the DON stated that staff should pull privacy curtains when providing personal care.
Failure to Include Estimated Private-Pay Costs on SNF ABN Notices
Penalty
Summary
The facility failed to inform residents or their representatives of charges for services available in the facility that were not covered under Medicare/Medicaid or by the facility's per diem rate for two of two applicable records reviewed. The deficiency involved two residents who came off their Medicare Part A benefit, still had benefit days remaining, and remained at the facility. Review of the notices provided to these residents showed that the SNF ABN (CMS-10055) forms did not include an estimated cost of services if they chose to pay privately. During interview, the Social Worker stated she was responsible for giving the SNF ABN notices and said she left the cost breakdown sections blank because she did not know the individual costs, although she acknowledged that the resident or representative should have been given a cost breakdown if they assumed financial responsibility for skilled services. The Operations Director also stated she was unsure of the cost breakdown for skilled services, but said it should be listed on the SNF ABN.
Persistent Urine Odor on Wing
Penalty
Summary
The facility failed to maintain a home-like environment on the [NAME] Wing because the hallway repeatedly had a strong odor of stale urine during multiple survey observations. The facility policy titled "Home-like Environment Policy" stated its purpose was to provide a safe, comfortable, and dignified environment that reflects a home-like atmosphere and promotes resident choice, independence, and well-being. During the resident group meeting, 4 of 8 residents reported unpleasant odors in the facility, including comments about a poor bathroom-like odor and a constant smell of feces, and one resident stated housekeeping did not stay on top of the odors. Staff interviews confirmed the odor problem was ongoing and not resolved. A nurse said staff frequently used deodorizing spray to cover odors on the [NAME] Wing, and the primary housekeeper said she had to wash the floors 3 to 4 times a day because urine had soaked into the flooring in two resident rooms, but the cleaning only covered up the smell. A CNA said there were often strong urine odors on the wing, especially in the morning before housekeeping arrived, and carried room spray to use when needed. The Administrator stated the wing smelled of urine because a resident urinated on the floor and the urine may have soaked into the floor. Another nurse said the wing often smelled of urine and that it was expected because it was a dementia unit. The housekeeper reported she had been telling administration for over a year that she could not get the smell out of the floor, and the DOF later confirmed the urine had soaked into the flooring and said it should have been fixed promptly but was not.
Late Quarterly MDS Assessment
Penalty
Summary
The facility failed to ensure that staff completed a quarterly MDS assessment in a timely manner for Resident #27. Review of the CMS RAI Manual showed that a quarterly MDS is due every quarter, with no more than 92 days between OBRA assessments, and must be completed no later than 14 calendar days after the ARD. Resident #27, who was admitted in April 2022, had a most recent quarterly MDS with an ARD of 10/2/25, and no further MDS assessments were completed or transmitted to CMS after that assessment. During interview, the MDS Coordinator stated that Resident #27 was supposed to have a quarterly MDS completed on 12/26/25 but it was missed and acknowledged that the assessment was overdue. The DON stated that he expected the MDS Coordinator to complete all MDS assessments following the RAI manual instructions.
Failure to Develop Care Plan for Suicidal Ideation
Penalty
Summary
A care plan for suicidal ideation was not developed for one resident out of a sample of 34. The resident was admitted in December 2025 with diagnoses including schizoaffective disorder and schizophrenia. The most recent MDS indicated a BIMS score of 14 out of 15, showing the resident was cognitively intact, and also showed the resident required substantial assistance with ADLs. Review of the psychiatrist note from 12/29/25 showed the resident had experienced suicidal ideation earlier that day, but no longer expressed suicidal ideation at the time of the visit. A medical provider note dated 1/25/25 stated the resident called police at the facility requesting to leave, expressed suicidal ideation with a plan, and was placed on 1:1 monitoring for safety; the note also stated there was no suicidal ideation on assessment that day. Review of the interdisciplinary care plans showed no care plan was created to address suicidal ideation after the 12/29/25 event. During interviews, the DON stated any resident who has expressed suicidal ideation should have a care plan developed to address the concern, and the Social Worker stated any resident who expresses suicidal ideation in the present or past should have a suicidal ideation care plan developed.
Care Plans Not Revised After Quarterly MDS Reviews
Penalty
Summary
The facility failed to review and revise the comprehensive care plan after quarterly MDS assessments for 2 residents. The record review and interviews showed that the interdisciplinary team did not keep the care plans aligned with the residents’ current needs and interventions, despite the facility policy stating that the IDT develops and implements a comprehensive, person-centered care plan based on the comprehensive assessment. For one resident admitted in March 2025 with diagnoses including dementia with behavioral disturbance, wandering, and traumatic brain injury, the most recent MDS showed severely impaired cognition and wandering but no behaviors other than wandering 1-3 days a week. The resident’s active physician orders and care plan still included 15-minute checks, yet the MAR and TAR did not show those checks were performed from July 2025 until they were later implemented in February 2026. The DON stated the 15-minute checks were an outdated intervention that should have been identified during quarterly care plan meetings, and the care plan should have been revised to reflect the current plan of care. For another resident admitted in March 2025 with Alzheimer’s dementia and failure to thrive, the most recent MDS indicated the resident spoke Swahili and needed or wanted an interpreter to communicate with staff. The care plan identified a communication problem related to a language barrier, but it did not include interventions such as a communication board or translator services. Interviews with CNA, nursing, social work, MDS, and DON staff confirmed that staff could not communicate with the resident when Swahili-speaking staff were unavailable and that the expected communication supports were not included in the care plan after the MDS review.
Physician Order for Padded Side Rails Not Implemented
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for one resident. Resident #74 was admitted in January 2026 with diagnoses including seizure and epilepsy, had a BIMS score of 13 out of 15 indicating intact cognition, and was dependent on staff for activities of daily living. The medical record included an active physician order for padded side rails while in bed secondary to seizure activity, dated 2/28/23. During multiple observations on 2/5/26, 2/6/26, and 2/9/26, the resident was seen lying in bed with two quarter side rails up, and the side rails were not padded. During interview, a nurse stated the resident should have padded side rails based on the physician orders. A CNA stated he had not seen the resident's bed with padded side rails and said nurses would be the ones to place them if required. The DON stated physician orders should be followed as ordered and that the resident was ordered to have padded side rails, which should have been in place.
Failure to Provide ADL Assistance
Penalty
Summary
The facility failed to provide assistance with activities of daily living for three residents, including two residents who were dependent on staff for toileting and one resident who required help with grooming. The report states that the facility did not provide incontinence care for two residents and did not assist one resident with grooming tasks and removal of unwanted facial hair. Resident #69 had diagnoses including Alzheimer's disease, a BIMS score of 00, severe cognitive impairment, and was dependent on staff for toileting tasks with frequent incontinence of both bowel and bladder. The resident's bowel and bladder assessment indicated the resident never voided appropriately without incontinence, had daily stool incontinence, and was never mentally aware of the need to toilet. The care plan directed staff to check and change the resident every 2 hours and as needed, provide incontinent care after each episode, and toilet every 2 hours. On multiple observations, the resident remained in a wheelchair in the dining room for more than four hours at a time without being assisted to the bathroom or checked for incontinence. On one occasion, when toileting assistance was finally provided, the resident's brief was observed to be saturated with urine. Resident #67 had diagnoses including Alzheimer's disease, severe cognitive impairment, and was dependent on staff for all functional tasks and always incontinent of both bowel and bladder. The resident's bowel and bladder assessment indicated the resident never voided without incontinence, had daily stool incontinence, and was not usually aware of the need to toilet. The care plan directed staff to check and change every 2 hours, assist to toilet every 2 hours and as needed, and provide incontinent care after each episode. On multiple observations, the resident remained in the dining room in the same position for over four hours at a time without being assisted to the bathroom or checked for incontinence. When toileting assistance was eventually provided, the resident's brief was observed to be saturated with urine. Resident #45 had diagnoses including Alzheimer's disease and schizophrenia and a BIMS score of 3, indicating severe cognitive impairment. The MDS indicated the resident required moderate assistance with grooming tasks. The resident was observed with significant long chin hair and stated a desire to have the chin hair removed and to have a smooth chin without hair. On a later observation, the chin hair was still present, and the resident again stated that staff had not offered to remove it and that the resident wanted it removed. The care plan identified the resident as needing assistance with bathing, dressing, and grooming, and a CNA stated that removing unwanted facial hair is part of daily care and that the resident does not refuse grooming assistance, including chin hair removal. The DON stated that all unwanted facial hair should be removed as part of daily grooming, and the record did not indicate that the resident refused grooming assistance.
Failure to Provide Activities on [NAME] Unit
Penalty
Summary
Provide activities to meet all residents' needs. The facility failed to provide an activities program for residents on the [NAME] Unit. The facility policy stated that activities must be appropriate to each resident's needs and interests, provided in individual and group settings for ambulatory and non-ambulatory residents, and include a variety of planned activities. It also stated that a staff member must be assigned responsibility for developing, documenting, and maintaining the activities program, and that sufficient support staff must be available to meet residents' activity needs. On 2/5/26, 2/6/26, and 2/10/26, the activities listed on the activity calendar for the [NAME] Unit did not take place during the morning hours between breakfast and lunch. Surveyors observed that only three residents were given individual activities at the table while the remaining residents were lined up in front of the television, several were sleeping, and CNAs supervising the room did not engage with residents. No activity staff member was present during these observations. During interview, the Activity Director stated she was the only activity staff member, the activity assistant was on medical leave, she primarily spent time on other units, and she had not trained CNAs to run activities while supervising the room. She also stated that the [NAME] Unit residents were not having their activity needs met.
Failure to Arrange Audiology Services and Maintain Hearing Aids
Penalty
Summary
The facility failed to ensure that Resident #48, who had a diagnosis of unspecified bilateral hearing loss and severe cognitive impairment, received proper treatment and assistive devices to maintain hearing abilities. The resident’s most recent MDS indicated highly impaired hearing with an absence of useful hearing and that hearing aids were not used during the assessment. The resident’s record also showed a request for audiology services, and physician orders existed for dental, ophthalmology, optometry, and podiatry consults, but the audiology order was not initiated until after survey concerns were raised. Survey observations showed the resident repeatedly without any hearing assistive devices while dressed and sitting in the room, walking with staff, and participating in activities. During one observation, the resident stated he/she could not hear the surveyor and that the hearing aids were not present. The resident’s record contained a DON note stating staff would check to make sure the resident had hearing aids in place because the resident was very hard of hearing and did not hear without them. The record also included a nurse practitioner note stating the resident had hearing loss and used hearing aids, but there was no documentation that the resident had ever been seen by audiology services or that the resident had refused hearing aids. Interviews with the HCP, nursing staff, the Unit Manager, the DON, and the Social Worker showed that the resident had hearing aids when admitted, that they later went missing, and that staff did not notify the HCP or arrange audiology follow-up. The HCP said the resident could not hear without an assistive device and had not been seen by audiology while in the facility. Staff stated that hearing aid loss should have been reported and that the resident should have been referred to audiology, but the resident was not on the upcoming audiology schedule and had never been seen by audiology during the admission. The DON also found hearing aid batteries in the resident’s drawer, but no hearing aids were present.
Failure to Follow Fall Care Plan Supervision Intervention
Penalty
Summary
The facility failed to maintain a safe environment for one resident by not following the resident’s fall-related plan of care. Resident #38 was admitted with diagnoses including dementia and hemiplegia, and the most recent MDS indicated the resident was rarely or never understood and had severe cognitive impairment. The resident’s care plan, revised 2/2/26, identified the resident as high risk for falls related to right-side paralysis and included the intervention: do not leave the resident unattended in the room by himself/herself. Surveyors observed Resident #38 in bed without staff present in the room or visible from the hallway on multiple occasions. On one observation, a nurse later entered the room and stated she was checking on the resident because he/she should never be left alone in the room, explaining that staff must stay with the resident because he/she is a fall risk and is always trying to get out of bed. During interviews, a CNA said staff often leave the resident unattended in the room and was unaware of the care plan requirement, and a nurse said she was also unaware of the intervention. The DON stated that fall interventions in the care plan should be implemented and that Resident #38 should not have been left unattended if the care plan indicated this was an intervention.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to identify and address a significant weight loss for a resident with dementia, adult failure to thrive, and schizoaffective disorder. The resident was cognitively intact on the most recent MDS and required setup assistance for self-feeding and maximal assistance for other ADLs. During observations and interviews, the resident stated he/she was not eating because the food was being poisoned and described refusing meals, while staff reported the resident would eat preferred foods when they were obtained from the kitchen. The resident’s weights showed a decline from 149 pounds to 145.6 pounds, then to 132.6 pounds, which reflected an 8.93% loss in one month and 11% loss in three months, followed by a further drop to 122.6 pounds, a 7.54% loss in one month and a total 17.72% loss over five months. The facility policy required nursing to report weight loss to the dietitian within 24 hours, and if weight loss was verified, the dietitian was to seek care plan adjustments including snacks and supplements, with a full assessment required for weight loss over CMS guidelines. The medical record did not show that the resident was referred to the dietitian after the weight loss occurred, and the resident had not been seen by the facility dietitian since before the documented decline. The nurse practitioner noted weight loss and documented encouraging oral intake and supplements, but the record did not show that supplements were trialed, initiated, or encouraged by nursing staff. Interviews with the nurse practitioner, nursing staff, the RD, and the DON confirmed that the significant weight loss had been identified, but an assessment was not completed and nutritional interventions were not added to the resident’s plan of care.
Failure to Provide Ordered Oxygen to Two Residents
Penalty
Summary
The facility failed to provide oxygen as ordered for two residents with severe cognitive impairment and chronic respiratory conditions. Resident #21 had diagnoses including COPD, dementia, and heart failure, and was ordered oxygen at 2 liters continuous via nasal cannula to keep oxygen saturation at or above 90%. Resident #9 had diagnoses including COPD, a pulmonary nodule, and heart failure, and was ordered oxygen at 2 to 3 liters per minute with oxygen saturation checks each shift and as necessary. Both residents were dependent on staff for care and mobility, and both had care plans directing staff to provide oxygen as ordered and monitor for respiratory distress. During observation, Resident #21 was seen in bed with oxygen at 1 liter via nasal cannula, then later was brought to the dining room without oxygen properly in place. The portable oxygen tubing was wrapped around the tank instead of being placed on the resident’s nose, and later the nasal cannula was on the resident while the portable tank was empty. The resident remained with an empty tank for an extended period while compliant with wearing the cannula. When the nurse checked the resident’s oxygen saturation, it was 85%, then later the DON obtained readings of 74%, 80%, and 80% after repeated checks. The nurse stated he did not know the ordered oxygen level and had not assessed the resident’s oxygen that day, and the CNA stated that CNAs fill tanks before the shift but do not check whether they remain full. Resident #9 was observed sleeping in the dining room with a nasal cannula in place and a portable oxygen tank attached to the recliner, but the tank was empty. The nurse checked the tank and confirmed it was empty, and stated he did not know the ordered oxygen level and had not assessed the resident’s oxygen yet that day. A working oximeter was not available on the unit, so the nurse left to obtain one from another unit. When oxygen saturation was finally obtained, the reading was 74%, and later the DON obtained a reading of 80% after repeating the check. The DON stated that CNAs should be filling portable oxygen tanks and that both CNAs and nurses should be monitoring the tanks and ensuring oxygen is provided at the physician-ordered level.
Delayed Pain Management Consult for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for a resident with chronic pain by not completing a pain management consult ordered by the Nurse Practitioner. Resident #3 was admitted with diagnoses including osteoarthritis, left shoulder pain, fatigue, and major depressive disorder, and the most recent MDS showed the resident was cognitively intact and required moderate to maximum assistance with ADLs. The resident reported ongoing pain in both shoulders that ranged in severity and limited arm movement, stated the current pain regimen was not working, and said staff told him/her to take more medication. The resident also said the pain was causing depression and frustration because of the inability to use his/her arms. The resident’s pain care plan included administering pain medication as ordered and PRN breakthrough medication with effectiveness noted, and the physician order dated 12/9/25 directed a pain management consult and orthopedic follow-up for pain in multiple joints. The medical record did not show that the pain management consult was completed. The Unit Manager stated the facility emails the pain doctor when a consult is ordered and believed the DON had done so, while the NP said the consult was still pending and that the resident’s pain could not be managed by medication alone. The DON acknowledged the consult had not been completed and said there was a two-month delay in communicating the consult to the pain doctor, providing an email request dated 2/9/26. The resident’s activated HCP said the pain regimen was not effective, the pain had worsened over the last one to two years, and the resident had declined and stayed in bed more.
Failure to Update Trauma Care Plan After Sexual Abuse Report
Penalty
Summary
The facility failed to ensure one resident was provided a trauma informed plan of care after the resident reported sexual abuse by a peer. The resident was admitted in April 2025 with diagnoses including anxiety disorder, paraplegia, and depression, and the most recent MDS indicated intact cognition with a Brief Interview for Mental Status score of 15 out of 15, no behaviors, and dependence on staff for care and transfers. The resident’s trauma care plan, last updated on 4/28/25, addressed a history of trauma related to an accident and paraplegia, with interventions such as encouraging the resident to identify trauma triggers, verbalize feelings, and providing support for loud noises or aggressive behavior from others. The resident reported that another resident repeatedly made sexually explicit and threatening comments, including an incident in which the other resident approached the resident in the hall and made vulgar sexual statements. The resident stated that the issue had been reported to the facility multiple times, that an email was sent to the DON and NHA, and that police were called. The resident also stated that the other resident’s behavior continued after the police response and that the resident lived in fear because he/she could not protect himself/herself or get up and run. Review of the medical record showed the trauma care plan was not updated after the sexual threats and abuse report to include resident-specific triggers and interventions related to the incident. Interviews with staff confirmed the need for an updated trauma care plan: the CNA said the resident became scared and uncomfortable when hearing the accused resident nearby during care, the SW said the resident should have a trauma care plan addressing support needs, the DON said the plan should have been updated after the incident, and the NHA said safeguards should have been put in place and the trauma care plan updated following the event.
Failure to Manage Dementia-Related Wandering and Sexual Behaviors
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident diagnosed with dementia, traumatic brain injury, wandering, and other behavioral disturbance. The resident had severely impaired cognition on the most recent MDS assessment and was documented as wandering, entering other residents’ rooms, disrobing in hallways and common areas, and making sexually inappropriate remarks and gestures toward other residents. Nursing progress notes repeatedly described the resident as disruptive, difficult to redirect, and continuing the same behaviors after redirection attempts. The resident’s record showed multiple behavior-related care plans, including plans for cognitive impairment, psychotropic medication use, aggression, and inappropriate sexual behavior. Those plans included interventions such as monitoring target behaviors, documenting episodes, protecting other residents, and closely monitoring the resident to prevent recurrence of aggression. The record review found that the care plans and interventions were not reviewed after the resident’s sexual abuse of a peer, and they were not revised when the documented interventions were ineffective. Survey findings and interviews showed that staff were aware of the resident’s ongoing behaviors and that the behaviors continued despite repeated redirection. A DON note documented that police were called after residents reported the resident exposing himself/herself and making sexually explicit statements. During interviews, residents reported feeling unsafe and described repeated sexual comments and exposure. Staff, including CNAs, the SW, the DON, and the psychiatrist, stated that the resident was not appropriate for the facility, that the resident should be on a dementia specialty care unit, and that the resident’s behaviors were not being adequately managed within the facility.
Failure to Provide Social Services Support After Sexual Threats
Penalty
Summary
The facility failed to provide medically-related social services to support the highest practicable mental and psychological well-being for one resident. Resident #36, who had diagnoses including anxiety disorder, paraplegia, and depression, was cognitively intact on the most recent MDS and was dependent on staff for self-care and transfers. The resident reported that another resident repeatedly made sexually explicit threats and inappropriate comments, including an incident in which the other resident allegedly exposed his/her genitals and made vulgar sexual statements while the resident was seated in the hall with other residents. Resident #36 stated that the incident was reported to the DON and NHA by email and that police were called the same day. The resident said the accused resident was taken to the hospital by responding police officers but returned the next day, and the behaviors continued. Resident #36 also stated that he/she lived in fear that the other resident would take the abuse further and that the facility SW never followed up in person or offered emotional support. Emails in the record showed the resident repeatedly asked that the residents be removed from the area because they were out of control and sexually inappropriate, while the SW responded by email that staff would try to redirect wandering residents and supervise them more closely. The medical record did not show that the abuse was addressed by the SW, and the care plan did not include resolved or current care plans related to the sexual abuse incident or the resident’s report of ongoing abuse. During interviews, the psychiatrist, DON, NHA, and medical director each stated that the resident should have received support and follow-up from the SW after the sexual abuse and threats. The SW stated she was not informed about the initial incident, did not meet with the resident in person, and did not provide talk therapy in the facility because the psychotherapist had left and had not been replaced.
Delayed Response to Pharmacist Eye Drop Recommendation
Penalty
Summary
The facility failed to address and implement the Consultant Pharmacist’s medication regimen review recommendation in a timely manner for one resident. The resident was admitted in September 2022 with diagnoses including glaucoma, dementia, and bipolar disorder, and had physician orders for Latanoprost 0.005% ophthalmic solution in both eyes in the evening for glaucoma and Artificial Tears ophthalmic solution 1% in both eyes three times a day for dry eye. The Consultant Pharmacist’s medication regimen review repeatedly noted that the resident was ordered multiple eye drops and that the eye drops should be separated by at least 5 minutes during administration. The recommendation was documented in December 2025 and again in February 2026, but the resident’s clinical record did not show that the December 2025 recommendation was reviewed or responded to by the provider. During interview, the DON stated the Consultant Pharmacist sends recommendations to him, he gives them to the provider for agreement or disagreement, and nursing enters the orders into the EHR; he also stated that a two-month delay in implementing recommendations would be considered a delay in care.
Unnecessary Psychotropic Medication Use and Missing AIMS Monitoring
Penalty
Summary
The facility failed to ensure that four residents were free from unnecessary psychotropic medication use. For one resident with diagnoses including anxiety, dementia with psychotic disorder, unspecified psychosis, major depression, generalized anxiety, and restlessness/agitation, the psychiatrist recommended decreasing Seroquel and discontinuing the morning dose, but the resident’s record did not show that nursing notified the physician or that the recommendation was implemented. The resident’s orders still reflected Seroquel in the morning and at other times, and staff interviews showed the recommendation had been reviewed but not acted on. For two residents receiving antipsychotic medications, the facility did not complete AIMS assessments as expected. One resident with schizophrenia, unspecified mood disorder, and anxiety disorder was ordered ziprasidone, but the record did not show an AIMS assessment since the psychiatrist noted no AIMS symptoms. Another resident with schizoaffective disorder bipolar type and schizophrenia was ordered clozapine, and the record did not show an AIMS assessment completed upon admission. Staff interviews showed uncertainty about who completed AIMS assessments and when they were required, while the DON stated they should be completed upon admission and quarterly. A third resident with dementia, bipolar disorder, unspecified psychosis, anxiety, and major depressive disorder was receiving risperidone 0.5 mg daily and 2 mg in the evening. The resident’s psychotropic care plan included monitoring for side effects and adverse reactions, but the medical record did not show an AIMS assessment since the prior year. Interviews with nursing, social work, and the DON showed inconsistent understanding of responsibility for completing AIMS assessments, and the DON stated the assessment should have been completed for this resident.
Failure to Provide Dental Services and Replace Missing Dentures
Penalty
Summary
The facility failed to provide dental services and replace missing dentures for one resident with severe cognitive impairment and dependence on staff for activities of daily living. The resident was admitted with diagnoses including unspecified dementia, mood disturbance, anxiety, and major depression. The resident’s daughter and health care proxy reported that the resident’s dentures had been missing for about a year and said she had not seen the resident wearing them in a long time. She also believed the resident may have lost weight because of not wearing the dentures. During the survey, the resident was observed in the dining room for breakfast and lunch without dentures in place. The resident’s medical record included a dental consult order and a signed consent for dental services, but the record did not show that the resident was ever seen by a dentist or dental hygienist. An email from the resident’s daughter to the social worker stated that staff had tried to locate the missing lower dentures and could not find them, and that a request had been made for the resident to be seen by the dentist. The resident’s care plan included oral hygiene and brushing three times daily and noted that the resident had dentures that should be washed daily and ensured clean in the mouth. When the unit manager and surveyor searched the resident’s room and treatment cart, they found a container labeled with the resident’s name containing a pair of lower dentures, but the upper dentures could not be found. The unit manager said she was unaware the resident had dentures and did not know why the resident had not been seen by the dentist. The CNA said she was unaware whether the resident had dentures and did not assist with placing dentures in. The social worker said she was unaware of the missing dentures and did not recall the email about the lost dentures and dental appointment. The DON said he was unaware the dentures were missing and was unaware the resident had not been seen by the dentist while at the facility.
QAPI Program Did Not Address Identified Clinical Concerns
Penalty
Summary
The facility failed to develop, implement, and maintain a QAPI program that addressed the full range of care and services and used a systematic, data-driven approach to identify underlying causes of problems, develop corrective actions, and monitor whether performance improvement activities were effective. The facility policy stated that QAPI should cover clinical care, quality of life, resident choice, care transitions, feedback, data monitoring, performance improvement projects, and system analysis, but the facility's QAPI plan did not show that a QAPI had been developed for the systemic concerns identified by surveyors in rehabilitation services, contracture management, or abuse reporting, investigation, and prevention. During interview, the Administrator said he oversaw QAPI, that the facility had recently moved from quarterly to monthly meetings, and that recent projects had focused on environmental improvements and dietary menu accuracy. When asked about clinical areas, he could not name any recent QAPI work. He stated that QAPI projects should be triggered by adverse events, including events related to contracture management, rehabilitation services, and abuse allegations, but the facility did not complete QAPI projects for those concerns even though they were known issues. The DON said he identified issues by talking with nursing staff and was responsible for the clinical part of QAPI, but QAPI projects were not developed for contracture management or rehabilitation services; he also stated that he recognized concerns when therapy staff were not available for necessary treatments earlier in the fall.
Failure to Follow EBP During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program on the North Unit for two residents who were on Enhanced Barrier Precautions (EBP). Resident #74 was admitted with dysphagia and a gastrostomy tube, and physician orders included enteral feeding every shift and daily tube site care. On 2/5/26 and again on 2/6/26, a CNA was observed providing morning care to Resident #74 without wearing a gown, despite an EBP sign posted at the room entrance and a PPE bin located in the hallway outside the room. During interview, the CNA stated the resident was not on precautions and believed the signage and PPE bin belonged to a previous resident. A nurse later stated that residents with wounds and medical devices should be on EBP and that the CNA should have worn PPE when providing care. Resident #6 was admitted with dementia and a pressure ulcer, and had an order dated 2/11/26 for daily wound care to a stage 4 full-thickness right heel wound. On 2/6/26, a nurse brought the entire treatment cart into Resident #6's room to perform the dressing change and was observed multiple times removing soiled gloves without performing hand hygiene before putting on new gloves. During interview, the nurse stated the resident was on EBP, that the treatment cart should not have been brought into the room, and that hand hygiene should have been performed between glove changes. The DON stated that EBP should be followed for residents with medical devices or wounds and that nurses are expected to perform hand hygiene when changing gloves.
COVID-19 Vaccine Given Without Proxy Consent
Penalty
Summary
The facility failed to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible residents and staff after education, and properly document vaccination status when it administered the COVID-19 vaccine to one resident without consent from the resident or the resident’s health care proxy. The resident was admitted in October 2022 with diagnoses including unspecified dementia, mood disturbance, anxiety, and major depression, and the most recent MDS showed a BIMS score of 1, indicating severe cognitive impairment. The resident was dependent on staff for activities of daily living and required supervision for mobility tasks, and was not able to participate in an interview during the survey period because of cognitive status. The resident’s daughter and health care proxy told surveyors that she had informed the facility she did not want the resident to receive the COVID-19 vaccine and that the resident would not have agreed to it if cognitively able. The medical record contained an email from the daughter stating she did not want the resident getting the vaccine. Despite this, the physician record included an order for Comirnaty COVID-19 vaccine, and the November 2025 MAR and nursing note documented the vaccine as administered. The DON initially stated he believed the resident had not received the vaccine because he only saw the nursing note, but after re-reviewing the record he stated that because there was an order and the nurse documented administration, the vaccine must have been given without the health care proxy’s consent.
Inaccurate MDS Coding for Restraints, Communication, and Pressure Ulcer
Penalty
Summary
Resident #1’s MDS assessment dated 12/23/25 inaccurately coded the use of restraints as less than daily. The resident was admitted in September 2025 with diagnoses including Alzheimer’s dementia and had a BIMS score of 3 out of 15, indicating severe cognitive impairment. Survey observations on multiple dates found the resident seated without restraints, and review of the physician’s orders, plan of care, and nursing progress notes for the assessment period did not show restraint use. A nurse who worked with the resident in December 2025 stated the facility was restraint free and that the resident was never restrained, and the MDS Coordinator confirmed the assessment was coded inaccurately. Resident #50’s MDS assessment dated 12/11/25 inaccurately coded the resident as rarely/never understood and did not complete the BIMS and Mood interviews. The resident was admitted in March 2025 with diagnoses including Alzheimer’s dementia and preferred to speak Swahili, with an interpreter needed or wanted to communicate with staff. A CNA stated the resident speaks Swahili, can understand English enough to answer basic questions, and communicates other needs with Swahili-speaking staff. The MDS Coordinator and Social Worker both stated the resident was usually able to understand and make needs known in Swahili, that the resident should not have been coded as rarely/never understood, and that the interviews should have been attempted and completed in the resident’s preferred language. Resident #24’s discharge MDS dated 12/16/25 and annual MDS dated 12/19/25 failed to indicate a pressure ulcer despite documentation of an unstageable necrosis wound on the left hand. The resident was admitted in December 2024 with diagnoses including osteoarthritis, heart failure, and hypertension. Records showed a weekly skin assessment identifying unstageable necrosis on the left hand, a dietitian note describing an unstageable necrosis left hand wound, ongoing treatment orders for soaking and dressing the left hand throughout December 2025, and a hospital discharge summary stating the patient had a pressure ulcer with wound care recommendations. A nurse confirmed the resident had a known unstageable pressure ulcer in the contracted left hand at discharge, and the MDS Coordinator stated both MDS assessments were coded inaccurately.
Failure to Honor Resident Access to Personal Funds and Maintain Interest-Bearing PNA Accounts
Penalty
Summary
The facility failed to honor a resident’s right to manage personal finances by not providing access to personal funds of less than $100 within the same day. Resident #15, admitted in February 2023 with diagnoses including vertigo of central origin and major depressive disorder, had intact cognition on the most recent MDS with a BIMS score of 15 out of 15 and was identified in the care plan as his/her own responsible decision-making party. During interview, the resident stated that the NHA refused access to the resident’s personal account balance of $3,300, saying it was not right because the resident was a Veteran and had earned the money. The care plan did not identify any concerns about financial mismanagement or the need for a conservator, yet the NHA stated she often would not let the resident have money when requested because the resident had previously lost cash after receiving it and because the resident frequently asked for money and used it for takeout purchases. The facility also failed to maintain the resident’s personal needs account in an interest-bearing account, and this issue affected 7 of 18 residents in the sample. The facility policy stated that residents’ money managed by the facility would be kept in a separate interest-bearing account and that accurate records and quarterly accounting would be maintained. Review of the resident’s PNA statement for the period reviewed of 2023 to 2025 did not show accrued interest, and the NHA acknowledged that the pooled resident funds were not interest bearing and should be. For the additional 7 residents whose PNA statements were reviewed, the records likewise did not show accrued interest for the period reviewed, and the NHA confirmed the facility was the rep-payee for those residents and that their PNAs should have been accruing interest.
Failure to Document and Administer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or administer influenza and pneumococcal vaccinations in accordance with its policies and CDC recommendations for four of five residents reviewed. The deficiency involved three residents who did not have documentation of receiving the most recent influenza vaccine for the 2024 to 2025 season, and two residents who did not have documentation of receiving pneumococcal vaccination. The facility policy stated that residents would be assessed for vaccination status, offered vaccines unless medically contraindicated or previously vaccinated, and that refusals or administrations would be documented in the medical record. Resident #6, who was admitted in May 2020 and was greater than [AGE] years old, had influenza vaccine consents dated 9/25/20 and 11/5/22 and an active physician order dated 11/1/23 stating the resident may have the annual influenza vaccine. Review of the immunization tab in the electronic health record and the paper medical record did not include documentation showing the resident received the most recent influenza vaccine. The same resident also had a pneumococcal vaccine consent dated 9/25/20 and a physician order dated 11/1/23 stating the resident may have the annual pneumococcal vaccine, but the immunization record did not include documentation showing the pneumococcal vaccine was given. Resident #21, admitted in February 2022 and greater than [AGE] years old, had an active physician order dated 10/26/23 stating the resident may have the annual influenza vaccine, but the immunization record did not show documentation of the most recent influenza vaccine. Resident #25, admitted in June 2020 and greater than [AGE] years old, had an influenza vaccine consent dated 9/19/23 and a physician order dated 10/29/23 stating the resident may have the annual influenza vaccine, but the immunization record also lacked documentation of the most recent influenza vaccine. Resident #42, admitted in December 2024 and greater than [AGE] years old, had a pneumococcal vaccine consent dated 1/14/25 and a physician order dated 12/23/24 stating the resident may have the pneumococcal vaccine, but the immunization record did not show that the pneumococcal vaccine had been administered. During interview, the Administrator and Director of Social Services stated they were unable to find documentation that the three residents received influenza vaccines, noting they had received them in the past with consent in the medical record. They also stated they were unable to provide documentation of the pneumococcal vaccines for Residents #6 and #42. During a separate interview, the DON stated they did not have the influenza vaccines because they did not have an annual consent signed by the resident's health care agent and said he was unsure why the pneumococcal vaccines were not administered.
Care Plan Not Revised After Fall-Related Wrist Fracture
Penalty
Summary
The facility failed to ensure the comprehensive care plan was revised by the interdisciplinary team after each assessment for one resident out of 18 sampled residents. Resident #21, admitted in February 2025 with diagnoses including dementia, diabetes, and rheumatoid arthritis, had a severe cognitive impairment with a BIMS score of 0 and required assistance with all personal care and mobility. The most recent MDS dated 7/31/25 indicated a recent fall, but did not identify a fracture. Record review showed that after an unwitnessed fall, the resident sustained an undisplaced distal radial fracture of the left wrist, with nursing and physician notes documenting the injury on 7/9/25. A later physician note stated the resident remained nonweightbearing on the affected extremity, had a cast in place, was to have orthopedic follow-up and repeat x-ray, and was to continue Tylenol for pain. The current plan of care did not include care for the wrist fracture or interventions to prevent future falls. During interviews, the MDS nurse, Unit Manager, and DON stated that care plans should be updated after MDS assessments and when the resident returned from the hospital, and the DON stated the resident’s care plans did not include the new diagnoses, treatments, precautions, or rehabilitative measures.
Failure to Implement Ordered Protective Devices
Penalty
Summary
The facility failed to ensure that nursing services met professional standards for two residents by not implementing physician-ordered protective devices as documented. One resident had diagnoses including dementia and a history of a right ankle unstageable pressure ulcer, and the most recent MDS showed severe cognitive impairment and dependence on staff for lower body dressing, including footwear. The resident had active orders for heel protectors while in bed and a heel protector protocol, but survey observations on multiple occasions showed the resident in bed with heels directly touching the mattress and no heel protectors in place. Documentation in the MAR and TAR indicated the heel booties were being implemented, but this conflicted with what the surveyor observed. Staff interviews also reflected that the resident was not wearing heel boots, with one CNA stating the resident had not worn them in a long time and did not need them. Another nurse stated the resident was supposed to wear heel booties and that staff were responsible for ensuring they were on, while the DON stated nursing should implement the order and, if the resident was not using them, the order should be discontinued. At the time of observation, there were no booties in the resident’s room. A second resident had diagnoses including dementia, atrial fibrillation, depression, and anxiety, and the MDS showed severe cognitive impairment, need for substantial assistance with upper body dressing, risk for skin breakdown, anticoagulation use, and daily rejection of care. The resident had active orders for Eliquis, aspirin, and bilateral geri sleeves for frail, fragile, paper-thin skin. Survey observations on multiple occasions showed the resident’s arms without geri sleeves, including when the resident was in bed. The MAR documented the geri sleeves as implemented, but staff interviews stated the resident had not worn them in a long time and staff had stopped applying them because the resident would take them off, while other staff acknowledged the resident was supposed to wear them and the DON stated the order should be implemented or revised.
Air Mattress Set Incorrectly for Resident With Stage 4 Pressure Ulcer
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident with a history of a stage 4 sacral pressure ulcer, Alzheimer’s dementia, moderate protein-calorie malnutrition, severe cognitive impairment, and dependence on staff for all activities of daily living. The facility policy required air mattresses to be pumped in accordance with the resident’s weight, and the resident’s physician order dated 10/24/23 directed that the air mattress be checked for placement and function and set to the 120 weight line with the static bottom off every shift. The resident’s care plan also directed that the air mattress be set to the weight line of 118 pounds and the static light be off. During observations on multiple days, the resident was lying or sleeping in bed while the air mattress was operating and set between the 320-400 line, with a black mark next to the dial indicating the correct weight setting should have been between 80-160. A TAR dated 9/4/25 documented ongoing treatment for the resident’s stage 4 coccyx wound. During interviews, a CNA stated only the company adjusts the mattress settings, a nurse stated the mattress should be at line 120 and that setting it too high could affect the resident’s skin and increase pressure ulcer risk, and the Unit Manager and DON stated the mattress should be set according to the physician’s order and resident weight.
Failure to Follow Foley Catheter and Drainage Bag Orders
Penalty
Summary
The facility failed to ensure professional standards of practice for the care of a urinary catheter for one resident. Resident #23 was admitted with diagnoses including urinary tract infection, urinary retention, acute kidney failure, and heart failure, and the most recent MDS indicated the resident was cognitively intact, dependent on staff for toileting, and required an indwelling urinary catheter. The resident's care plan and physician's order directed that a 16 Fr Foley catheter with a 5 ml balloon be changed every month on the 12th day, and a separate physician's order directed that the urinary catheter drainage bag be changed every Thursday. During observation on 9/2/25, the resident's urinary catheter drainage bag was dated 8/14/25, and it remained dated 8/14/25 during a later observation the same day. The TAR showed nursing documented the catheter was changed on 8/12/25 as ordered, but the MAR showed the drainage bag was documented as changed on 8/14/25, 8/21/25, and 8/28/25. In interviews, nursing staff and the Unit Manager stated that catheter and bag changes should follow physician orders, that the correct catheter size should be used, and that bag changes are completed to help reduce infection risk. On 9/4/25, the DON and surveyor observed the resident with a 16 Fr 30 ml balloon catheter inserted into the bladder, which did not match the documented order for a 16 Fr 5 ml balloon catheter.
Unqualified Food Service Director
Penalty
Summary
The facility failed to designate a person who met the minimum qualifications to serve as the Food Service Director (FSD). Based on record review and interviews, the facility did not employ a full-time dietitian and did not have a qualified dietary employee who met the minimum qualifications for the FSD role. The FSD stated he had been employed since March 2025, had attended college but did not complete a degree, and provided food safety training, a certificate for food service professionals, and an allergen awareness certificate. The Registered Dietician stated she was not employed by the facility on a full-time basis and came to the facility two to three days a week. During review of the regulatory requirements, the FSD acknowledged he did not meet the requirements to serve as the FSD, and the Executive Director also stated that the FSD did not meet the regulatory requirements for the position.
Pureed Diets Not Served Per Posted Menu
Penalty
Summary
The facility failed to serve the pureed meal items listed on the posted menu for three observed meals. The facility policy on Nutritional Services - Menu Planning indicated that standard and therapeutic diets are to be professionally planned and approved by a qualified registered dietitian in accordance with physician orders and current dietary allowances. However, during lunch on 9/3/25, the Food Service Director (FSD) served pureed diets beef in tomato, mashed potatoes, and spinach instead of the menu items of chicken piccata or spinach stuffed sole, parmesan orzo, and spinach. The FSD stated that the facility practice was to serve pureed diets foods that were up to five days old and not to puree the posted menu items for those diets. During dinner on 9/3/25, the cook served pureed diets ground beef in tomato, spinach, and mashed potatoes instead of the posted cheeseburger with caramelized onions or egg salad, steak fries, and carrots. On 9/4/25, the surveyor again observed pureed diets being served ground beef in tomato, mixed vegetables, and mashed potatoes instead of the posted breaded pork chop and gravy or broccoli and cheddar quiche, au gratin potatoes, and summer blend vegetables. The Dietitian stated that residents requiring a pureed diet should receive the same entree as the regular textured diets and was not aware the FSD was not following the menus. The FSD later said he did not understand that he should be serving the pureed diets based on the menu breakdown, and the Executive Director stated that the cooks and FSD needed to follow the menu for pureed diets and that the puree diet should be receiving the same meal as posted.
Inappropriate Dessert Served to Resident on Nectar-Thickened Liquids
Penalty
Summary
The facility failed to provide the appropriate dessert for one resident who required nectar-thickened liquids. Resident #42, admitted with diagnoses including dementia and diabetes, had an active physician order for a controlled carbohydrate diet with pureed texture and nectar consistency for dysphagia. The resident’s MDS indicated memory impairment and severely impaired cognitive skills for daily decision making, and the care plan directed staff to provide and serve the diet as ordered. During observation, Nurse #2 was seen feeding Resident #42 green gelatin, which returns to a thin liquid consistency. When interviewed, Nurse #2 stated the resident required a pureed diet and nectar-thickened liquids but believed gelatin was allowed under the diet order. The Dietitian stated gelatin should not be served to residents requiring nectar-thickened liquids and reported that six residents who required nectar-thickened liquids received gelatin because kitchen staff, including the FSD, were not aware that gelatin was not appropriate. The DON also stated Resident #42 should not have received gelatin, and the FSD later stated residents on nectar-thickened liquids should have received pudding.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment and utensils for one resident in the sample, Resident #62, who had diagnoses including paranoid schizophrenia, dysphagia, moderate protein-calorie malnutrition, and dementia with behavioral disturbances. The resident’s most recent MDS indicated severe cognitive impairment, required set up and clean up assistance with eating, and had no weight recorded. The resident’s physician’s orders, care plan, dietary communication slip, and dietician assessment all identified the need for adaptive eating utensils and a two-handled cup or sippy cup to support self-feeding and meal intake. During multiple meal observations, the surveyor found that the meal tray slips indicated a two-handled cup and built-up utensils should have been provided, but these items were not on the tray. Instead, the resident was served regular cups with straws on some occasions, and the resident was observed with shaking hands and difficulty managing cups and utensils while eating breakfast and lunch. CNA #6 stated she had asked the kitchen for the built-up utensils but was told none were available. The Food Service Director stated the meal slip should match what is served on the resident’s tray, and the Unit Managers and DON stated nursing staff were responsible for checking the tray and obtaining the adaptive equipment if it was missing.
Inaccurate Skin Check Documentation
Penalty
Summary
The facility failed to ensure nursing accurately documented weekly skin checks in the electronic health record for three sampled residents. The deficiency involved inaccurate skin documentation that did not match the residents’ actual skin condition as observed by surveyors and as described by facility staff during interviews. Resident #35 was admitted with dementia and a history of a right ankle unstageable pressure ulcer, and the most recent MDS showed severe cognitive impairment. The resident had an order for weekly skin assessments and a care plan directing staff to document weekly skin checks. However, multiple Skin Only Evaluation assessments documented a left foot discoloration measuring 5 cm by 2.5 cm that was painful and warm. A consultant podiatry note described the feet as having pallor, normal temperature, thin skin texture, and no skin discoloration. CNA #1, Nurse #2, and the DON all stated the resident had no skin issues on the feet, and the surveyor and DON observed no skin issues on the resident’s feet during the survey. Resident #8 was admitted with dementia, atrial fibrillation, depression, and anxiety, and the most recent MDS showed severe cognitive impairment. Earlier records documented a left buttock abscess and a swollen, reddened right ring finger, and later wound orders were entered for the left buttock and right fourth finger. Despite documentation showing ongoing skin issues on repeated Skin Only Evaluations, the surveyor was unable to observe a blister on the right ring finger on multiple days, and CNA #2, the Unit Manager, and the DON stated the resident no longer had areas on the buttocks or finger. The DON also stated the left buttock wound had healed in May and the finger wound had healed in June, but nursing continued to document the areas on skin checks. The surveyor and DON observed no skin issues on the resident. Resident #62 was admitted with paranoid schizophrenia, moderate protein-calorie malnutrition, and dementia with behavioral disturbances, and the most recent MDS showed severe cognitive impairment and multiple pressure ulcers/injuries or open lesions. The resident had numerous active wound and skin-monitoring orders, including treatment for the left great toe, forehead, left ankle, left thigh, right lower leg, right shin, and monitoring of reddened areas. Skin checks documented ongoing forehead carcinoma and right shin wounds on several dates, and one note documented no skin issues. Nursing notes and interviews showed inconsistent documentation: Nurse #7 listed multiple wounds, Nurse #6 stated weekly skin checks should match current treatments, then later stated the resident did not have wounds on the left thigh or left great toe and that she did not document daily because the resident was not followed by the wound doctor. The DON and Unit Manager stated skin checks should reflect the resident’s actual skin integrity, while the resident was described as resistive and combative during wound care and the surveyor could not fully observe some areas.
Late Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure quarterly MDS assessments were completed within the required time frame for two residents out of 18 reviewed. Resident #20 was admitted in January 2025, and the quarterly MDS assessment dated 4/30/25 was completed on 5/26/25; as of 9/5/25, another quarterly MDS had not been completed, making it 37 days late. Resident #6 was admitted in April 2025, and the quarterly MDS assessment dated 7/30/25 was not completed until 9/3/25, making it 21 days late. During a telephone interview, the MDS Nurse stated she was responsible for completing MDS assessments and was not aware that the MDSs for Resident #30 and Resident #6 were late, describing the late assessments as oversights on her part. The DON stated he would expect the MDSs to be completed timely and according to the RAI manual.
Late Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted within 14 days after completion for three residents, identified in the report as Residents #38, #7, and #28, out of a sample of 18 residents. Review of the CMS RAI Manual, Version 3.0, indicated that assessments must be completed no later than 14 calendar days after the ARD and transmitted and encoded within 14 days of assessment completion. Resident #38 was admitted in November 2023, and the most recent MDS assessment was completed on 8/15/25 but had not been submitted as of 9/5/25, 21 days later. Resident #7 was admitted in July 2021, and the most recent MDS assessment was completed on 8/15/25 but had not been submitted as of 9/5/25, also 21 days later. Resident #28 was admitted in April 2025, and the most recent MDS assessment was completed on 8/14/25 but had not been submitted as of 9/5/25, 22 days later. During interview, the MDS Nurse said quarterly MDS assessments should be submitted within 14 days of completion, but these three residents' assessments were not submitted on time. She stated she was in training on how to submit MDSs and relied on the previous MDS Nurse to submit them, and was not aware they were late. The DON stated he expected MDS assessments to be completed per the RAI manual and submitted within 14 days of completion.
Inaccurate MDS Coding for Medications and Diagnosis
Penalty
Summary
The facility failed to ensure that MDS assessments were coded accurately for four residents. For Resident #24, the 7/01/25 MDS indicated antianxiety medication use, but review of the June and July 2025 MAR and physician orders did not show an antianxiety medication; the order for donepezil 10 mg at bedtime was listed for bipolar/anxiety, but donepezil is a cholinesterase inhibitor used to treat dementia. The MDS Coordinator stated she was not aware medications should be coded by classification rather than the reason for use, and the Executive Director stated it was his expectation that the MDS be coded accurately. For Resident #42, the 7/22/25 MDS coded antianxiety medication use and did not code hypoglycemic or anticonvulsant medication use. Review of physician orders showed glipizide ER 5 mg daily for diabetes and divalproex sodium 750 mg twice daily related to dementia, both administered during the assessment reference date. The MDS Nurse reviewed the orders, MAR, and MDS and stated she did not code the antianxiety, hypoglycemic, and anticonvulsant medication use correctly, and said she was not aware medications should be coded by classification rather than the reason for use. For Resident #3, the 7/23/25 MDS coded antianxiety medication use, but the July 2025 MAR did not show an antianxiety-classified medication. The physician orders showed fluvoxamine 50 mg twice daily for OCD and trazodone 50 mg daily for agitation related to unspecified mood disorder. For Resident #7, the 5/03/25 MDS listed schizophrenia as an active diagnosis, but the physician stated a 12/19/22 note documenting paranoid schizophrenia had been entered in the wrong medical record for another resident. The physician, DON, and MDS Nurse all acknowledged the diagnosis was inaccurate and that the MDS should reflect the accurate active diagnosis.
Neglect in Implementing Wound Care Treatments
Penalty
Summary
The facility failed to protect three residents from neglect, specifically in the implementation of wound care treatments as recommended by the Consultant Wound Physician. For Resident #20, the facility neglected to implement wound treatments, resulting in the deterioration of a pressure injury from a closed unstageable to a Stage 4 pressure injury. The facility also failed to follow up on a progress note indicating right hip redness and did not implement the use of an air mattress. Observations revealed that care-planned interventions, such as the use of prevalon boots and an air mattress, were not implemented, and there was a lack of documentation and follow-up on new skin issues. Resident #23 was also neglected as the facility failed to implement treatment recommendations for a stage two pressure wound on the left heel. The resident was observed with heels directly on the mattress and without the necessary dressing, despite the wound physician's recommendations. The nursing staff did not communicate the wound recommendations to the medical doctor, and there was no treatment order in place for the resident's pressure ulcer. For Resident #26, the facility neglected to implement the treatments as recommended by the Consultant Wound Physician, resulting in undocumented wound treatment and failure to implement treatment orders for newly identified pressure ulcers. The resident had multiple pressure ulcers and non-pressure wounds, and the facility did not follow the wound physician's dressing treatment plans. Interviews with staff revealed a lack of awareness and communication regarding the residents' wound care needs and treatment recommendations.
Failure to Implement Wound Care Recommendations
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure injuries for three residents. For one resident, the facility did not implement the treatments and physician orders recommended by the Consultant Wound Physician, resulting in the deterioration of an unstageable pressure wound to a Stage 4 pressure injury. The facility also failed to use an air mattress and did not follow up on a progress note indicating right hip redness, leading to the development of a right hip wound. Another resident did not receive the treatment recommendations by the Wound Consultant Physician for wound care. The facility's policy on pressure injury risk assessment and decubitus prevention was not followed, as evidenced by the lack of timely risk assessments, skin inspections, and implementation of care plans based on identified risk factors. The facility also failed to notify the attending providers of the wound consultant's recommendations and did not implement the recommended wound treatments in a timely manner. The facility's lack of communication and documentation contributed to the deficiencies. Nursing staff did not have access to wound recommendations and visit notes, and there was no unit manager or Director of Nurses to oversee the implementation of wound care. The Medical Director and Nurse Practitioner were not made aware of the resident's condition and treatment orders, leading to inconsistencies in care and documentation. The facility's failure to follow the wound consultant's recommendations and implement preventative measures resulted in the worsening of pressure injuries for the residents.
Inadequate Training and Competency in Wound Care
Penalty
Summary
The facility failed to ensure that nursing staff were adequately trained and demonstrated the necessary competencies to provide appropriate care for residents, particularly in the area of pressure injury and wound care. This deficiency was highlighted by the case of a resident who was admitted with several medical conditions, including Alzheimer's disease and a cognitive communication deficit. The resident developed an unstageable deep tissue injury (DTI) on the right heel, which deteriorated into a Stage 4 pressure injury due to the staff's failure to implement recommended treatments and notify the physician of the wound's progression. The survey revealed that the facility did not conduct proper training or competency evaluations for its nursing staff. Personnel files of 13 nursing staff members, including licensed nurses and certified nursing assistants, lacked documentation of competencies necessary for wound care and other specialized care areas. Interviews with nurses indicated that they had not received adequate training or competency evaluations related to wound care, and some nurses admitted to not documenting wound assessments or notifying physicians of changes in wound conditions. Additionally, the facility's policy on wound care was not effectively implemented, as evidenced by the incomplete wound care competency checklists for licensed nurses. Observations during the survey showed that some nurses did not follow proper infection control protocols during wound dressing changes. The facility's lack of a structured training curriculum and reliance on verbal confirmations for staff training further contributed to the deficiency, as there was no formal process to ensure that nursing staff were competent in providing the necessary care for residents.
Removal Plan
- The MDS/Educator Nurse has developed nursing competencies specific to wound care to be provided to all clinical team members to ensure that this practice does not recur.
- Wound Care competencies will be completed.
- The nursing competencies evaluate the nurse on identifying, assessing and treating wounds, wound care testing regarding sterile dressing changes, Decubitus care, knowledge of and review of each nurse's documentation, evaluations of careplan knowledge, lifting and positioning knowledge, transfer technique, incontinent skin relation to skin integrity, medication evaluations and many other skilled nursing techniques.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,358 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookhaven At Lexington | 1.3 mi | ★★★★★ | 7 | 0 |
| Care One At Lexington | 1.6 mi | ★★★★★ | 11 | 0 |
| Park Avenue Health Center | 1.8 mi | ★★★★★ | 10 | 0 |
| Meadow Green Nursing And Rehabilitation Center | 2 mi | ★★★★★ | 17 | 0 |
| Belmont Manor Nursing Home, In | 2.3 mi | ★★★★★ | 13 | 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 July 2026) and official state health department websites.