Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Regalcare At Glen Ridge during CMS and state inspections, most recent first.
Late MDS Assessment Transmission: The facility failed to transmit multiple MDS assessments within the required timeframe for several residents, including residents with severe, moderate, and intact cognition. Records showed assessments were completed and submitted well after the ARD, and one resident had an MDS still in progress. The MDS nurse reported a backlog of assessments when she started, and the DON stated MDSs were expected to be submitted timely per the RAI manual.
Food and Drink Served at Unsatisfactory Temperatures and Poor Quality: Surveyors found that breakfast test trays on four units contained items that were lukewarm, cool, bland, dry, hard to chew, or otherwise unappetizing. Meal cart and tray delays were noted, and the FSD, Corporate FSD, and DON agreed the temperatures were not satisfactory and that residents should receive palatable meals at acceptable temperatures.
A resident with dementia and total bowel and bladder incontinence was observed walking the unit with a foul odor, visibly wet pants, and a bulged brief, then was taken to the dining room and ate breakfast before receiving incontinence care. Staff were present in the area, and a psych NP noted the resident had an odor and needed to be changed. Interviews confirmed the resident had not received incontinence care during the shift and that residents should be changed when wet or soiled.
Failure to Identify and Investigate a Resident’s Facial Injury: A resident with severe cognitive impairment and wandering behaviors was found with a large facial bruise/redness, but staff documentation was inconsistent and incomplete. An unwitnessed fall report conflicted with statements that the bruise was not new, the RN did not document the injury in the chart, and staff gave differing accounts of whether a fall occurred. The DON and UM stated the injury was not properly documented or fully reported, and the Administrator said staff did not follow policy.
Inaccurate MDS coding for upper extremity ROM. A resident with CVA-related hemiplegia/hemiparesis, dementia, and a severely impaired BIMS score was repeatedly observed holding the left arm against the body with limited movement and stiffness. CNA and nursing interviews confirmed the arm was longstanding and impaired, and OT documented moderate LUE shoulder and elbow/forearm ROM impairment, yet the comprehensive MDS and two quarterly MDSs did not code upper extremity impairment.
Medication Administered via Incorrect Route: A resident with ALS, dysphagia, and a PEG tube had physician orders for Lasix and IBU to be given by mouth, but an RN administered IBU via the feeding tube and another nurse gave Lasix via the feeding tube. The nurses stated they were not aware the orders specified PO, and the DON confirmed the medications were given via the incorrect route.
Failure to Provide Timely Incontinence Care: A resident with dementia and total incontinence was observed walking the unit and eating breakfast with a wet, likely soiled brief and a foul odor. Staff and an NP saw the resident in this condition, but the assigned CNA had not provided incontinence care since the start of the shift. Interviews confirmed the resident should have been changed when wet or soiled and should not have remained in the dining room in that condition.
Failure to Care Plan for Impaired Upper Extremity ROM: A resident with CVA, hemiplegia/hemiparesis, and dementia was repeatedly observed holding the L arm against the body with limited movement, stiffness, and pain. Staff confirmed the arm was weak, not used, and not addressed in the care plan; OT records showed impaired LUE ROM and stretching/PROM goals, but the resident’s care plan, ADL plan, Kardex, and recent MDS assessments did not reflect the upper extremity impairment.
A resident with severe cognitive impairment, adult failure to thrive, and severe protein calorie malnutrition experienced ongoing weight loss from 100 lbs. to 90.4 lbs. The chart showed a 5% loss that was not acted on promptly, no new nutrition interventions were documented for weeks, and an ordered dietary consult was not completed as written. Staff interviews and tray observations showed that fortified foods were not consistently communicated or provided, and the resident’s meal tickets did not reflect the ordered nutrition support.
Pharmacy review recommendations were not timely acknowledged or acted upon for two residents. One resident receiving quetiapine and risperidone had pharmacist recommendations for lipid panel and A1c monitoring left blank on the prescriber response section, and the labs were not requested. Another resident with COPD received fluticasone-salmeterol without an order to rinse the mouth after use until later, despite the pharmacist’s recommendation. The DON stated the recommendations were missed or addressed only when seen.
Failure to provide timely dental care for an ill-fitting denture. A resident with COPD and RA, intact cognition, and significant ADL needs reported that upper dentures were too big and did not fit, making it hard to chew. Staff documentation noted tooth discomfort and that the resident’s dentures did not fit well, while the RD recorded that dentition affected intake and that the resident was gumming food because the dentures could not be worn. Interviews confirmed the resident had been waiting to be seen by dental and that consent for dental services was not obtained until much later.
Incomplete medical records and CNA charting were found for two residents. One resident's physician and NP encounter notes were not accessible in the chart, despite significant cognitive impairment and extensive ADL dependence. Another resident, who had moderate cognitive impairment and required extensive assistance with ADLs, had repeated missing CNA documentation across many care areas, and staff stated all care should be documented every shift.
The facility failed to maintain infection control practices when a resident with stage III pressure ulcers did not have EBP implemented during high-contact care, despite wound-related precautions being in the care plan. Staff also handled clean linen improperly when blankets touched the floor during folding, which the Housekeeping Director, IP, and DON identified as an infection control concern.
A resident with multiple complex diagnoses was admitted and assessed as being at risk for elopement, displaying exit-seeking and wandering behaviors. Despite facility policy requiring a baseline care plan within 48 hours, no such plan or interventions were documented prior to the resident's elopement. The DON confirmed that the required care planning was not completed as per policy.
A resident in an LTC facility was physically and emotionally abused by a contracted podiatrist who began clipping the resident's toenails while they were asleep. The resident, who was cognitively intact, woke up startled and told the podiatrist to stop, leading to a physical altercation where the resident was struck, resulting in injuries. The resident expressed ongoing fear and anxiety about the podiatrist's presence, and the podiatrist's account of the incident was inconsistent.
A resident with an ileostomy was found without an ostomy appliance, leading to fecal contamination of their abdominal wound. Despite physician's orders for ileostomy care every shift, the resident's abdomen and incision were covered in fecal matter, and the incision had dehisced. The nurse on duty was aware of the missing appliance but did not assess the resident until prompted by the physician. Temporary supplies were available but not used until after the physician's assessment. The resident was transferred to the hospital for further care.
The facility failed to provide adequate ADL assistance, resulting in two residents developing pressure ulcers due to prolonged incontinence, a resident left unattended during meals despite needing assistance, and two residents not receiving necessary grooming care. Staff shortages and lack of adherence to care plans were cited as contributing factors.
The facility failed to provide adequate wound care and treatment for several residents, resulting in untreated wounds and delayed healing. Staff did not identify or address deteriorating skin injuries, failed to obtain necessary tests, and did not complete physician-ordered treatments. Communication lapses with healthcare providers further exacerbated these issues.
The facility failed to prevent and treat pressure ulcers for several residents, leading to the development and worsening of wounds. One resident developed an unstageable deep tissue injury due to lack of preventive measures, while another's stage II ulcer deteriorated due to unimplemented treatment recommendations. Additionally, a resident was left in soiled briefs for extended periods, resulting in multiple stage II wounds. The facility also failed to notify medical staff about new wounds and did not provide appropriate treatment for a resident's calf wound.
The facility failed to notify physicians of changes in medical status for several residents, leading to deficiencies in care. A resident experienced worsening pain due to unavailable medication, and the physician was not informed. Another resident's wound culture was delayed due to a lack of kits, and the physician was not notified. Additionally, a resident's pressure wound and another's skin injury were not reported to physicians, resulting in inadequate care.
A resident was subjected to abuse during medication administration when a nurse attempted to force-feed medications without communication. Additionally, two residents experienced neglect due to a lack of incontinence care for 17 hours, resulting in pressure ulcers. The facility's inadequate staffing contributed to the neglect, as staff admitted they could not meet the care needs of all residents.
A resident with multiple health issues, including neuropathy, developed a contracture that was not identified or addressed by the facility. Despite a podiatry note indicating limited range of motion, the facility failed to notify the physician or update the care plan. The occupational therapist was unaware of the contracture, and no physical therapy evaluation was conducted. Staffing shortages and lack of a Director of Rehabilitation contributed to the oversight.
A resident with Marfan Syndrome and muscle contracture experienced worsening pain due to inadequate pain management upon admission and when scheduled medication ran out. The facility delayed applying Fentanyl patches for 19 hours and failed to administer a required patch, resulting in severe pain without notifying the physician or providing alternative pain management.
A facility failed to provide sufficient staffing on a nursing unit, resulting in inadequate care for residents. Staffing levels were below budgeted amounts, and staff reported difficulties in maintaining adequate coverage due to frequent call-outs. On the day of the survey, only one nurse and one CNA were available for 24 residents, leading to residents being left in soiled briefs and developing pressure areas. The facility's failure to maintain adequate staffing levels directly contributed to these care deficiencies.
The facility failed to maintain an effective infection prevention and control program. A stained ceiling tile in the laundry room posed a contamination risk. Two residents did not receive proper enhanced barrier precautions during care, and nursing staff did not adhere to hand hygiene protocols during medication administration. These deficiencies were confirmed through observations and staff interviews.
The facility failed to implement person-centered care plans for several residents, leading to deficiencies in care. A resident at high risk for pressure ulcers was observed without required heel offloading, while another was without heel boots despite care plans. Additionally, a resident was not monitored for weight as required, and another was not wearing protective gear as ordered. These observations indicate a lack of adherence to care plans and documentation of resident refusals.
The facility failed to implement a physician's order for two residents, resulting in deficiencies. One resident's significant weight change was not reported to the NP or MD, despite a physician's order. Another resident's Stage 2 wound was not treated or reported to the physician, with the wound remaining uncovered and undocumented in the medical record. The DON confirmed the wound required a medicated dressing, but it was initially misassessed as a scab by a corporate nurse.
The facility failed to secure medication and treatment carts, leaving them unlocked and unattended on multiple units. The medication room was also found unlocked, and opened insulin pens lacked proper labeling. Additionally, a nurse left a medication cup and an uncapped insulin syringe unattended, accessible to residents. Staff interviews confirmed these actions violated facility policies.
The facility failed to accurately document and manage care for several residents, including improper documentation of pressure injuries, failure to follow physician orders for dialysis care, and inaccurate treatment records for pressure ulcer prevention. Observations and staff interviews revealed discrepancies in care provided versus documented, highlighting significant deficiencies in resident management.
The facility failed to provide a dignified dining experience for two residents, with one experiencing delayed meal service and another not receiving appropriate assistance during meals. Additionally, meals were served on institutional trays, lacking a homelike atmosphere. Privacy was also compromised for a resident during toileting, as they were left exposed and visible to others.
A facility failed to obtain informed consent for psychotropic medications for a resident with Alzheimer's, depression, and lymphedema. Despite policy requirements, the resident's medical record lacked consent documentation for Sertraline, Lorazepam, and Olanzapine, which were administered as ordered. Staff interviews confirmed the necessity of obtaining consent prior to medication administration.
A resident with multiple health conditions, including severe obesity, has not received a shower since admission due to the facility's failure to provide a suitable shower chair. Despite the resident's intact cognition and dependency on staff for all tasks, and repeated requests for assistance, the facility did not accommodate the resident's needs. Interviews with staff revealed a lack of awareness and communication about the issue, and no effective action was taken to resolve the resident's concerns.
A facility failed to ensure consistent documentation of a resident's Advance Directives, resulting in a discrepancy between the MOLST indicating DNR/DNI and the physician's orders stating Full Code. The resident, with Alzheimer's and cognitive impairment, had conflicting documentation, which was confirmed by staff interviews.
The facility did not inform two residents about their potential financial liability for non-covered services under Medicare. The SNFABN form used by the facility failed to include the cost of rehab services, only indicating costs for room and board. This oversight was confirmed by the MDS Nurse during an interview.
A resident with Alzheimer's and dementia was found with pillows under the fitted sheet, restricting movement, without proper assessment or documentation. Facility staff had differing views on whether the pillows were restraints, but the DON confirmed they should not be used this way.
A resident with depression and anxiety reported intentions of self-harm and alleged being beaten by staff, but the DON was not informed, preventing an investigation and state reporting.
Two residents in a LTC facility experienced neglect in incontinence care, with one resident left in a saturated brief for 17 hours, resulting in a new stage one pressure area. Another resident was found with multiple stage II wounds after wearing two saturated briefs for 17 hours. Despite acknowledging the neglect, the facility failed to report the incidents to the state agency within the required timeframe.
Two residents in the facility were found in saturated incontinent briefs, having not received care for 17 hours, leading to skin breakdown and pressure ulcers. Despite the facility's policy requiring regular incontinence care and repositioning, these actions were not taken, and no investigation was initiated. Staff interviews confirmed the neglect, but the facility failed to produce an investigation report.
The facility inaccurately coded the MDS for three residents, leading to deficiencies in their assessments. One resident's MDS incorrectly indicated the use of non-invasive mechanical ventilation, another resident's significant weight loss was not documented, and a third resident's discharge status was inaccurately recorded. These errors were confirmed through interviews and record reviews.
A facility failed to create a baseline care plan for a resident requiring dialysis three times a week, despite the resident's severe cognitive impairment and dependence on renal dialysis. The care plan was not developed until five months after admission, as confirmed by the DON and a Corporate Nurse.
The facility failed to update care plans for three residents, leading to discrepancies in their care. A resident's sleep apnea care plan was not revised after discontinuing CPAP use. Another resident's dialysis care plan was incomplete and delayed by five months. Additionally, a resident's care plan inaccurately required total care for eating, despite being able to eat independently.
A resident with moderate cognitive deficits and vision needs was not provided routine vision services for new eyeglasses. Despite a consent and doctor's order for optometry consultation, the resident had not been seen by an eye doctor, leading to the use of two pairs of glasses for reading and watching TV. Staff interviews revealed a lack of awareness and follow-through in addressing the resident's vision needs.
A resident with hemiplegia and legal blindness, identified as high risk for falls, fell while reaching for snacks. The fall was not reported or assessed by nursing staff until the following day, violating the facility's fall protocol. The incident was discovered when a CNA noticed abrasions on the resident's back during rounds.
The facility failed to maintain nutritional status for two residents, leading to significant weight loss and inadequate dietary management. One resident experienced a 23.98% weight loss without timely intervention, and the facility did not obtain weekly weights as ordered. The resident's dislike of the facility's food was not addressed, and the RD did not evaluate the resident promptly. Another resident, receiving nutrition via a feeding tube, did not receive a timely RD consult as ordered, and weight records were inconsistent. Communication lapses among staff contributed to these deficiencies.
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in oxygen therapy management. A resident with chronic respiratory conditions was observed with unchanged oxygen tubing for several months, contrary to expectations for weekly changes. Another resident received incorrect oxygen levels and had undated tubing initially. Staff interviews confirmed the need for weekly tubing changes and adherence to physician orders, which were not followed.
A resident with ESRD requiring dialysis three times a week did not receive appropriate care at the facility. The resident's blood pressure was incorrectly taken from the arm with a dialysis fistula, and a complete care plan was not developed until five months after admission. Additionally, nursing staff failed to consistently follow physician orders for monitoring dialysis access sites, as evidenced by missing documentation in the TAR.
A facility failed to create a trauma-informed care plan for a resident with PTSD, despite the resident's severe cognitive deficits and need for substantial assistance. The care plan lacked individualized interventions and identified triggers, contrary to the facility's policy. Staff interviews confirmed the necessity of such a plan for residents with PTSD.
The facility failed to timely address pharmacy recommendations for two residents. One resident continued receiving an incorrect dosage of metoprolol succinate despite recommendations to adjust it. Another resident had duplicate Tylenol orders and ibuprofen administration instructions that were not updated promptly. These issues persisted for several months before being addressed.
A facility failed to limit the duration of a PRN psychotropic drug for a resident with severe cognitive impairments. The resident was prescribed Lorazepam for anxiety without a stop or re-evaluation date, contrary to facility expectations. Interviews with staff confirmed the oversight.
The facility did not offer pneumonia vaccinations to two residents as required by their policy. One resident admitted in April 2024 had no documentation of receiving, declining, or contraindication for the vaccine, and their MIIS record showed it was due but not given. Another resident admitted in July 2021 also lacked documentation, and their MIIS record was not provided. The Infection Preventionist and Corporate Nurse confirmed that the electronic medical records did not reflect the vaccine status.
Late MDS Assessment Transmission
Penalty
Summary
The facility failed to ensure that MDS assessments were transmitted within 14 days after completion for six residents in a sample of 34. Review of the CMS RAI Manual indicated assessments must be completed no later than 14 calendar days after the ARD and transmitted and encoded within 7 days of assessment completion. Resident #49, admitted in July 2024 with contracture of the muscle and bilateral primary osteoarthritis of the knee, had an MDS dated 7/30/25 with a BIMS score of 5, indicating severe cognitive impairment; the assessment was completed on 8/28/25 and submitted on 9/2/25, 34 days after the ARD. Resident #4, admitted in November 2024 with follicular lymphoma and ischemic cardiomyopathy, had an MDS dated 7/30/25 with a BIMS score of 15, indicating cognitive intactness; it was completed on 8/29/25 and submitted on 9/2/25, 34 days after the ARD. Resident #10, admitted in April 2025 with muscle weakness and diabetes, had an MDS dated 7/30/25 with a BIMS score of 11, indicating moderate cognitive impairment; it was completed and submitted on 9/2/25, 35 days after the ARD. Resident #123, admitted in January 2025 with spinal stenosis, chronic kidney disease, and vascular dementia, had an MDS dated 7/30/25 with a BIMS score of 4, indicating severe cognitive impairment; it was completed on 8/29/25 and submitted on 9/2/25, 34 days after the ARD. Resident #86, admitted in October 2024 with diabetes and radiculopathy, had a most recent MDS dated 4/9/25 with a BIMS score of 11, indicating moderate cognitive impairment; on 9/4/25, the record showed an MDS in progress dated 7/9/25 but not yet completed. Resident #7, admitted in April 2025 with dysphagia and diabetes, had a significant change MDS completed on 7/23/25 and submitted on 7/24/25, 31 days after the ARD date; the record also included a physician order for hospice dated 9/1/25 with a diagnosis of primary biliary cirrhosis. During interview, the MDS nurse stated she began working at the facility at the end of July and found a large backlog of MDS assessments because no one had been in the position before her arrival. She stated the expectation was that MDS assessments be completed and submitted timely in accordance with the RAI manual, and the DON stated she would expect MDS assessments to be submitted timely as per the RAI manual.
Food and Drink Served at Unsatisfactory Temperatures and Poor Quality
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures on four of four units. During resident screening, numerous residents told surveyors they were concerned about the quality and temperature of the food, especially breakfast meals. On 9/8/25, surveyors completed test tray audits on all units and found multiple items that were lukewarm, cool, bland, dry, hard to chew, or otherwise unappetizing. Examples included banana French toast casserole ranging from 66 to 141 degrees Fahrenheit, oatmeal ranging from 90 to 113 degrees Fahrenheit, sausage that was dry or hard to chew/cut, and milk and juice that were cool but not cold. One tray also had spilled juice, and the replacement juice tasted sour. The surveyors observed delays between cart arrival and tray receipt on each unit, including 16, 18, and 20 minutes on several units, and one unit where the test tray arrived on a rolling cart instead of the meal cart. The Food Service Director and Corporate Food Service Director were informed of the test tray results and stated they would expect residents to have palatable meals that taste good and are at an appropriate temperature; they agreed the temperatures were not satisfactory. The DON also stated she would expect residents to have palatable meals at an acceptable temperature.
Failure to Provide Timely Incontinence Care and Maintain Dignity
Penalty
Summary
The facility failed to maintain Resident #121’s dignity by not providing timely incontinence care. Resident #121 was admitted in August 2025 with diagnoses including adult failure to thrive, dementia, adjustment disorder with mixed anxiety and depressed mood, and incontinence without sensory awareness. The nursing assessment described the resident as oriented to person with short-term memory issues and as always incontinent of bladder and bowel. The care plan review did not show a care plan addressing bowel and bladder incontinence. On 9/3/25, surveyors observed Resident #121 walking around the unit with a foul odor and pants that were dark and wet on the backside, with the brief bulged on one side. The resident continued walking in the hallway near the medication carts, the nursing desk, and other residents, including being hugged by another resident and walking with another resident by the hand. A psych NP observed the resident and stated the resident had an odor and needed to be changed. Despite repeated staff presence in the area, the resident remained wet and likely soiled for an extended period, including while standing and walking near the dining room. At 9:09 A.M., Nurse #8 escorted Resident #121 into the dining room and assisted the resident to sit at a table, and the resident ate breakfast while still wearing the wet, likely soiled brief. The resident remained in the dining room afterward, continued to stand and ambulate with other residents, and still had a wet brief with odor later in the morning. CNA #7 stated she had not provided incontinence care since the start of her shift and said residents needing incontinence care should be changed when needed and twice during the shift. Other staff interviewed stated residents with incontinence should be changed when wet or soiled and should not walk around or eat with a wet or soiled brief. The Administrator stated the resident should have been provided care and dignity.
Failure to Identify and Investigate Resident Facial Injury
Penalty
Summary
The facility failed to implement policies and procedures to prevent abuse, neglect, and theft for one resident with severe cognitive impairment. The resident was admitted with diagnoses including major depressive disorder, unspecified dementia with behavioral disturbance, presbyopia, and Alzheimer’s disease. The most recent MDS indicated the resident was unable to complete the BIMS and required substantial to maximal assistance with bathing, toileting, hygiene, and lower body dressing. The resident also exhibited physical and verbal behaviors, rejected care, and wandered during the look-back period. On 8/17/25, an incident report documented an unwitnessed fall in the resident’s room, stating the resident was found on the floor in front of the bed and had large redness on the left side of the face extending from the head to the mouth and chin. The report also stated “no injuries observed at time of incident,” which conflicted with the facial redness described in the same report. Nurse #10 later wrote in an incident investigation statement that the resident had a bruise on the face that was “not new,” but the medical record did not contain a progress note from that nurse about the bruise or a fall, and there was no documentation in the notes from 8/6/25 through 8/17/25 showing a facial bruise or large redness. Additional statements were inconsistent about when and how the facial injury occurred. Nurse #11 stated the resident was sitting by the nurse station with a bruised face and that the outgoing nurse said the resident had fallen a few shifts earlier, but the resident’s record did not show a prior fall or injury. Another staff statement referenced hearing that the resident had fallen 2-3 days earlier, but did not provide a direct observation of the event. During interviews, Nurse #3 said she saw a big bruise on the resident’s face on the day after the incident and had not received report of any fall or injury. The DON stated the resident was a fall risk and that the bruise was not an injury of unknown source, while the Unit Manager said the investigation began only after the bruise was brought to her attention and that Nurse #10 failed to document the bruise, notify the provider or family, complete nursing assessments, or complete an incident report. The Administrator stated staff did not follow policy and described the documentation as sloppy.
Inaccurate MDS Coding for Upper Extremity ROM
Penalty
Summary
The facility failed to accurately code three MDS assessments for one resident by not reflecting the resident’s left upper extremity range of motion impairment. The resident was admitted in November 2021 and had diagnoses including cerebral infarction, hemiplegia, hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and unspecified dementia. The resident’s 5/28/25 MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. During multiple observations in September 2025, the resident was repeatedly seen holding the left arm against the side or across the chest, with the forearm across the body and fingers folded in, including while sitting in the dining room, lying in bed, sitting on the toilet, eating breakfast, and walking in the hallway. Staff interviews confirmed the resident’s left arm position was longstanding and impaired. The resident stated the arm was stiff and painful when moved. A CNA said the resident always held the arm that way, could not move it on his/her own, and required total assistance for dressing. Another CNA said the arm was stiff but could be moved during care, and a nurse said the resident always held the left arm against the body and had been that way for a long time. Review of the OT evaluation dated 11/19/24 showed the left shoulder was moderately impaired with 25-50% of full range and the elbow/forearm was moderately impaired with 26-50% of full range. Despite this, the comprehensive MDS and two quarterly MDS assessments did not code upper extremity impairment. During interview, the MDS nurse stated that range of motion impairment should be documented on the MDS, and the DOR stated the resident’s arm was fixed at the elbow, which is an impairment.
Medication Administered via Incorrect Route
Penalty
Summary
The facility failed to follow professional standards of nursing practice for one resident by administering medications via the wrong route instead of as ordered by the physician. Resident #68 was admitted in December 2024 with diagnoses including amyotrophic lateral sclerosis and dysphagia. The most recent MDS indicated intact cognition, dependence on staff for activities of daily living, and no rejection of care. During an observation, the resident was in bed with a PEG tube visible and stated that some medications were taken through the PEG tube because that was preferred. Review of the physician’s orders showed Lasix 20 mg was ordered by mouth once daily for edema and IBU 600 mg was ordered by mouth twice daily for pain. During a medication administration observation, Nurse #3 administered IBU 600 mg via the feeding tube even though the order specified by mouth. During interview, Nurse #4 stated that Lasix 20 mg was being given via the feeding tube and confirmed she had administered it that way, then acknowledged the order indicated by mouth. Nurse #3 stated she was not aware the IBU was ordered by mouth and thought the resident took all medications via feeding tube. The DON stated that medications were administered via the incorrect route and that physician’s orders should be followed as written.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely ADL and incontinence care for Resident #121, who was admitted with diagnoses including adult failure to thrive, dementia, adjustment disorder with mixed anxiety and depressed mood, and incontinence without sensory awareness. The nursing assessment indicated the resident was oriented to person with short-term memory issues and was always incontinent of bladder and bowel. The record review also showed the resident was dependent on staff for showering/bathing and toileting hygiene, and the care plan did not include a plan to address bowel and bladder incontinence. On 9/3/25, surveyors observed Resident #121 walking around the unit with a foul odor and wet, darkened pants consistent with a soiled brief. The resident was seen repeatedly walking in the hallway, near the medication carts, and into the dining room while still wet/soiled, with staff and other residents nearby. A psych NP observed the resident and stated the resident had an odor and needed to be changed. The resident remained in the dining room and ate breakfast from 9:09 A.M. to 9:56 A.M. while still wearing the wet/likely soiled brief, and later continued to ambulate and stand in the dining room with the brief still bulged and wet. Interviews confirmed the resident had not received incontinence care during the shift before the observation. CNA #7 stated she had started at 7 A.M., was assigned to the resident, and had not provided incontinence care since the start of the shift. Staff interviewed later stated residents with incontinence should be changed when wet or soiled and should not walk around or eat with a wet or soiled brief. Nurse #8 said the issue should have been addressed, and the Administrator stated the resident should have been provided care and dignity.
Failure to Care Plan for Impaired Upper Extremity ROM
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan with individualized interventions for a resident’s impaired left upper extremity range of motion. The resident was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis following a cerebral infarction affecting the right dominant side, type 2 diabetes mellitus, and unspecified dementia. The resident’s MDS assessment showed severe cognitive impairment, and the resident required substantial to maximal assistance with bathing/showering and upper body dressing. Observations showed the resident repeatedly holding the left arm against the body with the forearm across the chest and the hand/fingers flexed. During one observation, the resident was sitting at a table with the left arm positioned against the side and the forearm across the body while using the right hand. On another observation, the resident was lying in bed with the left arm against the side and the forearm across the body, and the resident stated the arm was stiff and painful when moved. Additional observations in the bathroom, dining area, hallway, and sitting room showed the same positioning and limited movement of the left arm. Staff interviews confirmed the resident’s left arm was consistently held in that position and was stiff, weak, and not used by the resident. A CNA stated the resident always kept the arm held that way and that no instructions or care plan were provided for the left arm. Other staff said the resident needed assistance moving the arm during dressing, that OT would tell nursing what to do, and that the resident had been like that for a long time. Review of OT records documented moderately impaired left shoulder and elbow/forearm range of motion and included stretching and PROM goals, but the discharge summary did not explain how 24-hour care staff would carry out stretching and PROM. The resident’s care plans, ADL care plan, and Kardex did not include interventions for the left upper extremity impairment, and recent MDS assessments were not coded as showing an upper extremity impairment. During interviews, the MDS nurse and DOR acknowledged the resident’s impaired upper extremity range of motion should have been reflected and addressed in care planning.
Failure to Address Significant Weight Loss and Implement Ordered Nutrition Interventions
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of one resident with severe cognitive impairment, frontotemporal neurocognitive disorder, Alzheimer’s disease, and adult failure to thrive. The resident was admitted in July 2025 with a comprehensive nutritional evaluation noting severe protein calorie malnutrition, a current weight of 100 lbs., and a plan to monitor for supplementation needs. The resident’s weights then declined from 100 lbs. to 99.5 lbs., 95.6 lbs., 95 lbs., 94.1 lbs., 92.6 lbs., and 90.4 lbs. over the following weeks, including a 5% weight loss by 8/4/25 and a 9.6% loss by 9/3/25. The record showed that the resident’s significant weight loss was not addressed in a timely manner. The active nutrition care plan identified risk for nutritional decline and included monitoring weight, intake, skin, labs, notifying the MD of weight loss, and providing meals per MD orders, but it did not show new interventions between 7/21/25 and 9/6/25 despite the ongoing decline. A nurse practitioner note on 8/5/25 documented adult failure to thrive, poor oral intake, and need for assistance with meals, but the record did not show that the weight loss trend was acted on when the 5% loss was identified. A later note on 9/2/25 again documented the resident at 92 lbs. with continued poor intake and monitoring by the dietitian. The record also showed that physician-ordered interventions were not implemented as written. An order for a dietary consult related to weight loss was dated 8/29/25, but the record as of 9/5/25 did not show that the consult had been completed. After the surveyor interviewed the dietitian, orders were entered for fortified foods, encouragement of oral fluids with documentation of intake, and nutritional supplements, but observations on 9/8/25 and 9/9/25 showed the resident’s meal tickets did not indicate fortified foods and staff stated the resident would not receive them unless the tray ticket showed it. The food service director’s list of residents receiving fortified foods did not include the resident at the time it was reviewed, and staff interviews reflected uncertainty about whether the dietitian’s recommendations had been communicated to the kitchen.
Pharmacy Review Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to ensure that recommendations from the consultant pharmacist’s monthly medication regimen reviews were addressed and acknowledged by the physician in a timely manner for two residents. The facility policy titled Consultant Pharmacist Reports stated that the consultant pharmacist performs a monthly comprehensive review of each resident’s medication regimen and clinical record, reports findings and recommendations to the DON and attending physician, and that recommendations are acted upon and documented by facility staff and/or the prescriber. The policy also stated that resident-specific irregularities and clinically significant medication risks are documented in the resident’s active record and reported as appropriate. For one resident, admitted in January 2025 with diagnoses including schizoaffective disorder and heart failure, the pharmacist documented recommendations on 4/9/25 and 6/6/25 that because the resident was receiving quetiapine and risperidone, lipid panel and A1c labs should be included on the next lab day and every 6 months thereafter. The physician/prescriber response sections on both reports were blank. The resident’s MAR showed continued administration of quetiapine and risperidone during April, May, and June 2025, and the lab results reviewed did not show that a lipid panel or A1c had been requested. During interview, the DON stated the recommendations were missed by the facility and were not acknowledged or completed. For a second resident, admitted in October 2024 with diagnoses including pneumonia and COPD, the pharmacist’s 8/8/25 monthly review recommended updating the fluticasone-salmeterol inhaler order to instruct the resident to rinse the mouth after use. The physician order reflecting that instruction was dated 9/5/25, and the record did not show the recommendation had been implemented before the surveyor requested the review. The resident received fluticasone-salmeterol on the August 2025 MAR and through 9/5/25 in September 2025 without instructions to rinse the mouth after use. The DON stated the facility did not have a specific time frame for following up on pharmacy recommendations and that she addressed them as soon as possible when she saw them.
Failure to Provide Timely Dental Care for Ill-Fitting Dentures
Penalty
Summary
The facility failed to provide dental services for a resident who had an improper fitting upper denture documented by staff. The resident was admitted in July 2024 with diagnoses including chronic obstructive pulmonary disease and rheumatoid arthritis, had intact cognition on the most recent MDS, and required substantial to maximal assistance with activities of daily living. During an interview, the resident stated that the dentures were too big, did not fit, and needed to be fixed so the resident could chew food more easily. The surveyor observed that the resident had no upper teeth and was missing some bottom teeth, and the resident said the goal was to be able to chew food again. Facility records showed that the resident’s denture concerns were documented months before the survey, including a nursing note noting tooth discomfort and a care plan meeting note stating the resident had no upper teeth, one loose bottom tooth, and dentures that did not fit well. The Registered Dietitian documented that the resident was at nutritional risk, was on a regular texture diet with thin liquids, and reported that dentition impacted intake. The RD also stated that the resident gummed a lot of food because the dentures could not be worn and that the resident had been waiting to be seen. Staff interviews confirmed that consent for dental services was not obtained until much later, and the DON stated the resident should have been assessed by the dentist when the concern was identified and that consent should have been obtained on admission.
Incomplete Medical Record and CNA Documentation
Penalty
Summary
The facility failed to ensure medical records were completed for two residents in a sample of 34. For one resident, the medical record did not contain accessible clinical encounter notes from the physician or nurse practitioner. The resident had diagnoses including major depressive disorder, Alzheimer's disease, unspecified dementia, and hyperlipidemia, and the most recent MDS indicated severe cognitive impairment and substantial to maximal assistance needs for bathing, toileting, hygiene, and lower body dressing. During record review, the EMR and chart did not show visit notes from the physician or nurse practitioner for that resident. The DON stated the resident was on the PACE program and the facility was working on getting the medical providers to document in the EMR, and that the nurse practitioner and physician notes should be accessible in the resident's medical record. Later, the surveyor reviewed nurse practitioner notes that had been faxed. For the second resident, the facility did not fully document CNA daily care in the EMR. The resident had diagnoses including severe protein calorie malnutrition, muscle weakness, and type 2 diabetes, and the MDS showed moderate cognitive impairment with partial/moderate to substantial/maximal assistance needed for all ADLs. Review of CNA documentation for June through September 2025 showed repeated missing entries across many care areas, including behavior symptoms, bladder and bowel functions, dressing, hygiene, transfers, toileting, intake and output, skin observation, positioning, snacks, amount eaten, and eating. Staff interviews confirmed that all care should be documented every shift, and the DON stated that without documentation it could not be determined what care was provided and that the resident's CNA care needed to be completely documented.
Infection Control Failures With EBP and Linen Handling
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. For one resident with a wound, the facility did not implement Enhanced Barrier Precautions (EBP). The resident was admitted in June 2025 with diagnoses including dysphagia, sleep apnea, and chronic kidney disease, and the MDS assessment dated 7/9/25 showed a BIMS score of 10 out of 15, indicating moderate cognitive impairment. The resident’s wound care note dated 9/4/25 documented facility-acquired stage 3 pressure ulcers to the coccyx, and the active care plan indicated an actual alteration in skin integrity with a stage III pressure ulcer and a plan for EBP due to wounds. During observation, the resident received morning care without a gown, and the doorway entry to the room did not indicate that staff should use EBP during high-contact care. The facility also failed to handle clean linen in a manner that prevented possible contamination. During a laundry observation, a staff member was seen folding blankets while the blankets came into contact with the floor. The Housekeeping Director stated that blankets should not touch the floor while being folded, and the Infection Preventionist and DON both stated that laundry being folded should not come into contact with the floor because it was an infection control concern.
Failure to Develop Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a baseline plan of care within 48 hours of admission for one resident. The facility's policy required a baseline care plan to be created within 48 hours to address the resident's immediate needs. The resident in question was admitted with multiple diagnoses, including diabetes, vascular dementia, chronic kidney disease, and dysphagia. Upon admission, the resident was assessed by nursing as being at risk for elopement, exhibiting behaviors such as exit seeking, wandering, and disorientation. However, the section of the Elopement Risk Evaluation intended for documenting interventions and care planning was left blank. Further review of the resident's care plan report and medical record showed that no baseline plan of care or interventions were documented prior to the resident's elopement from the facility. The Director of Nursing confirmed that a baseline plan of care, including an elopement plan, should have been developed within 48 hours of admission but was not completed in this case.
Resident Abused by Contracted Podiatrist
Penalty
Summary
The facility failed to protect a resident from physical and emotional abuse by a contracted podiatrist. The incident occurred when the podiatrist began providing care to the resident's feet while the resident was asleep. Upon waking abruptly, the resident was startled and told the podiatrist to stop, leading to a verbal and physical altercation. During this altercation, the resident was struck on the left side of the face and left arm, resulting in injuries that required evaluation at a hospital emergency department. The resident, who was cognitively intact with a BIMS score of 15/15, expressed fear and anxiety following the incident, particularly concerning the podiatrist's presence in the facility. The resident's medical history included dementia, insomnia, and anxiety, which may have contributed to the heightened emotional response. The resident consistently reported the incident to various parties, including the facility staff, police, and during a psychological evaluation, indicating a significant impact on their sense of safety and well-being. The podiatrist's account of the incident was inconsistent, with conflicting statements provided to the police and during interviews. The podiatrist admitted to attempting to clip the resident's toenails without ensuring the resident was awake or aware of his presence, which led to the resident being startled and the subsequent altercation. The Director of Nurses noted the resident's injuries were new and consistent with the resident's account, although she did not witness the incident herself.
Failure to Provide Appropriate Ileostomy Care
Penalty
Summary
The facility failed to provide appropriate care for a resident with an ileostomy, resulting in contamination of the resident's abdominal wound with fecal matter. The resident, who had been admitted with an intestinal obstruction and ileostomy, was found without an ostomy appliance in place, despite having physician's orders for ileostomy care every shift. On the day of the incident, the physician discovered that the resident's abdomen, dressing, and abdominal incision were covered in fecal matter, and the gauze within the incision was soaked. The peristomal skin was red and inflamed, and the abdominal incision had dehisced. Nurse #2, who was aware of the missing ostomy appliance since the beginning of her shift, did not assess the resident's abdomen or stoma until prompted by the physician. Although specific ostomy supplies had not been delivered, temporary supplies were available in the facility but were not used until after the physician's assessment. The Director of Nurses confirmed that the resident should have had an ostomy appliance in place to protect the abdominal incision from fecal contamination. The resident was subsequently transferred to the hospital for further care due to the high risk of infection.
Deficiencies in ADL Assistance and Care
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADLs) for several residents, leading to significant deficiencies in care. For two residents, the facility did not provide timely incontinence care, resulting in them remaining in soiled briefs for 17 hours. This neglect led to the development of pressure ulcers, with one resident developing three Stage II wounds, which were observed to have progressed to Stage III due to the presence of slough. The staff cited insufficient personnel as the reason for the lack of care, as both residents required assistance from two staff members for repositioning and incontinence care. Another resident, who required supervision or assistance with meals, was repeatedly left unattended with meal trays, unable to initiate eating due to their condition. Observations over several days showed that the resident's meal trays were left untouched, and no staff were present to assist, despite the care plan indicating the need for supervision during meals. This lack of assistance could potentially lead to nutritional deficiencies and other health issues. Additionally, the facility failed to provide necessary grooming care for two residents, who were observed with long, dirty fingernails, and another resident who had not received facial hair removal. Despite the care plans indicating the need for assistance with grooming, these tasks were not performed, and there was no documentation of any refusal of care by the residents. Interviews with staff revealed a lack of awareness and follow-through on these grooming needs, further highlighting the facility's failure to adhere to its own care policies.
Deficiencies in Wound Care and Treatment Implementation
Penalty
Summary
The facility failed to provide appropriate treatment and care for several residents, leading to deficiencies in maintaining their highest practicable well-being. For one resident, the staff did not identify and address a deteriorating skin injury, resulting in a wound with slough and delayed healing. The physician noted that the dressing was undated, saturated, and visibly soiled, indicating it had not been changed for an unknown period, putting the resident at risk for infection. Despite the physician's orders, there was no documentation of treatment implementation until much later. Another resident did not receive a culture and sensitivity test as ordered by the physician for ten days, and the facility failed to notify the physician of their inability to fulfill the order due to a lack of culture kits. This delay in obtaining the necessary test resulted in a deterioration of the resident's wound condition, as noted by a nurse practitioner. The facility's records showed multiple instances where the order was not completed, and there was no documentation of communication with the physician regarding the delay. Additional deficiencies were noted for other residents, including the failure to monitor and treat a stage 2 calf wound, complete physician-ordered wound treatments, and implement treatment orders for a skin tear. In several cases, the facility's staff did not document refusals of treatment or notify physicians of changes in residents' conditions, leading to untreated wounds and potential risks for infection. These failures highlight significant lapses in the facility's adherence to care protocols and communication with healthcare providers.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to provide adequate care and treatment to prevent the development and worsening of pressure ulcers for several residents. For one resident, the facility did not implement necessary interventions to prevent pressure ulcer development, resulting in an unstageable deep tissue injury on the right heel. The care plan lacked specific pressure ulcer prevention measures, and the resident was observed without the prescribed Prevalon boot, with heels directly on the mattress, and with visible signs of wound deterioration. The facility also failed to notify the wound nurse practitioner and the physician about the deteriorating condition of the wounds. Another resident experienced a deterioration of a stage II pressure ulcer to an unstageable ulcer due to the facility's failure to implement the wound nurse practitioner's treatment recommendations. Despite multiple recommendations for specific wound care treatments, the facility did not follow through with the prescribed interventions, leading to the worsening of the resident's condition. The resident expressed non-compliance with wearing booties, but the facility did not document or address this issue adequately. Additionally, the facility did not provide timely incontinence care for a resident, resulting in the development of pressure ulcers. The resident was left in soiled briefs for extended periods, leading to skin breakdown and the formation of multiple stage II wounds. The facility's documentation did not reflect the provision of necessary care, and staff interviews revealed a lack of awareness and adherence to care protocols. The facility also failed to notify the physician or wound nurse practitioner about new wounds, and there was a lack of appropriate wound treatment and documentation for another resident with a calf wound.
Failure to Notify Physicians of Changes in Resident Conditions
Penalty
Summary
The facility failed to notify physicians of changes in medical status for several residents, leading to deficiencies in care. For Resident #78, the facility did not inform the physician when pain medication was unavailable upon admission and when scheduled pain medication ran out, resulting in worsening pain. The resident experienced significant pain due to the lack of medication, and the facility's records did not indicate that the physician was notified of these issues. Interviews with staff revealed that the admitting nurse should have discussed pain management with the physician, but this was not documented. Resident #42's physician was not notified when the facility was unable to fulfill an order to obtain a culture and sensitivity of a new wound for over a week. The resident had a history of multiple sclerosis and chronic venous hypertension with an ulcer on the right lower extremity. Despite the order for a wound culture, the facility ran out of the necessary kits, and the physician was not informed of the delay. This lack of communication resulted in a delay in obtaining the culture and addressing the resident's wound condition. For Resident #81, the facility did not notify the physician or nurse practitioner of a Stage 2 pressure wound on the left calf. The resident, who had a primary diagnosis of stroke and was at risk for pressure injuries, was observed with an open wound that was not reported to the physician. Similarly, Resident #30's deteriorating wounds and the recommendations of the wound nurse practitioner were not communicated to the physician in a timely manner. Lastly, Resident #99's physician was not alerted to a skin injury, and the nurse responsible for the resident's care did not notify the physician due to a lack of awareness of the requirement.
Abuse and Neglect in Medication Administration and Incontinence Care
Penalty
Summary
The facility failed to protect Resident #5, who is cognitively impaired, from abuse during medication administration. A surveyor observed Nurse #3 attempting to administer oral medications to Resident #5 by squeezing the resident's cheeks and trying to force open their mouth with a plastic spoon. This action was taken without any communication or explanation to the resident, who was observed resisting the medication. The nurse admitted to not being familiar with the resident's medication needs and acknowledged that her actions were inappropriate. Residents #63 and #10 were subjected to neglect as they did not receive incontinence care for 17 hours, leading to the development of pressure ulcers. Resident #63, who is dependent on staff for all functional tasks, was found in bed with two saturated incontinence briefs, resulting in skin excoriation and the development of stage II wounds. The resident reported that they requested two briefs because staff did not change them regularly. Similarly, Resident #10, who is also dependent on staff for toileting needs, was found in a saturated brief with a new stage one pressure area on the coccyx. The facility's failure to provide adequate staffing and care for residents requiring assistance with incontinence care and repositioning was highlighted by the staff's admission of insufficient personnel to meet the needs of all residents. The lack of timely care and repositioning contributed to the residents' discomfort and the development of pressure ulcers, indicating neglect in adhering to the facility's care protocols.
Failure to Address Newly Developed Contracture in Resident
Penalty
Summary
The facility failed to identify and address a newly developed contracture in a resident, leading to a deficiency in care. The resident, who was admitted with multiple diagnoses including morbid obesity, diabetes, and neuropathy, was observed to have limited passive range of motion and contractures in the lower extremities during a podiatry visit. However, these findings were not documented in the resident's admission nursing assessment or the occupational therapy evaluation. The resident was dependent on staff for all functional tasks and had intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status exam. Despite the podiatry note indicating limited range of motion and contractures, the facility did not notify the physician or update the resident's care plan. Interviews revealed that the occupational therapist was unaware of the contracture, and there was no physical therapy evaluation on file since admission. The facility lacked a Director of Rehabilitation and was short-staffed, contributing to the oversight. The corporate nurse confirmed that new contractures should trigger a change in condition protocol, but this was not followed, resulting in a failure to address the resident's needs adequately.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident upon admission, resulting in the resident experiencing worsening pain for 19 hours without any medication being administered. The resident, who has a history of Marfan Syndrome and muscle contracture, was admitted with a discharge order for Fentanyl patches to manage chronic pain. However, the facility did not apply the Fentanyl patch until nearly 19 hours after admission, during which time the resident was in significant pain and requested to be transferred back to the hospital. Additionally, the facility failed to manage the resident's pain effectively when the scheduled pain medication ran out. The resident was supposed to have three Fentanyl patches applied, but the facility ran out of one of the patches, and it was not administered as ordered. The resident reported a pain level of 10 out of 10, indicating severe pain, but there was no documentation of the physician being notified or alternative pain management being provided. Interviews with the nursing staff revealed that the nurse on each shift is responsible for monitoring medication supplies and reordering them when low. However, in this case, the nurse did not notify the physician or document a plan for pain management while waiting for the medication to arrive. The facility's emergency medication supply system was not accessed to provide any pain medication for the resident during this time.
Inadequate Staffing Leads to Resident Care Deficiencies
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents on one of its nursing units, resulting in inadequate care for multiple residents. The staffing plan outlined in the Facility Assessment Tool indicated a need for 16-18 licensed nurses and 20-28 nurse aides per day, with specific nurse-to-resident and CNA-to-resident ratios. However, the facility's Hours Per Patient Day (HPPD) report showed that staffing levels were below budgeted amounts for 12 out of the previous 30 days. Interviews with staff, including the Scheduling Coordinator and various nurses, revealed difficulties in maintaining adequate staffing, particularly during the 7:00 A.M. to 3:00 P.M. shift, due to frequent call-outs and insufficient staff coverage. On the day of the survey, only one nurse and one CNA were available to care for 24 residents on the unit until a second CNA was floated to the unit at 11:00 A.M. This staffing shortage led to significant care deficiencies, as observed by the surveyors. Nurse #9 and CNA #4 reported being unable to provide necessary care, including medication administration, treatments, and incontinence care, due to the overwhelming workload. As a result, residents were left in soiled briefs for extended periods, and some required assistance from two staff members, which was not available. The Director of Nursing and Corporate Nurse #1 acknowledged the staffing issues and the impact on resident care. The inadequate staffing resulted in residents developing pressure areas and skin breakdowns. Resident #63 was found wearing two soiled incontinent briefs, with excoriation and open ulcers on the buttocks and thigh, indicating a lack of timely incontinence care. Similarly, Resident #10 was observed with a saturated brief and a new stage one pressure area on the coccyx. Staff interviews confirmed that these residents had not received the necessary care due to the insufficient number of staff available to assist with repositioning and other care needs. The facility's failure to maintain adequate staffing levels directly contributed to the observed deficiencies in resident care.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. In the laundry room, a stained and potentially moldy ceiling tile was found above a bin of clean clothing, with water occasionally dripping from it. The Director of Laundry Services and Laundry Staff were unaware of the duration of the leak, and the Maintenance Director expressed concern about possible contamination of clean clothing due to the leak. For Resident #30, who has schizoaffective disorder, dementia, and heart failure, the facility did not implement enhanced barrier precautions (EBP) during the treatment of an open wound. The resident was observed with an open heel wound, and staff entered the room without donning the required gown, failing to follow EBP protocols. Similarly, for Resident #45, who has cerebral infarction and a feeding tube, staff did not use personal protective equipment (PPE) during care, and there was no EBP sign on the resident's door, contrary to the care plan. Additionally, the facility's nursing staff did not adhere to hand hygiene protocols during medication administration. Observations included nurses failing to perform hand hygiene after removing gloves, touching contaminated items, and handling medications. Interviews with the nurses and management confirmed the lapses in infection control practices, with acknowledgments that hand hygiene should have been performed as per facility policy.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to implement person-centered care plans for six residents, leading to deficiencies in care. Resident #3, who was at high risk for developing pressure ulcers, was observed multiple times with heels directly on the mattress, contrary to the care plan that required offloading heels while in bed. Despite the care plan and high-risk score on the Norton Plus Pressure Ulcer Scale, staff were unaware of the requirement, and the resident's heels were not offloaded as needed. Resident #28, also at high risk for pressure ulcers, was observed without heel boots on several occasions, despite physician orders and a care plan specifying their use while in bed. The nursing progress notes did not document any refusal of the heel boots by the resident, indicating a failure to follow the care plan. Similarly, Resident #30, with a history of pressure areas, was observed without Prevalon boots, and no documentation indicated a refusal, highlighting a lack of adherence to the care plan. Additional deficiencies were noted for Resident #99, who was observed without a pillow between the legs and with only one floor mat, despite care plan requirements. Resident #100's care plan required weekly weight monitoring due to nutritional risks, but weights were not consistently recorded. Lastly, Resident #90, with severe cognitive impairment, was not wearing Geri sleeves or Prevalon boots as ordered, and there was no documentation of refusal, indicating a failure to implement the care plan effectively.
Failure to Implement Physician's Orders and Report Wounds
Penalty
Summary
The facility failed to implement a physician's order for two residents, leading to deficiencies in care. For one resident, the facility did not report a significant weight change to the Nurse Practitioner (NP) or Medical Doctor (MD) as required by the physician's order. The resident's weight increased from 123 lbs to 143.6 lbs within a day, which was a change greater than the 3 lbs threshold that necessitated notification. Interviews with the MD, a nurse, and the Director of Nurses (DON) confirmed that the weight change was not communicated, and no nursing progress note was written to document the notification. For another resident, the facility failed to treat and accurately report a Stage 2 wound to the physician. The resident, who was at risk for pressure injuries, was observed to have a 1 cm x 1 cm wound on the left calf, which was not covered with a dressing. The wound was initially identified by a nurse and later confirmed by a unit manager and the DON as a Stage 2 pressure injury. However, the wound was not documented in the resident's medical record, and there was no evidence that the physician or NP was notified or that a treatment order was obtained. The corporate nurse initially assessed the wound as a scab and did not report it to the physician, leading to a lack of appropriate treatment. The DON later confirmed that the wound was not a scab and required a medicated dressing. Despite the assessment indicating a treatment was applied, the wound remained uncovered, and there was no documentation of physician notification or treatment orders in the resident's medical record.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored securely and in accordance with professional standards. On multiple occasions, medication carts on the Oak Grove Unit were observed unlocked and unsupervised in the hallway, with no staff present. Similarly, treatment carts on the [NAME] and Maplewood Units were found unlocked and unattended, allowing unauthorized access to medications. Interviews with nursing staff and the Director of Nurses confirmed that these carts should be locked when not in use. Additionally, the medication room on the Oak Grove Unit was found unlocked and unsupervised for an extended period, contrary to the facility's policy that requires such areas to be secured when not in use. Furthermore, opened insulin pens and an antibiotic solution on the [NAME] unit's medication carts lacked proper labeling, including resident names and opening or expiration dates, which is a violation of both state and federal laws. The surveyor also observed unsafe practices involving medication handling. A medication cup containing pills and an uncapped insulin syringe were left unattended on a medication cart and later on a countertop at the nurse's station, with residents nearby. Nurse #3 was seen placing these items in front of a resident and walking away, leaving them accessible. Interviews with the nurse, unit manager, and corporate nurse confirmed that medications and syringes should not be left unattended, and medication carts must be locked at all times.
Documentation and Care Deficiencies in Resident Management
Penalty
Summary
The facility failed to accurately document and manage the care of several residents, leading to deficiencies in their medical records and treatment. For one resident, the facility did not properly document a Stage 2 pressure injury on the left calf, which was observed by multiple staff members and surveyors. Despite the wound being identified, there was no documentation of physician notification or appropriate treatment orders, and the wound remained uncovered during subsequent observations. Another resident, who required Prevalon boots for pressure ulcer prevention, was observed multiple times without the boots, and the treatment sheet inaccurately indicated that the boots were worn. Staff interviews revealed a lack of awareness regarding the resident's need for the boots, and the boots were not found in the resident's room. This discrepancy between the treatment sheet and actual care provided highlights a failure in following physician orders and accurately documenting care. Additionally, the facility failed to consistently follow physician orders for a resident requiring dialysis care. The Treatment Administration Record (TAR) lacked documentation of necessary checks on dialysis access sites and monitoring for complications on several dates. Interviews with nursing staff confirmed that these orders were not followed, as indicated by the absence of documentation. This lack of adherence to physician orders and documentation requirements represents a significant deficiency in the resident's care management.
Deficiencies in Dignity and Privacy for Residents
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, Resident #50 and Resident #30. Resident #50 experienced a delay in meal service, receiving their meal 32 minutes after their tablemates, which caused distress as they had to watch others eat while they remained hungry. Resident #30, who requires supervision and assistance with eating due to dysphagia and moderate cognitive impairment, was not provided with appropriate assistance. A CNA was observed feeding Resident #30 while standing and without engaging with the resident, contrary to the facility's policy of providing assistance at eye level and engaging with residents during meals. The facility also failed to serve meals in a homelike atmosphere on the [NAME] Unit, as observed by the surveyor. Meals were served on institutional trays, and staff were not aware that they were supposed to place the contents of the meal trays onto the table and remove the tray to create a more homelike dining experience. Additionally, the facility failed to provide privacy for Resident #86 during toileting. The resident, who has severe cognitive impairment and is dependent on assistance for toileting, was left exposed in the bathroom with the door open, visible to others in the hallway. This lack of privacy was observed by the surveyor, and staff interviews confirmed that privacy should have been ensured during personal care activities.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consents for psychotropic medications for a resident prior to administration. The facility's policy, revised in April 2022, mandates that informed consent from the resident or a legally authorized individual is required before administering psychoactive medication. However, the medical record of a resident admitted in January 2024 with Alzheimer's disease, depression, and lymphedema, did not contain consent for the prescribed psychotropic medications, including Sertraline, Lorazepam, and Olanzapine. The resident's Minimum Data Set indicated a low cognitive score, and the Medication Administration Record for August 2024 showed that Sertraline and Olanzapine were administered daily as ordered. Interviews with facility staff, including a nurse and the Director of Nurses, confirmed that consent should have been obtained prior to administering these medications, but it was not documented in the resident's medical record.
Failure to Provide Adequate Shower Facilities for Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident who was admitted with multiple diagnoses, including morbid severe obesity, type two diabetes, and congestive heart failure. The resident, who has intact cognition and is dependent on staff for all functional tasks, has not received a shower since admission due to the lack of a suitable shower chair. Despite the resident's repeated requests and the involvement of the Ombudsman and community care worker, the facility did not provide the necessary equipment to meet the resident's needs. Interviews with various staff members, including nurses, the unit manager, the corporate nurse, and the director of nursing, revealed a lack of awareness and communication regarding the resident's need for a shower chair. The occupational therapist confirmed that the resident requires a large shower chair and is capable of transferring with a hoyer lift, yet no assessment or provision of such equipment was made. The social worker's notes indicated awareness of the resident's concerns, but no effective action was taken to resolve the issue, leading to the resident's prolonged lack of proper hygiene care.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that Advance Directives were consistently documented in the medical record for a resident. The facility's policy requires that advance directives be respected and documented in accordance with state law and facility policy. However, for one resident, there was a discrepancy between the Medical Orders for Life-Sustaining Treatment (MOLST) and the physician's orders. The MOLST indicated a Do Not Resuscitate (DNR) and Do Not Intubate (DNI) status, while the physician's orders and care plan indicated a Full Code status. The resident, who was admitted with Alzheimer's disease, depression, and lymphedema, had a low score on the Brief Interview for Mental Status (BIMS), indicating cognitive impairment. Despite the MOLST reflecting a DNR and DNI, the active physician orders and care plan meeting notes documented the resident as Full Code. This inconsistency was confirmed during interviews with Nurse #6 and the Director of Nurses, who acknowledged that the physician's orders should align with the MOLST. The failure to ensure consistent documentation of advance directives led to a deficiency in the facility's compliance with its policy and state law.
Failure to Inform Residents of Potential Financial Liability
Penalty
Summary
The facility staff failed to inform two out of three residents, or their representatives, about their potential financial liability for non-covered services under Medicare. The Advanced Beneficiary Notice (SNFABN) is intended to provide residents with information to decide whether to continue receiving skilled services that may not be covered by Medicare, thereby assuming financial responsibility. However, the facility's SNFABN form did not include the cost of rehab services for two of the three applicable residents. During an interview, the Minimum Data Set Nurse confirmed that the form only indicated costs for room and board, excluding skilled services such as rehab.
Improper Use of Pillows as Restraints
Penalty
Summary
The facility failed to properly assess and identify the use of pillows under the fitted sheet as a potential restraint for a resident diagnosed with Alzheimer's disease, dementia, aphasia, peripheral vascular disease, and depression. The resident was observed on multiple occasions with two pillows placed under the fitted sheet along the length of the mattress on both sides, which restricted the resident's movement. The facility's policy on the use of restraints, revised in April 2022, clearly states that restraints should only be used for the safety and well-being of residents after other alternatives have been tried unsuccessfully, and only upon a physician's written order with consent from the resident or their representative. Despite these guidelines, the resident's medical record lacked documentation of a restraint assessment, a physician's order, consent for restraint use, and a care plan for a restraint. Interviews with facility staff, including a nurse, unit manager, corporate nurse, and the Director of Nursing, revealed differing opinions on whether the pillows constituted a restraint. The nurse believed the pillows were necessary to prevent the resident from falling, while the unit manager and corporate nurse acknowledged that the pillows were a restraint and should not be used in this manner. The Director of Nursing confirmed that placing pillows under the fitted sheet is considered a restraint and emphasized the need for proper assessment.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to effectively implement its abuse policy regarding the reporting of alleged abuse for one resident. The policy, dated March 2022, mandates the investigation of all alleged incidents of resident abuse, neglect, mistreatment, injuries of unknown etiology, and misappropriation of property. A resident, admitted in May 2024 with diagnoses of depression and anxiety, reported to a nurse on September 17, 2024, that they intended to harm themselves due to the conditions at the facility and alleged being beaten by staff during changes. Despite this report, the Director of Nursing was not informed of the alleged abuse, preventing the initiation of an investigation and the reporting of the incident to the state agency.
Neglect in Incontinence Care and Reporting Failures
Penalty
Summary
The facility failed to report allegations of neglect related to incontinence care for two residents to the state agency as required. Resident #10, who was admitted with diagnoses including pain, spinal stenosis, and osteoarthritis, was found in a saturated incontinent brief that had not been changed for 17 hours. The resident, who is totally dependent on staff for toileting needs, was observed with a new stage one pressure area on the coccyx. The Unit Manager acknowledged the neglect and attributed it to insufficient staffing, as only one CNA and one nurse were available to care for 24 residents requiring assistance. Resident #63, admitted with multiple diagnoses including morbid obesity, type two diabetes, and congestive heart failure, also experienced neglect in incontinence care. The resident, who is dependent on staff for all functional tasks, was found wearing two saturated incontinent briefs after 17 hours without care. The resident had dried feces on the skin and multiple stage II wounds, which were incorrectly identified as stage III due to the presence of slough. The Corporate Nurse and other staff confirmed the neglect and the expectation for residents to receive care every two hours. Despite acknowledging the neglect, the Corporate Nurse did not report the incidents to the state agency. The facility's policy requires reporting such allegations within 24 hours if they do not result in serious bodily injury. The neglect was only reported to the Department of Public Health six days after the facility was notified of the allegations, indicating a failure to comply with mandatory reporting requirements.
Failure to Investigate Allegations of Neglect for Two Residents
Penalty
Summary
The facility failed to investigate allegations of neglect for two residents, as required by their policy. Resident #10, who was admitted with diagnoses including pain, spinal stenosis, and osteoarthritis, was found in a saturated incontinent brief that had not been changed for 17 hours. This neglect was observed by a surveyor and Unit Manager #1, who noted a new stage one pressure area on the resident's coccyx. Despite being informed of the situation, the facility did not initiate an investigation into the alleged neglect. Resident #63, admitted with multiple diagnoses including morbid obesity and type two diabetes, was also found in a similar state of neglect. The resident was wearing two saturated incontinent briefs and had not received incontinence care for 17 hours. Observations revealed excoriation and multiple stage II wounds, which were not properly addressed. Despite the facility's policy requiring repositioning and incontinence care every two hours, these actions were not taken, and no investigation was initiated. Interviews with facility staff, including Corporate Nurse #1 and the Director of Nurses, confirmed that the lack of incontinence care for 17 hours constituted neglect. The facility's failure to investigate these incidents of neglect for both residents was noted by the surveyor, and no investigation report was produced by the time of the survey exit.
Inaccurate MDS Coding for Three Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for three residents, leading to deficiencies in their assessments. For one resident, the MDS inaccurately indicated the use of non-invasive mechanical ventilation, despite the discontinuation of the CPAP machine in April 2024, as confirmed by nursing progress notes and interviews with the nursing staff. Another resident experienced a significant weight loss of 32.4 pounds, or 15.93%, over two months, which was not reflected in the MDS. This discrepancy was acknowledged by the MDS Nurse during an interview. Additionally, the MDS for a third resident inaccurately documented the discharge status, stating the resident was discharged home, whereas the resident had been sent to the hospital for evaluation following a fall. This error was also confirmed by the MDS Nurse. These inaccuracies in the MDS coding highlight a failure in ensuring accurate assessments for the residents, as evidenced by the interviews and record reviews conducted during the survey.
Failure to Develop Timely Dialysis Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan that included necessary instructions for providing effective and person-centered care for a resident requiring dialysis three times a week. The resident, admitted in February 2024, had diagnoses including Type II diabetes mellitus with diabetic chronic kidney disease, End Stage Renal Disease (ESRD), and dependence on renal dialysis. Despite the resident's severe cognitive impairment, as indicated by a score of 3 out of 15 on the Brief Interview for Mental Status exam, the facility did not create a baseline care plan for dialysis until July 2024, five months after admission. This omission was confirmed during an interview with the Director of Nursing and a Corporate Nurse, who acknowledged that a dialysis care plan should have been part of the baseline care plan upon admission.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were reviewed and revised with the interdisciplinary team as required for three residents. For Resident #28, the care plan for sleep apnea was not updated despite the discontinuation of the CPAP machine, which was noted in a nursing note and confirmed by the Director of Nurses. The resident, who is cognitively intact, had refused the CPAP machine, and the physician had approved its discontinuation, yet the care plan still listed CPAP as ordered. Resident #16's care plan was not revised to include a dialysis plan of care upon admission or during the initial comprehensive assessment. The resident, who has severely impaired cognition and requires dialysis three times a week, had a dialysis care plan created five months after admission. The care plan was incomplete, lacking specific interventions and details about the dialysis schedule and site protection, which was acknowledged by the Director of Nursing and Corporate Nurse. For Resident #77, the care plan was not updated to reflect the resident's current ability to eat independently. Despite observations of the resident eating alone and a CNA confirming that the resident only requires setup help for eating, the care plan still indicated that the resident requires total care for eating. This discrepancy was not addressed in the care plan, which had not been revised since the previous intervention update.
Failure to Provide Routine Vision Services
Penalty
Summary
The facility failed to provide routine vision services to a resident who required new eyeglasses. The resident, who was admitted in November 2023, had diagnoses including hemiplegia and diabetes mellitus, and demonstrated moderate cognitive deficits with a BIMS score of 8. The resident required assistance for self-care activities and had adequate vision with corrective lenses. Despite signing a consent to see optometry and having a doctor's order for an ophthalmology consultation in November 2023, the resident had not been seen by an eye doctor by August 2024. The resident was observed wearing two pairs of glasses simultaneously to read and watch television, indicating a need for updated vision services. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's vision needs. Nurse #4 stated that the process for scheduling an eye doctor appointment involves the nurse reaching out to the consultant service and the unit manager ensuring the resident is on the appointment list. However, Nurse #4 was unaware of the resident's use of two pairs of glasses. Corporate Nurse #1 emphasized the responsibility of the entire team to make referrals for new glasses when needed. The facility's vision services records confirmed that the resident had not been seen by an eye doctor, highlighting a deficiency in providing necessary vision care.
Failure to Initiate Timely Falls Assessment and Investigation
Penalty
Summary
The facility failed to ensure timely initiation of a falls assessment and investigation following a fall with injury for a resident. The resident, who has diagnoses including hemiplegia, hemiparesis, and legal blindness, was identified as being at high risk for falls. Despite this, after the resident fell while attempting to reach a container of cheese balls, no immediate nursing assessment or falls investigation was conducted. The resident reported the fall occurred when they stood up from their wheelchair and lost balance, resulting in abrasions on their back. The incident was only discovered the following morning when a CNA noticed the injuries during rounds. The facility's policy requires that all accidents involving residents be investigated and reported to the administrator. However, in this case, the staff member who found the resident did not notify a nurse, and no assessment was performed before the resident was assisted off the floor. The Director of Nursing and Corporate Nurse confirmed that a falls investigation was not initiated as they were unaware of the incident until the morning after it occurred. This lack of timely response and documentation represents a deficiency in the facility's adherence to its fall protocol and accident investigation procedures.
Failure to Maintain Nutritional Status for Residents
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for two residents, leading to significant deficiencies in their care. Resident #103 experienced a significant weight loss of 23.98% since admission, which was not addressed in a timely manner. The facility did not obtain weekly weights as ordered, with only 5 out of the 18 required weights recorded. Additionally, the resident's dislike of the facility's food was known but not adequately addressed, as the Food Service Director was not informed of the resident's preferences. The Registered Dietitian (RD) did not evaluate the resident promptly after a significant weight loss was recorded, with the first evaluation occurring over two months later. Resident #45, who was admitted with severe cognitive impairments and received nutrition via a feeding tube, also experienced deficiencies in care. The facility failed to obtain a Registered Dietitian consult as ordered by the physician. The resident's weight was not consistently recorded, with no weight documented for June 2024, and the RD did not follow up after a weight loss was noted in July. The RD was not alerted to the need for a consult due to a lack of communication from the Director of Nurses, who was responsible for notifying the RD of such orders. Interviews with facility staff revealed systemic issues in communication and adherence to protocols. The RD, who worked remotely, was not informed of significant weight changes or the need for consultations in a timely manner. The Director of Nursing and Corporate Nurse acknowledged that residents with orders for weekly weights should be weighed accordingly, and any significant weight loss should prompt immediate re-evaluation and notification of the RD and physician. The Food Service Director was unaware of Resident #103's food preferences due to a lack of communication from the nursing staff.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, leading to deficiencies in the management of their oxygen therapy. Resident #6, who has chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, and heart failure, was observed multiple times over several days with oxygen tubing that had not been changed since May 15, 2024. Despite the physician's order for oxygen therapy as needed, there was no specific order for changing the oxygen tubing. Interviews with nursing staff and the Director of Nurses revealed that the expectation was for oxygen tubing to be changed weekly and as needed, but this was not documented in the physician's orders. Similarly, Resident #30, who has dysphagia, dementia, type two diabetes mellitus, and protein-calorie malnutrition, was observed receiving oxygen therapy with tubing that was not dated initially and later dated August 5, 2024. The resident's physician orders specified oxygen at 2 liters per minute, but observations showed the resident receiving 2.5 liters. Interviews with the Unit Manager and Corporate Nurse confirmed that the oxygen tubing should be changed weekly and that the orders should be followed as prescribed by the physician. These observations and interviews highlight the facility's failure to adhere to professional standards of practice for respiratory care.
Deficiency in Dialysis Care for Resident with ESRD
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident with End Stage Renal Disease (ESRD) who required dialysis three times a week. The resident, who had severely impaired cognition, was admitted with a dialysis fistula in the left upper extremity and a dialysis catheter in the right upper chest wall. The facility did not consistently obtain the resident's blood pressure from the correct arm, as it was taken from the left arm, where the fistula was located, on nine occasions in the past 30 days, contrary to professional standards of practice. Additionally, the facility did not create a complete and resident-specific care plan for the resident's dialysis care. The care plan was not developed until five months after admission and was incomplete, lacking specific details such as dialysis days and the protection of the access site. The care plan also failed to include comprehensive interventions tailored to the resident's dialysis needs, which should have been established at the time of admission or during the comprehensive quarterly assessment. Furthermore, the facility's nursing staff did not consistently follow physician orders regarding the monitoring of the dialysis access sites. Documentation in the Treatment Administration Record (TAR) showed that nurses failed to check and document the observation of the dialysis access sites, AV fistula, and hemodialysis site for signs of complications on multiple occasions. Interviews with nursing staff and the Director of Nursing confirmed that these orders were not followed, and the necessary documentation was not completed, indicating a lapse in adherence to physician orders and facility protocols.
Failure to Develop Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to develop a comprehensive trauma-informed care plan for a resident with a history of trauma, specifically Post-Traumatic Stress Disorder (PTSD). The resident, who was admitted in March 2024, has severe cognitive deficits and requires substantial assistance for daily activities. Despite having an active diagnosis of PTSD, the resident's care plan did not include individualized interventions or identified triggers related to their condition. Interviews with facility staff, including a nurse, a social worker, and a corporate nurse, confirmed that a care plan should have been developed for residents with PTSD, identifying specific triggers to better care for the resident. The facility's policy on Trauma Informed Care, dated May 2022, outlines the need for nursing staff to be trained on trauma assessment and the identification of triggers, as well as the development of strategies to address these triggers. However, this policy was not effectively implemented for the resident in question.
Delayed Implementation of Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that recommendations from the Monthly Medication Reviews (MMRs) conducted by the consultant pharmacist were addressed and acknowledged by the physician in a timely manner for two residents. Resident #28, who was admitted with diagnoses including vascular dementia and chronic kidney disease, was receiving metoprolol succinate 25 mg twice a day, despite the pharmacist's recommendation to change the order to metoprolol succinate 50 mg once daily. This recommendation was not implemented, and the resident continued to receive the incorrect dosage as per the physician's orders from December 2023 to August 2024. The Director of Nurses acknowledged that the MMRs for this resident should have been completed but were not. Similarly, Resident #104, admitted with coronary artery disease and diabetes, had pharmacy recommendations for duplicate medication orders and administration instructions that were not implemented in a timely manner. The recommendations included discontinuing duplicate Tylenol orders and updating the administration instructions for ibuprofen to include giving with food or milk. Although the physician signed off on these recommendations, they were not implemented until several months later, in August 2024. Corporate Nurse #1 was aware of the delay in implementing these recommendations.
Failure to Limit PRN Psychotropic Drug Duration
Penalty
Summary
The facility failed to ensure that PRN psychotropic drugs were limited to 14 days for a resident diagnosed with Alzheimer's disease, depression, and lymphedema. The resident, who was admitted in January 2024, had severe cognitive impairments as indicated by a score of 3 out of 15 on the Brief Interview for Mental Status (BIMS). A physician's order dated July 17, 2024, prescribed Lorazepam, an anti-anxiety medication, to be administered as needed every 4 hours for anxiety. However, the order did not include a stop date or a re-evaluation date, which is a requirement for such medications. Interviews with Nurse #6 and the Director of Nurses confirmed the expectation that PRN orders for Lorazepam should have a stop and re-evaluation date, which was not present in this case.
Failure to Offer Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that pneumonia vaccinations were offered to two of five sampled residents. According to the facility's policy revised in January 2024, all residents should be assessed for eligibility to receive the pneumococcal vaccine upon admission and offered the vaccine unless contraindicated, refused, or previously vaccinated. Resident #45, admitted in April 2024, had no documented history of receiving, declining, or having a contraindication for the pneumonia vaccine in their electronic medical record. The Massachusetts Immunization Information System (MIIS) record indicated the vaccine was due but not administered. Similarly, Resident #90, admitted in July 2021, also lacked documentation of receiving, declining, or having a contraindication for the vaccine, and the facility did not provide their MIIS record. During an interview, the Infection Preventionist and Corporate Nurse confirmed that if the electronic medical records did not indicate the vaccine status, the information would not be found elsewhere.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 1,290 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Medford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Regalcare At Courtyard-medford | 1.1 mi | ★★★★★ | 2 | 0 |
| Dexter House Healthcare | 1.4 mi | ★★★★★ | 17 | 0 |
| Life Care Center Of Stoneham | 1.4 mi | ★★★★★ | 15 | 0 |
| Medford Rehabilitation And Nursing Center | 1.6 mi | ★★★★★ | 0 | 0 |
| Melrose Healthcare | 1.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.