Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Royal Wood Mill Center during CMS and state inspections, most recent first.
A resident with HTN, orthostatic hypotension, CKD, and moderate cognitive impairment did not receive an ordered dose of Pyridostigmine Bromide for postural orthostatic hypotension. The EMAR showed the dose as not given, nursing notes said the med was unavailable from pharmacy, but the bottle was actually on the med cart. The nurse later said she withheld it because the resident’s BP was low and there were no hold parameters in place, while the MD and DON stated the dose should have been administered and that the documentation was incorrect.
A resident with dementia, intrusive and rummaging behaviors, and a care plan requiring supervision while eating was assisted with a meal in their room by a CNA, who then moved the tray across the room, reported removing all food wrappings, and left the resident alone to assist another person. Shortly afterward, staff found the resident unresponsive on the floor with vomit present, initiated a Code Blue, and transferred the resident to the hospital, where EMS removed a piece of plastic wrap containing food from the resident’s airway during attempted intubation. The DON later reported the source and timing of the resident’s access to the plastic wrap could not be determined, despite policies requiring an environment free from accident hazards and adequate supervision during meals for cognitively impaired residents.
Staff were found sleeping during overnight shifts without clocking out for breaks, a nurse failed to triple-check medications against physician orders and instead relied on memory and handwritten lists, and a resident with an AV fistula had blood pressure readings repeatedly taken on the arm that was specifically restricted by physician order. These actions did not meet professional standards of care.
Staff failed to keep medication and treatment carts locked and unattended medications were left on top of carts, allowing residents and others access. In one case, a resident who was not assessed for self-administration was found with a cup of pills left at bedside by a nurse, contrary to policy and assessment findings.
Surveyors identified that medical records for four residents were incomplete or inaccurate, including errors in documenting oxygen therapy, blood pressure site, seizure pad placement, and air mattress settings. In each case, staff documentation did not match actual care provided, as confirmed by observations and interviews with nursing leadership.
Staff did not immediately notify administration after a resident with moderate cognitive impairment accused a CNA of wrapping a call light cord around their neck, resulting in a delay in reporting and investigating the alleged abuse as required by facility policy.
A resident with severe cognitive impairment and behavioral issues entered another resident's room and slapped them, but the incident was not reported to the state agency as required by facility policy. The DON confirmed that the event should have been reported.
A resident with severe cognitive impairment was found with a dislocated shoulder, and the facility only interviewed CNAs from the morning shift when the injury was discovered. The investigation did not include staff from previous shifts, contrary to facility policy, resulting in an incomplete investigation of the injury of unknown origin.
A resident with severe cognitive impairment and a history of behavioral issues physically abused another resident, but the care plan was not reviewed or updated after the incident as required by facility protocol. The DON confirmed that the care plan should have been updated but was missed.
Three residents with cognitive impairment, mobility limitations, or existing wounds had air mattresses set significantly above their current weights, contrary to physician orders and facility policy requiring settings to match each resident's most recent weight. Despite staff and DON acknowledging the correct procedure, repeated observations showed the air mattresses were not set as ordered.
Three residents were not adequately protected from accidents and hazards, including one who eloped from a secured unit without proper risk identification or investigation, another who experienced multiple unwitnessed falls without timely care plan updates or PT intervention, and a third with epilepsy who did not consistently have seizure pads applied to both side rails as ordered.
A resident with a history of stroke, left-sided hemiplegia, and hand contracture was admitted without timely continuation of occupational therapy interventions, including the use of a palm guard/hand splint, as recommended by the prior facility. The lack of therapy screening and absence of orders or care plan documentation led to the resident not receiving necessary rehabilitative services until after the issue was identified by surveyors.
Surveyors observed multiple infection control deficiencies, including a nurse failing to perform hand hygiene during wound care for a dependent resident, a nurse touching medication with bare hands, lack of readily available PPE outside a precaution room, and delayed implementation of contact precautions for a resident with C-Diff. These actions did not follow facility policy or professional standards.
The facility failed to lock medication rooms on two units and did not date opened medications on two of three medication carts. Medications including insulins were found opened and undated, and the medication rooms were left unattended and unlocked. Staff and the DON confirmed that these practices were against the facility's policy.
The facility failed to ensure proper food storage and kitchen maintenance, with multiple instances of improperly stored food and freezer temperatures consistently above the required levels. Unlabeled and undated food items were also found in the refrigerator, and the ice machine's scoop holder had standing water and debris.
The facility failed to maintain a reach-in freezer in the main kitchen at the proper temperature, resulting in frozen food not being kept solid. Observations and interviews confirmed that the freezer temperatures were consistently above the required 0 degrees F, and no corrective actions were documented.
A facility failed to respect a resident's room privacy when a CNA was observed using the shared closet space and storing personal belongings in the room of a severely cognitively impaired resident. The CNA retrieved the items upon noticing the surveyor, and the Unit Manager confirmed that staff should store personal belongings in a designated area.
The facility failed to identify and assess the use of a specialized low chair for a resident with severe cognitive impairment and a history of falls as a potential restraint. The resident's medical record did not include an order for the low chair, nor was there an evaluation for its use as a physical restraint. Staff interviews and observations confirmed the lack of proper assessment and documentation.
A facility failed to properly maintain a PICC line dressing for a resident, not adhering to physician orders and professional standards. The dressing was incorrectly dated, and gauze was used, preventing proper observation of the insertion site. The resident had a history of paraplegia, diabetes, and osteomyelitis.
The facility failed to clean the oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation stating the filters were cleaned, observations revealed they were covered in a thick layer of dust. The Unit Manager confirmed the filters had not been cleaned as required.
The facility failed to accurately document the cleaning of oxygen concentrator filters for a resident with COPD, asthma, and congestive heart failure. Despite documentation indicating the filters were cleaned, observations revealed they were covered in a thick layer of dust, indicating they had not been cleaned as required.
The facility staff failed to inform two residents or their representatives about potential liability for non-covered services, including the estimated cost of rehab services. The SNFABN form did not include these costs, and the DON confirmed the omission.
A resident with dementia accessed and ingested unsecured medications left at the Nurses' Station, leading to hospitalization and intensive care. The Facility's policies on medication storage and resident supervision were not followed, resulting in a serious health event.
A facility failed to secure medications, resulting in a resident with a history of wandering and rummaging ingesting multiple antipsychotic tablets. The resident required hospitalization, intubation, and intensive care due to respiratory failure and encephalopathy from the accidental overdose.
Failure to Administer Ordered Blood Pressure Medication
Penalty
Summary
The nursing facility failed to implement a physician’s order for a resident with hypertension, orthostatic hypotension, chronic kidney disease, and moderate cognitive impairment. The resident had an active order for Pyridostigmine Bromide 60 mg by mouth four times daily for postural orthostatic hypotension, scheduled for 8:00 A.M., 12:00 P.M., 4:00 P.M., and 8:00 P.M. The resident told the surveyor that the medication had not been received daily and that it was not given that morning, and also stated that blood pressure had not been taken since the prior day. The EMAR showed the 8:00 A.M. dose was not administered and was documented as “Other / See Nurse Notes.” Nursing progress notes stated the medication was unavailable from pharmacy and the MD was aware with no new orders. However, during interview and observation, the surveyor found an open bottle of the medication on the medication cart, and the nurse stated she did not give the dose because the resident’s blood pressure was low, not because the medication was unavailable. The nurse also stated there were no parameters in place for holding the medication and that she knew not to give it if blood pressure was too low. The Medical Director later stated the resident should have received the dose and was not aware it had been withheld, and the DON stated the nurse should not have withheld the medication without contacting the physician for parameters and should not have documented that it was unavailable when it was available.
Failure to Prevent Ingestion of Foreign Object in Cognitively Impaired Resident Requiring Meal Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents for a resident with dementia and known intrusive and rummaging behaviors. Facility policies on Safety and Supervision of Residents and Meal Supervision and Assistance required an environment as free from accident hazards as possible and adequate supervision during meals. The resident’s ADL care plan required supervision when eating, and the behavior care plan documented intrusive and rummaging behaviors, indicating a need for close monitoring, particularly around items that could pose a hazard. On the day of the incident, the resident, who had diagnoses including stroke, schizophrenia, anxiety, and dementia, was assisted with lunch in their room by a CNA. The CNA reported that the resident became drowsy during the meal and stated they did not want to eat anymore. The CNA then moved the food tray out of the resident’s reach by pushing it across the room, stated that all covers and wrappings were removed from the room, and left the resident alone to assist another resident, despite the care plan requirement for supervision when eating and the resident’s cognitive impairment and rummaging behavior. Shortly thereafter, another CNA found the resident lying face down on the floor and called for help. A nurse responded, found the resident unresponsive with vomit under them, and initiated a Code Blue and CPR. Suctioning by nursing staff removed a white substance resembling mashed potatoes from the airway. The resident was transferred to the hospital by 911, where paramedics continued CPR and, during attempted intubation, removed a foreign body from the airway that appeared to be a piece of plastic wrap with food inside. The DON later stated the facility could not identify where the plastic wrap came from or how the resident obtained it, despite the expectation that the resident was supervised at all times when eating, and acknowledged the resident should not have been able to get or ingest plastic wrap.
Failure to Meet Professional Standards: Staff Sleeping, Medication Administration Errors, and Non-Compliance with Physician Orders
Penalty
Summary
Staff on the overnight shift were observed sleeping while on duty, contrary to facility policy and professional standards. Multiple residents reported that staff routinely sleep during the 11:00 P.M. to 7:00 A.M. shift, and surveyors directly observed several CNAs and a nurse asleep in darkened dining rooms on both the first and second floors. Time card reviews showed that these staff members did not clock out for breaks, and interviews confirmed that staff were not following the required procedures for taking breaks or remaining alert and available to residents during their shifts. During a medication pass, a nurse dispensed medications without triple-checking them against the physician's orders, as required by standard practice. The nurse relied on memory and handwritten lists provided by a unit manager, rather than verifying each medication with the Medication Administration Record (MAR) or the physician's orders. The nurse admitted to not performing the required checks, and the DON confirmed that the expected practice is to check each medication three times for accuracy before administration. For a resident with end stage renal disease and an arteriovenous fistula, staff failed to follow physician's orders that specified no blood pressure should be taken on the right arm. Medical record review showed multiple instances where blood pressure readings were documented as being taken on the right arm, despite clear orders and facility policy prohibiting this practice for residents with AV fistulas. The DON and unit manager acknowledged that the orders were not followed in these cases.
Failure to Secure Medications and Improper Medication Storage
Penalty
Summary
Facility staff failed to store drugs and biologicals in accordance with state and federal requirements, as well as facility policy. Multiple incidents were observed where medication and treatment carts were left unlocked and unattended, sometimes out of the nurse's line of sight, and with medications left on top of the carts. On several occasions, nurses left carts open in hallways with residents and other staff nearby, providing full access to the medications. Interviews with the involved nurses confirmed that they were aware the carts should have been locked and medications should not have been left unattended or on top of the carts. Additionally, a resident with a history of malignant neoplasm of the kidney and urinary retention, who was assessed as not being able to self-administer or store medications at bedside, was found with a cup of pills left on the dresser by a nurse. The resident reported that the nurse had given the medications and left them at the bedside after the resident indicated they would take them later. Review of the Medication Administration Record confirmed that several medications had been administered in this manner, contrary to facility policy and the resident's assessment.
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for four residents, as evidenced by multiple documentation errors and discrepancies. For one resident with acute respiratory failure and diabetes, the physician's order for continuous oxygen was incorrectly transcribed and implemented as PRN, yet nursing staff documented continuous oxygen administration on the MAR, despite the resident not using oxygen during multiple observations and interviews. The DON and unit manager confirmed the order was transcribed in error and that documentation did not reflect actual care provided. Another resident with end stage renal disease and an arteriovenous fistula had a physician's order specifying that blood pressure should not be taken on the right arm. However, multiple entries in the medical record indicated that blood pressure was taken on the right arm, while the MAR documented it as being taken on the left arm. The DON and unit manager acknowledged that nurses should not document blood pressures on the left arm when they were actually taken on the right arm. A third resident with epilepsy had an order for seizure pads to be placed on both side rails and checked every shift. Observations revealed only one seizure pad in place, yet staff documented in the TAR that both pads were present. Similarly, a fourth resident with multiple deep tissue injuries had an order for an air mattress to be set according to weight, but observations showed the mattress was set incorrectly, while documentation indicated it was set per order. In both cases, the DON and unit managers confirmed that documentation did not accurately reflect the care provided.
Failure to Immediately Report Alleged Abuse
Penalty
Summary
Staff failed to implement the facility's abuse policies and procedures when an accusation of abuse was made by a resident. The facility's policy requires that any employee who suspects an alleged violation must immediately notify the executive director or designee. A resident with a history of stroke, dementia, and depression, who was totally dependent for all activities of daily living and had moderate cognitive impairment, accused a CNA of wrapping a call light cord around their neck. The accusation was documented in the progress notes, but facility administration was not notified until the following afternoon, significantly delaying the required immediate reporting and investigation of the alleged abuse. The DON confirmed during an interview that she was not made aware of the accusation until the next day, and acknowledged that the nurse who first heard the allegation should have reported it to administration immediately, as required by policy and to ensure timely reporting to the state agency.
Failure to Report Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of resident-to-resident abuse to the state agency as required by its own abuse policy and state law. Specifically, a resident with dementia and severe cognitive impairment, who exhibited verbal and physical behaviors, entered another resident's room and slapped them on the face. Although the incident was documented in an incident report, there was no evidence in the facility's reporting system that the event had been reported to the appropriate state agency. During an interview, the Director of Nursing acknowledged that the incident should have been reported.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for one resident. The resident, who had severe cognitive impairment as indicated by a score of 1 out of 15 on the Brief Interview for Mental Status exam, was found to have a dislocated right shoulder after reporting pain upon waking. The incident report documented that only the certified nursing aides on the morning shift, when the injury was discovered, were interviewed. There was no documentation of interviews with staff from other shifts who had cared for the resident prior to the incident. Facility policy requires that, in cases of injuries of unknown source, the Director of Nursing or designee should interview all staff members who may have been involved, including those on previous shifts, and document their statements. However, the investigation did not include interviews with staff from the night or day prior to the discovery of the injury. The Director of Nursing acknowledged during an interview that she should have interviewed staff from the previous shift, but this was not done according to the incident report.
Failure to Update Care Plan After Resident-to-Resident Abuse Incident
Penalty
Summary
The facility failed to update the care plan for a resident following an incident of physical abuse. The resident, who has a history of dementia and severe cognitive impairment as indicated by a low score on the Brief Interview for Mental Status exam, exhibited both verbal and physical behaviors. The care plan included multiple interventions to address these behaviors, such as 1:1 monitoring as needed, medication administration, and strategies to prevent frustration and aggression. However, after the resident entered another resident's room and slapped them, there was no evidence that the care plan was reviewed or updated to reflect this incident. Facility policy requires that after an incident of abuse, the care plan should be updated to address the new circumstances and ensure resident safety. Despite this, the care plan for the resident involved in the incident did not show any review or modification following the event. The Director of Nursing acknowledged during an interview that updating the care plan after such incidents is protocol, but admitted that this step was missed in this case.
Failure to Follow Physician Orders for Air Mattress Settings in Pressure Ulcer Care
Penalty
Summary
The facility failed to follow physician's orders regarding air mattress settings for three residents who were at risk for or had existing pressure ulcers. Facility policy and physician orders required that air mattresses be set according to each resident's most recent weight, with a margin of plus or minus 10 pounds, and that the settings be checked and documented every shift. However, observations revealed that the air mattresses for these residents were set significantly higher than their current weights, contrary to the orders and policy guidelines. One resident with Parkinson's disease, dementia, and chronic kidney disorder, who was severely cognitively impaired and at risk for pressure ulcers, was observed multiple times with an air mattress set at 200 lbs despite a current weight of 122 lbs. Another resident, dependent for all activities of daily living and with an unstageable wound, had an air mattress set at 280–330 lbs while their most recent weight was 85 lbs. A third resident with diabetes and multiple deep tissue injuries had an air mattress set at 210–320 lbs, while their weight was 169.8 lbs, with staff acknowledging the setting should have been around 180 lbs. Interviews with the Director of Nursing and unit managers confirmed that the expectation was for staff to set air mattresses according to physician orders and resident weights. Despite this, repeated observations showed that the required settings were not being followed, and the air mattress settings were not adjusted to match the residents' current weights as specified in the orders.
Failure to Prevent Accidents and Implement Safety Interventions
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision or implement appropriate interventions for three residents. One resident with severe cognitive impairment and a history of wandering was able to elope from the facility. The care plan did not identify this resident as an elopement risk prior to the incident, and the elopement assessment did not reflect the resident's risk. After the elopement, the facility did not conduct a thorough investigation, as witness statements were not obtained, and there was uncertainty among staff about how the resident exited the building. Another resident, who was dependent for all activities of daily living and had moderate cognitive impairment, experienced multiple unwitnessed falls. The care plan included several interventions for fall prevention, such as bed and chair alarms and physical therapy (PT) evaluations. However, after a fall, the care plan was not updated, and there was no documentation that PT evaluated or treated the resident as ordered. The Director of Nursing confirmed that the resident should have been seen by rehab after the fall, but this did not occur. A third resident with epilepsy had a physician's order for seizure pads to be applied to both side rails while in bed. Observations on multiple occasions revealed that only one seizure pad was in place, with the other found on the dresser. The Unit Manager and DON both acknowledged that the resident should always have two seizure pads in place according to the physician's order, but this was not consistently done.
Failure to Provide Timely Specialized Rehabilitative Services
Penalty
Summary
The facility failed to provide specialized rehabilitative services in a timely manner for a resident admitted with a history of stroke, left-sided hemiplegia/hemiparesis, contracture of the left hand, and dementia. Upon admission, documentation from the prior facility indicated the resident had been receiving occupational therapy for the left hand contracture, including the use of a palm guard/hand splint and passive range of motion (PROM) exercises. The occupational therapy discharge recommendations specifically advised continuation of splinting and PROM at the new facility. However, upon review, there was no physician order for a palm guard/hand splint, no rehabilitation therapy order, and no mention of splinting in the care plan. Multiple observations by the surveyor over several days confirmed the resident was not provided with a palm guard/hand splint, and staff interviews revealed that neither nursing nor therapy staff were aware of the need for these interventions until after the surveyor's inquiry. The Director of Rehab stated that therapy screenings are not automatically performed for all admissions and that nursing is responsible for notifying therapy of new residents requiring services. As a result, the resident was not screened by therapy upon admission, and the recommendations from the previous facility were not reviewed or implemented. The resident and staff confirmed that the palm guard/hand splint was not provided until after the surveyor's observations, indicating a delay in the provision of necessary specialized rehabilitative services.
Infection Control Lapses in Hand Hygiene, Medication Handling, PPE Availability, and C-Diff Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices. During a wound dressing change for a resident with a history of stroke, dementia, and total dependence for activities of daily living, a nurse repeatedly failed to perform hand hygiene before donning new gloves, despite facility policy requiring hand hygiene before and after glove changes. The nurse continued the dressing change process, including cleaning the wound and applying skin prep, with potentially contaminated gloves, which was acknowledged as incorrect during subsequent interviews. Additionally, during a medication pass, a nurse was observed opening an acidophilus capsule with bare hands, potentially contaminating the medication. The nurse believed that hand sanitization prior to handling the medication was sufficient, but the Director of Nursing clarified that medications should never be touched with bare hands. Another observation revealed that personal protective equipment (PPE) was not readily available outside a resident's room where enhanced barrier precautions were indicated, contrary to facility expectations that a PPE cart be present for staff use. For a resident who developed symptoms and tested positive for Clostridioides difficile (C-Diff), the facility failed to implement contact precautions promptly. Although the resident had reported diarrhea and later tested positive for C-Diff, contact precautions, including signage and a PPE cart, were not put in place until 48 hours after the positive test result. Interviews confirmed that contact precautions should have been initiated when symptoms began and while awaiting laboratory results, but this was not done in a timely manner.
Failure to Secure Medication Rooms and Date Opened Medications
Penalty
Summary
The facility failed to ensure that medication rooms on two units were locked and secured while not in use. On two separate occasions, the surveyor observed the medication rooms on the Arlington Unit and the Pacific Unit unlocked and unattended. In the Arlington Unit, the medication room was left unlocked for a total of 21 minutes, during which time the surveyor observed various medications including insulins and intravenous medications. Both Nurse #1 and Nurse #3 confirmed that the medication room doors should be locked when unattended. The Director of Nursing also acknowledged that medication rooms should be locked when not in use. Additionally, the facility failed to ensure that medications were properly dated when opened on two of three sampled medication carts. The surveyor observed multiple insulin vials and pens on the Arlington Unit high side and low side medication carts that were opened but not dated. Both Nurse #2 and Nurse #1 confirmed that medications should be dated when opened. The Director of Nursing reiterated that insulins should be dated when opened, indicating a lapse in adherence to the facility's medication storage policy.
Improper Food Storage and Kitchen Maintenance
Penalty
Summary
The facility failed to ensure food was stored and the kitchen was maintained in accordance with professional standards for food service safety, potentially leading to foodborne illness. During a tour of the kitchen, surveyors observed multiple instances of improper food storage, including soft and not frozen solid ice cream, open and exposed boxes of frozen cookies and French toast, and improperly wrapped pancakes. The freezer temperature logs indicated that the freezer temperatures were consistently above the required 0 degrees Fahrenheit, with no corrective actions documented. Additionally, the internal thermometer of the three-door reach-in freezer showed a temperature of 38 degrees Fahrenheit, far above the required freezing point. Further observations revealed unlabeled and undated food items in the reach-in refrigerator, including tortillas, a cut tomato, a cut onion, and bowls of fruit. The ice machine's scoop holder was found to have standing water and black debris particles. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the food should be properly covered, labeled, and frozen solid, and that the freezer temperatures were not being maintained at the required levels. The FSD acknowledged the issues and mentioned that a vendor had been called to service the malfunctioning freezer.
Improper Freezer Maintenance and Food Storage
Penalty
Summary
The facility failed to ensure that a reach-in freezer in the main kitchen was in a safe and operable condition, resulting in frozen food not being maintained in a solid state. Observations during a tour revealed that three individual containers of ice cream and one box of precooked French toast were soft and not frozen solid. The facility's policy requires that refrigerators and freezers be closely monitored for proper operation and temperature, with corrective actions taken if temperatures exceed 0 degrees Fahrenheit. However, the freezer temperature log indicated that for 17 out of the last 18 days, temperatures ranged between 4.1 degrees F and 16 degrees F in the morning, and between 3.1 degrees F and 30 degrees F in the evening, without any documented corrective actions for these deviations. Further observations showed the internal appliance thermometer reading 38.0 degrees F, well above the required 0 degrees F. Interviews with the Food Service Director (FSD) and Cook #1 confirmed that the frozen food was not always frozen solid, and the FSD acknowledged that the vendor had been called to service the freezer. Despite checking the freezer multiple times during the day, the FSD admitted that not all items were frozen solid. Follow-up observations continued to show elevated temperatures and improperly frozen food, indicating a failure to adhere to the facility's policies and FDA guidelines for food storage and safety.
Failure to Respect Resident Room Privacy
Penalty
Summary
The facility failed to ensure staff respected resident room privacy for one resident. Resident #15, who is severely cognitively impaired with diagnoses including chronic obstructive pulmonary disease, toxic encephalopathy, and unspecified psychosis, was observed sleeping in bed while a CNA was in the room using the shared closet space. The CNA was seen putting on a jacket and storing personal belongings in the resident's room, including a green purse, a phone, a plastic shopping bag, and a food container. Upon noticing the surveyor, the CNA left the room and later returned to retrieve the personal items, exiting through the stairwell. The Unit Manager confirmed that staff are expected to leave their personal belongings in a designated area and not in resident rooms.
Failure to Assess Specialized Low Chair as Potential Restraint
Penalty
Summary
The facility failed to identify and assess the use of a specialized low chair for a resident as a potential restraint. The resident, who has severe cognitive impairment and a history of repeated falls, was observed multiple times seated in a low chair that was not consistent with a manual wheelchair. The resident's medical record did not include an order for the use of the low chair, nor was there an evaluation for the use of a physical restraint completed. The care plan and Kardex also failed to indicate the use of the low chair, instead mentioning the use of a wheelchair. Interviews with staff revealed that the resident had been using a wheelchair but was given the low chair about a month prior due to leaning issues. The CNA mentioned that the resident could use their feet to move the chair and had not been seen trying to get up from it. However, the Director of Rehabilitation (DOR) stated that the low chair was not assessed by him and was not favorable as it was too low, making it difficult for the resident to stand up. The DOR also mentioned that the resident's hips were not in a neutral position in the low chair, which could further complicate standing up. The Director of Nursing confirmed that the low chair had not been assessed as a possible restraint. The facility's policy on the use of restraints clearly states that any device that restricts a resident's freedom of movement and cannot be easily removed by the resident is considered a restraint. The policy also requires a physician's order and a thorough assessment before using any restraint, none of which were followed in this case for the low chair used by the resident.
Failure to Properly Maintain PICC Line Dressing
Penalty
Summary
The facility failed to provide care and maintenance of a peripherally inserted central catheter (PICC) for a resident, consistent with professional standards of practice. Specifically, the facility did not ensure that nursing staff completed a PICC line dressing change as ordered by the physician. The dressing was observed to be dated 4/16/24, despite the Treatment Administration Record (TAR) indicating that it was changed on 4/18/24. Additionally, the insertion site was covered by a 2x2 gauze pad, preventing staff from observing the site for signs of complications. The resident involved had a history of paraplegia, diabetes, neuromuscular dysfunction of the bladder, and osteomyelitis. The resident was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14 out of 15. The facility's policy required the PICC line dressing to be changed every 7 days and the insertion site to be monitored every shift for signs of complications. However, the nursing staff did not adhere to these guidelines, as evidenced by the incorrect dressing date and the use of gauze that obscured the insertion site. Interviews with the nursing staff and the Director of Nursing confirmed these deficiencies.
Failure to Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to clean the oxygen concentrator filters for a resident with chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure. The facility's policy required that oxygen concentrator filters be cleaned no less than weekly. However, observations on two consecutive days revealed that the filters were covered in a thick layer of white dust, indicating they had not been cleaned as required. This was despite documentation in the treatment administration record (TAR) stating that the filters had been cleaned on the specified date. The resident's care plan included interventions for administering oxygen therapy to maintain blood oxygen saturation levels above 90%. The resident was observed lying awake in bed with an oxygen concentrator running and wearing a nasal cannula. During an interview, the Unit Manager confirmed that the filters were covered in dust and acknowledged that the nursing staff had not cleaned them as documented. A review of the resident's nursing progress notes did not reference the condition of the oxygen concentrator filters.
Failure to Accurately Document Cleaning of Oxygen Concentrator Filters
Penalty
Summary
The facility failed to accurately document the cleaning of oxygen concentrator filters for one resident. According to the facility's policy, oxygen concentrator filters should be cleaned no less than weekly. Resident #21, who has chronic obstructive pulmonary disease (COPD), asthma, and congestive heart failure, was observed with an oxygen concentrator running and wearing a nasal cannula. Despite documentation indicating that the filters were cleaned on a specific date, the surveyor observed that the filters were covered in a thick layer of white dust on two consecutive days, indicating they had not been cleaned as required. During an interview, the Unit Manager confirmed that the filters should be cleaned weekly and acknowledged that the filters appeared not to have been cleaned as documented. The Unit Manager reviewed the treatment administration record (TAR) and confirmed that the documentation was inaccurate. This discrepancy between the documented care and the actual condition of the equipment led to the identification of the deficiency.
Failure to Inform Residents of Potential Liability for Non-Covered Services
Penalty
Summary
The facility staff failed to inform two out of three residents reviewed, or their representatives, about potential liability for payment for non-covered services, including the estimated cost of services. The Advanced Beneficiary Notice (SNFABN) form, which is intended to provide residents and/or their beneficiaries with information to decide if they wish to continue receiving skilled services that may not be covered by Medicare, did not include the cost of rehab services for two of the three applicable residents. During an interview, the Director of Nursing confirmed that the cost indicated on the form was for room and board and did not include skilled services such as rehab.
Failure to Secure Medications and Provide Adequate Supervision
Penalty
Summary
The Facility failed to ensure that Resident #1, who had dementia and was known to wander and put objects in his/her mouth, was provided with adequate supervision and a safe environment. On 03/29/24, nursing staff did not secure medications delivered from the pharmacy, leaving them unattended at the Nurses' Station. Resident #1 accessed and ingested multiple Seroquel and Risperidone tablets, which were not prescribed to him/her. This resulted in Resident #1 being transferred to the Hospital Emergency Department, where he/she required intubation and admission to the Intensive Care Unit due to respiratory failure and encephalopathy from the overdose. The resident was later discharged to a rehabilitation facility on 04/06/24. The Facility's policies on Safety and Supervision of Residents and Storage of Medications were not followed. Nurse #1, who worked the 11:00 P.M. to 07:00 A.M. shift, admitted to leaving the medications in a red plastic bag on the desk at the Nurses' Station instead of securing them in the medication cart or locked medication room. Resident #1, who was known to wander and rummage, was found with the medication packages ripped open and multiple tablets missing. Nurse #1 acknowledged that she should have secured the medications but did not. Interviews with Certified Nurse Aides (CNA) #1 and #2 confirmed that Resident #1 was known to wander intrusively, rummage through belongings, and take unsupervised items, including food. The Director of Nurses (DON) stated that it was her expectation for nurses to secure all medications, but this protocol was not followed by Nurse #1, leading to the incident. The Facility's failure to secure medications and provide adequate supervision resulted in a serious health event for Resident #1.
Failure to Secure Medications
Penalty
Summary
The facility failed to ensure that medications were kept locked up or under direct supervision of nursing staff. On 03/29/24, Nurse #1 left a medication package delivered from the pharmacy unattended on the desk at the Nurses' Station. As a result, a resident known to wander, rummage, and eat food found the package, opened it, and was believed to have ingested multiple Seroquel and Risperidone tablets. This resident, who had a history of neurocognitive disorder, alcohol use, dementia, and substance use disorder, did not have physician's orders for these medications. The resident was transferred to the Hospital Emergency Department for evaluation and monitoring, later requiring intubation and admission to the Hospital Intensive Care Unit due to respiratory failure and encephalopathy from the accidental ingestion and overdose of the medications. The facility's policy, dated 05/2023, indicated that all drugs and biologicals should be stored in a safe, secure, and orderly manner. However, Nurse #1 admitted to not securing the medications in the medication cart or the locked medication room, leaving them on the desk at the Nurses' Station. The Director of Nurses confirmed that it was the facility's policy and expectation that all medications be secured, which was not followed in this instance. The incident led to the resident's hospitalization and subsequent transfer to a rehabilitation facility after discharge.
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Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lawrence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| M I Nursing & Restorative Center | 1 mi | ★★★★★ | 30 | 0 |
| Berkeley Retirement Home,the | 1.5 mi | — | 0 | 0 |
| Nevins Nursing & Rehabilitation Center | 1.9 mi | ★★★★★ | 13 | 0 |
| Cedar View Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 5 | 0 |
| Prescott House | 3 mi | ★★★★★ | 22 | 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.