Below average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Southeast Rehabilitation & Skilled Care Center during CMS and state inspections, most recent first.
Resident Council repeatedly raised concerns that staff were not wearing visible name tags, but the issue remained ongoing. Surveyors observed multiple CNAs and nurses without visible tags, and staff acknowledged they should be wearing them. Residents said the lack of name tags made it hard to identify caregivers and file grievances or concerns.
The facility failed to maintain a clean, comfortable, and homelike environment in several areas. Residents and staff reported old carpeting with a strong odor, and surveyors observed torn, lifting carpet in a dining area, dusty and dirty window AC units with black buildup and other maintenance problems, and a dark dining room with missing ceiling lights. Surveyors also found damaged walls, handrails, rugs, and furniture on one unit, along with dried tube feeding formula on a resident’s pump, pole, fan, and bedrail; staff acknowledged the buildup and lack of routine cleaning or maintenance.
Failure to develop and implement individualized care plans for three residents. One resident had a fall and the care plan was not revised after the incident. Another resident was observed smoking and listed by staff as a smoker, but no smoking care plan was in place despite prior assessment showing no smoking interest. A third resident had a prior fall with bed side rails noted in the care plan, but the rails were removed and no PTSD care plan was documented.
A resident with multiple pressure injuries and moderate cognitive impairment did not receive wound care as ordered. The record showed missing wound descriptions, wound orders that omitted the Dakins strength, failure to implement a right buttock treatment change, and direct observation of an RN using 1/2 strength Dakins instead of the ordered 1/4 strength, packing wounds with loose 4x4s instead of Kerlix, skipping HH between glove changes, and applying a dressing to a healed heel wound after the order had changed to skin prep only.
A resident with dementia and a prior elopement was observed walking off the property again after the earlier elopement was not fully investigated or tied to resident-specific interventions. The facility also missed ordered fall precautions for residents with repeated falls and fractures, and staff failed to supervise smoking safely: one resident was seen lighting cigarette butts from the ground, two residents shared a cigarette, and other residents smoked without completed smoking safety screens or proper monitoring.
Two residents experienced medication administration errors when ordered meds were not given as prescribed. One resident with HTN and heart disease had Amlodipine 10 mg signed off on the eMAR but not actually administered, while another resident with AFib and a prior stroke did not receive Eliquis 5 mg because it was marked unavailable/on order, and the provider was not notified in the progress notes.
Controlled substances were not stored with restricted access when liquid Ativan kept in refrigerator lock boxes was accessible to more than one nurse on two units. Nurses stated that both medication nurses had keys to the same lock box, and one nurse opened the box to show access to the medications. The DON said only the nurse responsible for counting the medication should have access, but staff reported both nurses had always been able to access the box.
Failure to Follow Prescribed Diets and Therapeutic Menus: Staff served 1% milk to residents ordered whole milk and repeatedly failed to follow therapeutic menus during meal service. Observations showed incorrect milk availability, improper substitutions for mechanical soft, puree, low sodium, vegetarian, and vegan diets, and staff stated they were using the regular menu, making substitutions as they went, and not documenting them.
A resident ordered CCHO, NAS, and vegan diets, but the facility had no preplanned vegan therapeutic menu and staff could not explain the difference between vegan and vegetarian diets. Surveyors observed a dietary aide assembling the resident’s lunch by adding hummus to a pre-made salad, while the resident reported repeated receipt of non-vegan items, limited variety, and meals such as hash browns and mashed potatoes that were not consistent with the vegan diet.
Unpalatable and Unappetizing Food on Test Tray: A surveyor observed a test tray with poor presentation, including dry meatballs, bland spaghetti, thin gravy pooled on the plate, and peas with different colors and textures. A resident on a mechanical soft diet and several other residents reported watery or missing gravy and disliked the peas, and the test tray findings matched those complaints.
Failure to provide ordered adaptive eating equipment: two residents did not receive the utensils listed on their meal tickets and in their records. One resident with stroke-related diagnoses and neuropathy was observed eating with regular silverware despite needing hollow-handled utensils, and the resident reported difficulty and discomfort using standard utensils. Another resident with dementia was observed eating without a rocker knife despite physician orders and meal ticket instructions for that equipment, and the resident stated meals were hard to cut without it.
Incomplete Infection Surveillance Logs: The facility failed to maintain an accurate infection surveillance system. Residents with UTI, MRSA, shingles, Influenza A, and loose stools were not consistently documented on the infection logs, and culture results for multiple UTI cases were omitted, including one ESBL-positive culture. The IP said the residents and culture results should have been listed, and the DON stated the facility did not have an accurate surveillance process.
Failure to Follow Antibiotic Stewardship and Document UTI Rationale: The facility did not follow its antibiotic stewardship program or its own UTI criteria. A resident was tracked for UTI based on foul odor alone, yet the record did not show enough symptoms to meet the facility’s McGeer criteria, and an antibiotic was still prescribed for 10 days. The chart also lacked nursing documentation for why urine was obtained or why the antibiotic was started, and there was no clinical rationale from the MD/APRN for initiating treatment.
Failure to provide pneumococcal vaccines for three eligible residents. Facility records showed each resident had prior PPSV23 history, and the IP stated each was overdue for PCV20 and not up to date. One resident’s pneumonia vaccine education form also left prior PCV13 history blank.
Failure to Educate, Offer, and Document Current COVID-19 Vaccination: The facility did not provide education, assess eligibility, offer, administer, or document the current COVID-19 vaccine for five residents and five staff members reviewed. Residents had documentation of the prior season’s vaccine, but their records did not show the current vaccine was offered, and staff files lacked proof of education, offer, or acceptance/declination of the vaccine. The HR Director and DON confirmed the missing documentation during interview.
Failure to Obtain HCP Consent for Psychotropic Medications: A resident with moderate cognitive impairment and an invoked HCP received gabapentin, Risperdal, sertraline, and trazodone, but the informed consent forms were signed by the resident instead of the HCP. The chart did not show HCP consent in the physician or nursing notes, and staff confirmed the forms should have been signed by the activated HCP.
Failure to notify the Physician/NP of a resident fall and another resident’s significant weight loss. One resident with stroke-related weakness and intact cognition had a bathroom fall, but the Fall Incident Report and record showed no notification to the MD/NP. Another resident with dementia and CHF had an 11% weight loss, but the chart lacked documentation that the MD/NP was notified, despite staff stating such notifications were expected and should be documented.
Failure to Follow Physician Orders for Treatments, Medications, and Monitoring: Staff did not follow physician orders for a resident’s specialty air mattress setting, a resident’s crushed Vitamin B6 dose, weekly weights for a resident with wt loss, hand rolls for a resident with contractures, and an albuterol inhaler for a resident with COPD. Surveyors observed the mattress set incorrectly, found an uncrushed pill after med pass, saw missing ordered weights and hand rolls, and observed a resident self-administering an inhaler without an order for self-administration.
A resident with COPD, CHF, chronic respiratory failure, and sleep apnea was ordered continuous O2 at 2 L/min via NC, but staff failed to provide a portable O2 cannister. The resident was observed walking and attending activities without supplemental oxygen, and staff confirmed the resident should have had portable oxygen available for use outside the room.
Failure to Provide Individualized Trauma-Informed Care: The facility did not ensure two residents with documented trauma histories received individualized trauma-informed care. One resident with PTSD and multiple losses had a generic care plan that did not identify personal triggers or specific interventions, despite reporting triggers such as feeling rushed, loud sounds, and mistreatment. Another resident with PTSD related to witnessing a family suicide had a trauma screen with blank trigger documentation and no PTSD care plan, even though the resident reported nighttime fear of falling and requested bed rails for security.
Medication administration errors exceeded the allowed rate when an RN made four errors during observed med pass, resulting in a 13.79% error rate. One resident received crushed meds that were ordered whole, and an Amlodipine dose was signed off without being given. A second resident’s Eliquis was marked not available and not administered, but the provider was not notified. The DON stated meds should be given per MD orders and double checked when signing off the MAR.
Incomplete Resident Evaluations: The facility failed to keep resident records complete when required evaluations for two residents remained in In Progress status for 59 and 73 days. Staff said the MDS nurse opened the evaluations in the EHR as prompts for nursing, and the DON confirmed the nurses were responsible for completing the needed assessments in a timely manner.
A resident with a stroke history, muscle weakness, and dependence for toilet transfers reported that the bathroom call light had not worked for weeks and that pulling the cord did nothing. CNA and Unit Manager testing confirmed the call light was nonfunctional, and the broken device had not been documented in the maintenance log or reported right away, despite facility policy requiring a working call system or alternate means for assistance.
Failure to Report Change in DON to State Agency: The facility did not report a change in DON to the state agency through HCFRS as required. Surveyors were given the name of the current DON, but the HCFRS record did not show the change had been reported. The Administrator said he believed he had 90 days to report the change, and the DON said she did not have HCFRS access and did not handle the reporting, though she agreed the change should have been reported.
Weekend Package Delivery Restricted by Administration: Staff did not deliver resident packages on Saturdays and Sundays after an Administrator-posted sign directed that weekend package delivery stop. Residents reported that packages arriving on weekends were held for management review before delivery, and several expressed frustration with delayed receipt. The Activities Director said mail was supposed to be delivered 7 days a week, while the Administrator said packages were being reviewed for contraband and some residents had to open packages in front of him.
A resident with multiple chronic diagnoses and intact cognition was not seen and assessed by a physician for 164 days, despite several NP and PA visits being documented. The resident said it had been many months since seeing the doctor, and the RN, ADON, and DON could not locate any physician visit notes in the record.
Missing Annual CNA Performance Reviews: The facility failed to ensure annual performance reviews were completed for three CNAs whose employee files did not contain a review within the past 12 months. The HR Director said the department managers were responsible for the appraisals and had not provided the documents for the files, while the DON said the DON or ADON would complete CNA reviews but was unable to locate the requested documentation.
A resident with complex medical needs was readmitted without proper medication reconciliation, resulting in missed and incorrectly administered doses of Eliquis, Buspar, and Gabapentin. Facility staff did not complete or document the required reconciliation process, leading to significant medication errors that went unaddressed until the resident reported missing medication.
Surveyors found significant sanitation and food safety deficiencies in the facility's kitchen and resident kitchenettes. Persistent odors and water leaks were observed, along with unlabeled and undated food items in the main kitchen refrigerator. Staff failed to follow proper hand hygiene and glove use during food preparation. Resident kitchenettes contained unlabeled and undated food, despite regular checks by staff.
The facility failed to maintain secure and accurate medical records, with missing physician documentation and overflowing shredding bins. A resident's physician visits were not properly documented, and secure medical record bins were full, making records accessible to unauthorized individuals. The facility had not been serviced by the shredding company due to billing issues, leading to unsecured medical records.
The facility failed to maintain essential equipment, including microwaves with rust and damage in resident kitchenettes, a malfunctioning milk refrigerator, and an inadequately serviced grease trap causing a persistent odor. The FSM and Maintenance Director acknowledged these issues, which were not addressed in a timely manner.
The facility failed to maintain kitchen plumbing, resulting in pungent odors, water puddling, and a black substance leaching from walls. Drainpipes leaked water/sewage, and the hand washing sink's malfunction led to wastewater on the floor. The dish machine's pipes were also leaking, with a container overflowing onto the floor. Despite staff awareness, a plumber was not contacted until surveyors' intervention.
The facility failed to provide a dignified dining experience, as residents were not served meals simultaneously, leading to some watching others eat. Staff were observed standing while assisting residents, contrary to policy. Additionally, basic hygiene practices were neglected, and a lack of supervision was evident during meal times.
A facility failed to obtain proper consent from a resident, who was responsible for their own care, for treatment and psychotropic medication administration. Despite the resident being cognitively intact, consent was obtained from the family without an Invocation of the Health Care Proxy. Interviews confirmed the resident did not sign the necessary paperwork, and the facility staff acknowledged the oversight.
A resident was found self-administering Mupirocin ointment without a physician's order or proper assessment. Despite being cognitively intact, the resident was not evaluated for self-administration capability, nor educated on the correct application frequency. Nursing staff were unaware of how the resident obtained the ointment, and the facility failed to follow its own protocols for self-administration of medications.
Staff at the facility failed to adhere to infection control protocols by not consistently wearing gowns and gloves during high-contact care activities for a resident on Enhanced Barrier Precautions. Despite the presence of a CDC sign indicating the need for PPE, staff were observed providing care without the required protective equipment, risking the spread of multi-drug resistant organisms.
The facility failed to implement an effective antibiotic stewardship program, as antibiotics were prescribed without necessity and not reassessed within 48-72 hours for several residents. Despite policies requiring reassessment and monitoring, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Interviews revealed systemic failures in monitoring and documentation, with no audit sheets completed to track antibiotic usage.
The facility failed to implement its vaccination policies, resulting in three residents not receiving proper education, consent, or administration of influenza and pneumococcal vaccines. The medical records lacked documentation of follow-up, education, and consent, leaving the residents not up to date with their vaccinations. Interviews with the IP and DON confirmed the facility's non-compliance with its policies.
The facility failed to educate, assess eligibility, and offer COVID-19 vaccinations to two residents per CDC guidelines and facility policy. Despite previous vaccinations, the residents were not up to date, and documentation of education, consent, and follow-up was lacking. Interviews revealed that the facility did not adhere to its immunization program, and a booster clinic did not ensure all residents received the vaccine.
Resident Council Concern About Staff Name Tags Not Resolved
Penalty
Summary
The facility failed to ensure grievances and concerns from the Resident Council about staff members not wearing name tags were acted upon to resolve the issue. The facility’s grievance policy stated residents have the right to voice grievances without discrimination or reprisal, and the staff handbook required all employees to wear nametags at all times. Resident Council minutes dated 5/16/25 documented the concern about staff not wearing name tags, but no follow-up was indicated. Minutes dated 6/25/25 again documented the concern and noted a follow-up form with a resolution to in-service staff on all shifts. During observations on 7/24/25, surveyors saw multiple staff members without visible name tags, including a CNA with her tag in her pocket, another CNA who pulled her tag from her pocket when asked her name, and two nurses who said they should have been wearing their tags. Staff told the surveyor that name tags should be worn and visible so residents and visitors can identify them. In a resident group meeting with 17 residents, residents said they repeatedly raised the concern each month, that it remained a problem across shifts, and that it made it difficult to identify caregivers and file grievances or concerns when staff could not be identified. The DON later stated staff are educated on the name tag policy during orientation and acknowledged the issue remained ongoing.
Unclean and Poorly Maintained Resident Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment in multiple areas of the building. On unit 200, residents and staff reported that the carpeting was old and smelled terrible even after cleaning. During survey observations, carpeting in two dining room areas was torn, tattered, and lifting, and a stale, musty odor was present in the dining rooms. Residents reported that the carpet was dirty, gross, and difficult to propel wheelchairs over where it had bunched and lifted. The Housekeeping Director and Administrator both acknowledged that the carpet was old, continued to have a lingering odor, and needed replacement, and the Director of Maintenance stated the second-floor dining area had safety hazards due to lifting carpet. The facility also failed to keep window air conditioners clean and sanitary on multiple units. Surveyors observed dust, debris, black spots, and dirty filters on air conditioners in resident rooms across the second and third floors, including numerous rooms with visible buildup from several feet away. One portable unit was dripping water, others had gaps leaving openings to the outside, one unit was very loud, one did not stay running, and one room was warm despite the unit being set to 60 degrees. Staff interviews showed there was no routine process in place to clean or maintain the units while in use, and both maintenance and housekeeping staff acknowledged the buildup and lack of a cleaning schedule. Additional environmental concerns were observed in dining and resident care areas. One dining room had three of six ceiling lights missing and appeared dark while residents were eating breakfast; residents and staff stated it was hard to see in the room, and the Administrator acknowledged the lighting was darker than it should be. On the 100 unit, surveyors observed gouged and splintered handrails, damaged doors, holes and scrapes in walls, unsanded plaster patches, frayed rugs, dirty baseboards, debris on windowsills, and worn tables. In Resident #12’s room, dried brown tube feeding formula was repeatedly observed on the feeding pump, pole, bedside fan, and bedrail, despite a sign reminding staff to clean spills; nursing and infection control staff stated spilled tube feeding should be cleaned and that dried formula should not remain on equipment or in the room. In another room, surveyors observed a black, splotchy raised area on the wall and a missing floorboard with a thick black raised area, and maintenance and housekeeping staff said it appeared something had spilled on the wall and was not cleaned up.
Failure to Develop and Implement Individualized Care Plans
Penalty
Summary
The facility failed to develop, implement, and revise individualized comprehensive care plans for three residents with identified needs. The report states that the facility’s policy required care plans to include measurable objectives and timelines and to be evaluated and revised as needed, but this did not occur for the residents cited. The deficiencies involved fall management, smoking-related care, and psychosocial needs documented in the residents’ records and interviews. For Resident #80, who was admitted with diagnoses including cerebral infarct and muscle weakness and had a BIMS score of 14 out of 15, the record showed a fall in the bathroom on 7/9/25. The incident report described the resident losing balance while trying to transfer back to the wheelchair, with nursing assisting the resident to the floor and completing skin, neurological, and pain assessments. The medical record and care plans did not show that the facility developed or implemented a fall care plan intervention after the fall, and the DON stated the fall care plan was not reviewed or revised after the incident. For Resident #144, who had diagnoses including lack of coordination, difficulty walking, mild neurocognitive disorder, seizures, and cannabis use, the MDS showed a BIMS score of 12 out of 15. Although a smoking evaluation dated 5/19/25 indicated the resident was a non-smoker and did not wish to smoke, later records and interviews showed the resident smoking in the facility’s smoking area and being listed by staff as a resident who smokes. The care plan did not include a smoking or smoking cessation plan. For Resident #135, who had diagnoses including muscle weakness, psychotic disturbance, mood disturbance, anxiety, and lack of coordination, the record showed a prior fall with a head laceration requiring a hospital visit and a care plan entry noting side rails were added to the bed to assist in preventing falls. The resident stated the side rails had been removed and that he/she slept on the side of the bed due to PTSD, but the care plan did not include a PTSD care plan, and the DON acknowledged awareness of the PTSD and uncertainty about why the side rails were removed.
Pressure ulcer care and wound orders not followed
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care and prevention for one resident with multiple pressure injuries. The resident was admitted with diagnoses including muscle weakness, malignant neoplasm, major depressive disorder, bed confinement, and lumbar vertebra fracture, and the MDS indicated moderate cognitive impairment and unhealed pressure ulcers. The record showed a new order on 4/7/25 for Silvadene cream to a deep tissue injury on the left upper buttock, but the 4/8/25 skin check did not identify that new DTI. A wound physician note on 4/9/25 documented an unstageable DTI of the left buttock with a treatment plan of Xeroform gauze followed by a superabsorbent dressing daily. The wound physician later documented worsening and additional wounds, including a stage 4 left buttock wound, an unstageable right buttock wound, and an unstageable DTI of the left heel. Across multiple wound physician notes from 4/30/25 through 7/25/25, the physician repeatedly ordered Dakins solution with 1/4 strength for the buttock wounds, but the facility’s physician orders did not include the strength of the Dakins solution. The record also showed that the facility failed to change the right buttock treatment when calcium alginate was added, and the treatment order for the right buttock was not implemented as written. Weekly skin checks also failed to describe or measure new skin impairments identified after the resident returned from being out of the facility. During direct observation on 7/30/25, Nurse #5 performed wound care to the buttocks using 1/2 strength Dakins, despite the wound physician’s 1/4 strength direction, and packed the wounds with loose 4x4 gauze instead of the ordered Kerlix packing. The nurse also did not perform hand hygiene between glove changes during the dressing changes and applied a dressing to the left heel even though the heel order had been changed to skin prep only after the wound had resolved. Interviews with the nurse, the infection control/wound nurse, the DON, and the ADON confirmed that the Dakins strength had not been clarified in the orders, that the wound should have been packed with Kerlix rather than loose gauze, and that hand hygiene should have been performed before, after, and between glove changes during wound care.
Accident Hazards and Smoking Supervision Failures
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and to provide adequate supervision for multiple residents. One resident with hemiplegia, dementia, epilepsy, moderate cognitive impairment, and a prior elopement was observed walking across the parking lot toward the main street with no sidewalks on a 95-degree day after an appointment. The resident had previously eloped from the facility on 6/25/25, when he/she was seen walking off the property and across the main road, but the record showed the elopement was not investigated in a timely or complete manner and no resident-specific interventions were in place before the second elopement was observed. Staff interviews indicated uncertainty about the resident’s elopement risk, lack of education on the elopement process, and that the missing-resident procedure was not initiated as expected. The facility also failed to implement ordered and planned fall-prevention measures for residents at risk for injury. One resident with muscle weakness, cancer, a compression fracture, and a history of falls had fallen twice in early May and later fractured the right distal humerus; the care plan called for floor mats on both sides of the bed, but survey observations repeatedly found only one mat or no mats at all. Another resident with paraplegia, dementia, anxiety, and impulse disorder had physician’s orders and a care plan for floor mats on both sides of the bed, yet surveyors observed only one mat in place on the left side and none on the right side. A third resident with severe cognitive impairment and repeated nighttime falls had a fall risk score of 13, then 21 after another fall, but the care plan did not show additional individualized interventions after the later fall despite the resident continuing to fall at night. The facility also failed to supervise smoking activities and to complete smoking safety screening before residents smoked on facility property. One cognitively intact resident was observed in the smoking area lighting and smoking cigarette butts picked up from the ground, while the area contained numerous cigarette butts and the resident had a burn area on a finger and burn holes in clothing. Two other cognitively intact residents were observed sharing a cigarette with each other in the designated smoking area even though one resident’s care plan and smoking screen called for routine supervision during scheduled smoking and prohibited giving cigarettes or lighters to other residents. In addition, one resident who was documented as a smoker but had an incomplete smoking evaluation was observed smoking after obtaining a cigarette from another resident, and another resident with moderate cognitive impairment was observed in the smoking area despite a smoking screen indicating non-smoker status and no evidence of a completed smoking evaluation before smoking occurred.
Medication Administration Errors for Two Residents
Penalty
Summary
The facility failed to ensure two residents were free from significant medication errors when ordered medications were not administered as prescribed. Resident #104, who was admitted with diagnoses including hypertension and heart disease, was observed receiving several medications, including Omeprazole, Plavix, Aspirin, and Clonazepam, while the ordered Amlodipine Besylate 10 mg for hypertension was signed off on the eMAR but was not poured or administered. During interview, the nurse stated she did not realize the Amlodipine had not been given. Resident #43, who was admitted with diagnoses including atrial fibrillation and cerebral infarct, was observed receiving multiple medications, but Eliquis 5 mg was not poured and was marked not available with a note that it was on order. The administered medications were given, and the resident refused a Salonpas patch. Review of physician and nursing progress notes did not show that the provider was notified that Eliquis was unavailable and not administered. The nurse stated she did not call the provider that morning, and the DON stated that if a significant medication is not available, the provider should be contacted and the event documented in a physician's order and progress note.
Controlled Substance Refrigerator Lock Boxes Accessible to Multiple Nurses
Penalty
Summary
Drugs and biologicals were not stored in accordance with State and Federal laws when liquid controlled substances kept in refrigerator lock boxes were accessible to more than one nurse in two medication rooms. The facility policy stated that medications are to be stored in a locked mobile cart accessible only to licensed personnel and that refrigerated drugs are to be stored separately in a refrigerator used exclusively for medications and medication adjuncts. The policy on narcotics stated that controlled substances are subject to special handling and record keeping, and that the person responsible for removing medication from count should sign the index. During observation, the surveyor found that both medication nurses on the Borderland Unit and both medication nurses on the [NAME] Unit had keys to the narcotic storage box in the refrigerator. Nurse #5, Nurse #7, and Nurse #11 each stated that both nurses on their unit had access to the lock box, and Nurse #11 opened the box to show access to the medications. The liquid Ativan in the Borderland Unit box was actively in use for Resident #116, while the liquid Ativan in the other box had been discontinued for Resident #76 and another had been discontinued for Resident #164, who had expired. The DON stated that only the nurse responsible for counting the medication should have access to the box, but nurses stated that both nurses had always had a key even though only the nurse whose book the medication was logged into should have had access.
Failure to Follow Prescribed Diets and Therapeutic Menus
Penalty
Summary
The facility failed to follow prescribed diets and therapeutic menus to meet residents’ daily nutritional and special dietary needs as ordered by the physician. Review of lunch tickets and direct observation showed that residents whose diet slips indicated whole milk were served 1% milk instead. On the units observed, meal trucks and kitchenettes contained only 1% milk in the coolers, while whole milk was either absent or not available on the serving line. The Food Service Manager stated that whole milk should have been available in the cooler and that nursing staff should obtain whole milk from the refrigerator if needed, while the Corporate Dietitian stated that residents ordered whole milk should have received whole milk. The facility also failed to prepare and serve therapeutic menu substitutions as planned. During lunch tray line observation, staff served regular menu items and inconsistent portions, including ground Swedish meatballs, spaghetti instead of noodles, and gravy that the Regional Dietitian and Food Service Manager identified as lower salt gravy rather than low sodium gravy. The therapeutic menu called for specific substitutions for mechanical soft, vegetarian, vegan, and low sodium diets, but staff were observed serving items that did not match those substitutions. Staff stated they were not aware of therapeutic menus, followed the regular menu posted on the bulletin board, and did not record substitutions made to the menu. Breakfast and later lunch observations showed additional failures to follow the therapeutic menus. Bacon was not served and sausage was substituted; a puree meal was served as eggs and toast with cinnamon rather than the prescribed pureed French toast and bacon; and a resident on a puree diet was given double portions of pureed toast with cinnamon. Later, mixed vegetables containing corn were plated for mechanical soft diets even though corn was not allowed, no vegetarian or vegan meals had been prepared ahead of service, and a resident on a vegan meal ticket was served macaroni and cheese and yogurt. The Corporate Dietitian and Food Service Manager stated the therapeutic substitutions were not made ahead of meal service and that the cooks should have been following the therapeutic menus.
Missing Preplanned Vegan Menu and Inconsistent Vegan Tray Service
Penalty
Summary
The facility failed to have an available vegan menu that was prepared in advance and followed to meet the needs of one resident who was ordered a CCHO, NAS, regular texture, thin liquids, and vegan diet for diabetes and hypertension. The facility policy stated therapeutic diets are to be prepared and served as prescribed, planned by a qualified registered dietitian, and that necessary substitutions are to be documented and kept on file. However, review of the therapeutic menus showed a preplanned menu for vegetarian diets but no preplanned therapeutic menu for a vegan diet, and the regional dietitian stated there was no policy for therapeutic diets and that the cooks just followed the menu as written. Food Committee Meeting Minutes documented the resident’s complaints that food was overcooked, lacked variety, and that non-vegan items were regularly received on the tray. During lunch tray service, a dietary aide was observed unwrapping a pre-made salad and adding an unmeasured scoop of hummus to the resident’s tray while the tray waited on the line. Staff interviewed during the survey could not explain the difference between a vegan and vegetarian therapeutic diet, and the resident stated he/she was sick of receiving salads and hummus, did not always trust the kitchen to send vegan food, and reported being served items such as hash browns, mashed potatoes believed to contain milk, and mixed vegetables without protein.
Unpalatable and Unappetizing Food on Test Tray
Penalty
Summary
The facility failed to provide food that was palatable and served with an appetizing presentation for one of two test trays. On 7/29/25, a surveyor requested a test tray, which arrived on the unit at 11:45 A.M. and was evaluated at 12:12 P.M. with Rehab Staff #3. The tray was visually poor, with three dry meatballs on top of spaghetti with thin liquid brown gravy pooled on the bottom of the plate, peas that were two different colors with the pale peas appearing dried out, and a dessert cake with whipped cream that was at room temperature. The Swedish meatballs were 131.5 F and described as dry and missing gravy, the spaghetti was 188.4 F and bland with no gravy sticking to it and half of it dry, the gravy was very thin and mild with not enough to coat the meatballs and spaghetti, the peas were 131.9 F and had different colors and textures, and the coffee was 155.5 F and palatable. During interviews after the test tray, residents reported that they could not taste the gravy, the meatballs were okay, the peas were disliked, the hamburger helper was watery on a mechanical soft diet, the gravy was watery, there was very little gravy, and there was no gravy. The test tray results validated the residents' complaints of unpalatable and unappetizing food.
Failure to Provide Ordered Adaptive Eating Equipment
Penalty
Summary
The facility failed to provide adaptive eating equipment for two residents who had documented needs for special utensils during meals. Resident #80 was admitted with diagnoses including cerebral infarction and neuropathy, and the MDS dated 5/8/25 showed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident’s meal ticket indicated hollow-handled utensils, and OT notes documented a trial of built-up utensils because the resident reported chronic hand pain from neuropathy and increased ease with the adaptive utensils. During observations on 7/24/25, 7/25/25, and 7/28/25, Resident #80 was seen eating with regular silverware and repeatedly repositioning the spoon, and the resident stated it was hard and uncomfortable to hold regular utensils because the hollow-handled spoon had not been provided. The tray at times included a hollow-handled knife and fork, but the spoon was missing. CNA #1 and UM #1 both reviewed the tray and confirmed the resident did not have the hollow-handled spoon that should have been on the tray according to the meal ticket. The OT also stated the resident had trialed hollow-handled utensils and dietary had been notified. Resident #109, who had dementia and a BIMS score of 8 out of 15, had physician’s orders and other records indicating a rocker knife with meals. The resident’s meal ticket also listed rocker knife as adaptive equipment. During observations on 7/28/25 and 7/29/25, the resident was seen eating without a rocker knife, including cutting chicken and pancakes with regular utensils, and stated the nurse had to cut the chicken because the resident could not cut it without the rocker knife and that it was hard to cut pancakes without it. Nurse #3 and CNA #7 reviewed the tray and confirmed the rocker knife was not present even though it should have been.
Incomplete Infection Surveillance Logs
Penalty
Summary
The facility failed to maintain an infection prevention and control program with a complete and accurate surveillance system to identify trends or potential infections. Facility policies stated that infection surveillance would include monitoring and documenting infections, tracking outbreaks, analyzing trends and clusters, and maintaining monthly infection reports by unit, including culture results and diagnoses for residents with infections or potential infections. Review of the April, May, and June 2025 Infection Surveillance Logs showed residents with symptoms of illness who were not treated with antibiotics were not documented on the surveillance sheets. The April 2025 logs did not include culture results for 5 of 5 residents with urinary tract infections, including one culture positive for ESBL-producing bacteria. The May 2025 logs did not include Resident #151, who was on contact precautions and treated for MRSA, or Resident #55, who was on contact precautions and treated for shingles, and again did not include culture results for 5 of 5 residents with urinary tract infections. The June 2025 logs did not include Resident #87, who was readmitted with Influenza A, placed on droplet precautions, and treated with oseltamivir, or Resident #151, who had loose stools and was tested for C. difficile. During interview, the Infection Preventionist stated he had just started at the facility and could not find any surveillance logs other than those provided to surveyors, and said the residents and culture results should have been listed. The DON and ADON reviewed the line listings and the ADON stated he was responsible for completing the logs but did not enter culture results from the facility or hospital; the DON stated the facility did not have an accurate surveillance process.
Failure to Follow Antibiotic Stewardship and Document UTI Rationale
Penalty
Summary
The facility failed to implement its antibiotic stewardship program, including antibiotic use protocols and monitoring of antibiotic use in accordance with its own policy. The facility’s policy required use of the Updated McGeer criteria to define infections, notification of the MD/APRN and responsible party when infection symptoms were identified, documentation of symptoms, inclusion of dose/duration/indication on antibiotic orders, and reassessment of antibiotics 48-72 hours after initiation. The facility’s surveillance policy also required close monitoring of residents with signs or symptoms of infection and documentation of symptoms in nursing notes each shift. Review of the April 2025 antibiotic surveillance tracking form showed Resident #128 was listed for UTI with onset on 4/17/25, symptoms of foul odor, final status of CAI, and not counted. The form did not document enough symptoms to show that the facility’s pre-defined McGeer criteria for UTI had been met, yet an antibiotic was prescribed for 10 days. The medical record did not show a nursing progress note explaining why urine was obtained on 4/13/25, did not show nursing progress notes explaining why the antibiotic was started on 4/17/25, and did not show a clinical rationale from the prescribing physician for starting the antibiotic even though the documented symptoms did not meet the facility’s criteria. During interview, the IP stated nurses needed to document signs and symptoms prompting urine culture collection, the physician or NP needed to document why the antibiotic was initiated, and the antibiotic needed reassessment 48-72 hours after initiation. The DON stated it was her expectation that nurses, physicians, and NPs follow antibiotic stewardship.
Failure to Provide Pneumococcal Vaccinations for Eligible Residents
Penalty
Summary
The facility failed to provide pneumococcal immunizations for three eligible residents out of a sample of five. The facility policy titled Procedures for Pneumococcal Vaccination, last revised December 2024, stated that residents or responsible parties are to be asked on admission about prior pneumococcal vaccinations, that records are to be used to determine immunization status, and that eligible residents are to be offered pneumococcal conjugate vaccine with risks and benefits explained before administration. The policy also stated that adults age 50 years or older who have not previously received a pneumococcal conjugate vaccine or whose vaccination history is unknown should receive a PCV vaccine, with PCV15 followed by PPSV23 in a year or more if used. Resident #4, admitted in August 2021 and currently [AGE] years old, had a documented PPSV23 vaccination on 11/25/19. The Infection Preventionist stated on 7/30/25 that Resident #4 was not up to date and was overdue for PCV20 and should have received it. Resident #9, admitted in June 2023 and currently [AGE] years old, had a documented PPSV23 vaccination on 2/15/22, and the Infection Preventionist stated that this resident was also not up to date and overdue for PCV20. Resident #109, admitted in November 2017 and currently [AGE] years old, had a documented PPSV23 vaccination on 2/12/13, with Prevnar13 listed as not eligible; the Infection Preventionist stated this resident was not up to date and was overdue for PCV20. Resident #109's Resident Pneumonia Vaccine Education Documentation Form, signed 11/8/17, indicated the vaccine would be offered to eligible residents, but the form left blank the section for prior PCV13 history.
Failure to Educate, Offer, and Document Current COVID-19 Vaccination
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, administer, and document the current 2024-2025 COVID-19 vaccine for five residents reviewed for immunizations. Residents #4, #9, #71, #87, and #109 were all admitted to the facility at different times and each had documentation showing receipt of the 2023-2024 COVID-19 vaccination, but their medical records did not show that the facility offered the current vaccine. The facility policy stated that COVID-19 vaccines would be offered according to CDC and/or FDA guidance unless medically contraindicated, already immunized during the time period, or refused by the resident or responsible party. CDC guidance reviewed by surveyors stated that the 2024-2025 COVID-19 vaccine is recommended for most adults, including those living in LTC facilities. The facility also failed to provide education, assess eligibility, offer, and document the current COVID-19 vaccine for five employees reviewed: Nurse #14, Nurse #3, Occupational Therapist #1, CNA #15, and CNA #16. Their staff medical records did not contain proof that they were educated about the 2024-2025 COVID-19 vaccine or that the vaccine was offered and either accepted or declined. The HR Director reviewed the employee files and could not locate documentation showing education or vaccine offer, and the DON stated that new employees should have been educated on the COVID-19 vaccine and have proof of whether it was offered and accepted or declined.
Failure to Obtain HCP Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that informed written consent for psychotropic medications was obtained from the resident's Health Care Proxy (HCP) before administering gabapentin, Risperdal, sertraline, and trazodone to one resident. The resident was admitted with diagnoses including major depressive disorder, insomnia, psychotic disorder, and chronic pain syndrome, had a BIMS score of 9 out of 15 indicating moderate cognitive impairment, and had an HCP on file that was invoked by the physician because the resident lacked capacity to make or communicate health care decisions. Record review showed the resident received the ordered psychotropic medications from March through July 2025, but the informed consent forms in the chart were signed by the resident rather than the invoked HCP. The forms for gabapentin, Risperdal, sertraline, and trazodone had the consent and refusal boxes left blank, and the physician and nursing progress notes did not indicate that informed consent had been obtained by the HCP. Staff interviews confirmed that the consent forms should have been signed by the activated HCP and not by the resident.
Failure to Notify Physician/NP of Resident Fall and Significant Weight Loss
Penalty
Summary
The facility failed to notify the Physician or NP of a resident’s fall for Resident #80. Resident #80 was admitted in May 2025 with diagnoses including cerebral infarct (stroke) and muscle weakness, and the MDS dated 5/8/25 showed the resident was cognitively intact with a BIMS score of 14 out of 15. The resident reported a recent bathroom fall, and the Fall Incident Report dated 7/9/25 listed no notifications found. Review of the medical record did not show that the Physician or NP was notified of the fall. Unit Manager #1, NP #1, and the DON each stated that the Physician or NP should have been notified and that the notification should have been documented in the record and on the Fall Incident Report. The facility also failed to notify the Physician or NP of a significant weight loss for Resident #109. Resident #109 was admitted in November 2017 with diagnoses including dementia and congestive heart failure, and the MDS dated 7/11/25 showed a BIMS score of 8 out of 15. The Registered Dietitian’s Nutrition Assessment dated 4/10/25 documented an 11% weight loss since January 2025. Nurse #11 reviewed the record and stated there was no documentation that the Physician or NP had been notified, although they should have been. NP #1 also reviewed the record and stated she had not been notified of the 11% weight loss, and the DON stated her expectation was that the Physician or NP be notified of significant weight loss and that the notification be documented in the resident’s medical record.
Failure to Follow Physician Orders for Treatments, Medications, and Monitoring
Penalty
Summary
The facility failed to ensure care was provided in accordance with professional standards of practice for five sampled residents. The deficiencies involved failure to follow physician orders for a specialty air mattress, medication administration, weekly weights, hand rolls, and an inhaler. The report states that licensed nurses are responsible for accepting, verifying, transcribing, and implementing orders from authorized prescribers, and that nursing management must ensure an infrastructure is in place to minimize error. For one resident with a stage four pressure ulcer on the right lower back and a stage three pressure ulcer on the left hip, the physician ordered a specialty air mattress to be checked each shift and set at standard for the resident’s weight of 211.4 pounds. Surveyors repeatedly observed the mattress set at 260 pounds, and a paper tape on the control panel indicated it should be set at 220. A nurse later confirmed the mattress was set at 260 pounds but should have been set at 220 pounds per the order, and the DON stated the mattress should have been set to the resident’s weight as ordered. For another resident with dementia, pneumonia, and dysphagia, the physician ordered Pyridoxine Hydrochloride 12.5 mg daily by mouth and allowed crushing of appropriate medications. Surveyors observed a white round pill on the resident’s chest after medication administration, and the resident said medications are taken crushed in applesauce. The nurse acknowledged she had administered the medication and said she must have forgotten to crush the Vitamin B6. In a separate case, a resident with dementia and congestive heart failure had a physician order for weekly weights, but review of the TAR for several months failed to show weekly weights were obtained, and staff confirmed they could not find documented weights in the chart. The report also found that a resident with severe dementia, paraplegia, and bilateral hand contractures had an order for hand rolls to be applied to both hands after washing, soaking, drying, and moisturizing the hands each shift. Surveyors observed the resident at times with hand rolls in place, but on later observations no hand rolls were present and none were nearby. An infection control nurse reviewed the order and said the resident should have had hand rolls in both hands. Finally, a resident with COPD had an order for albuterol inhalation aerosol, 2 puffs twice daily, but surveyors observed the resident self-administering the inhaler without an order for self-administration. The resident kept the inhaler at the bedside, took it out, shook it, and inhaled one short puff, while the nurse stated the resident did not have orders to self-administer the inhaler and should not have been doing so.
Failure to Provide Portable Oxygen for Resident Requiring Continuous O2
Penalty
Summary
The facility failed to provide a portable oxygen cannister for a resident who had physician-ordered continuous oxygen at 2 liters per minute via nasal cannula. The resident was admitted with diagnoses including COPD, CHF, chronic respiratory failure with hypercapnia, chronic sleep apnea, and intellectual disability, and the MDS indicated the resident was cognitively intact and required oxygen therapy. The care plan directed oxygen at 2 liters per minute continuously, and the physician order required continuous oxygen with pulse oximeter and LPM checks every shift. During interviews and observations, the resident reported that someone had stolen the oxygen tank and stated that he or she walked and attended activities without one. The surveyor observed the resident walking in the hallway with a walker and later sitting in the activity room without supplemental oxygen. The resident repeatedly stated that no portable oxygen tank had been provided, and the surveyor observed that the only portable cannister present belonged to the roommate and was empty. Staff interviews confirmed the resident was supposed to wear oxygen 24 hours a day, 7 days a week, and that a portable oxygen cannister should have been available for walking outside the room.
Failure to Provide Individualized Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for two residents with documented trauma histories and behavioral health needs. The report states that the facility did not ensure Resident #148 received a person-centered care plan that identified trauma-informed approaches and triggers to avoid re-traumatization, and did not ensure Resident #135 had a completed trauma-informed assessment with identified triggers and a care plan for the use of side rails for nighttime security. Resident #148 was admitted with a diagnosis of PTSD and was cognitively intact with a BIMS score of 13. The resident told surveyors about multiple losses over the past 10 years, including the death of a parent and sibling and a traumatic death of a significant other, and identified triggers such as feeling rushed, being under pressure, loud sounds, and feeling mistreated. Records also showed a hospital discharge summary documenting childhood abuse and multiple losses, including the death of a parent, suicide of a sibling, loss of a leg, and death of a significant other. Although the facility completed a trauma screening and psychosocial evaluation, the trauma-informed care plan did not reflect an individualized approach or specific interventions tied to the resident’s trauma history. Resident #135 was cognitively intact with a BIMS score of 14 and had a history of mental health diagnoses, including PTSD documented in PASRR records. The resident told surveyors he/she slept on the side of the bed because of PTSD after witnessing a family member commit suicide and wanted side rails restored for security and fall concerns. The trauma screening completed by facility staff in 2020 documented a traumatic event, ongoing distress, and a coping method of talking about it, but the triggers section was left blank and no referral was documented. The care plan did not include a PTSD-related plan, and staff interviews showed the SW initially believed the resident did not have PTSD and was unaware of prior trauma documentation, while the DON and psychiatric NP later confirmed the resident’s PTSD history and nighttime fear of falling out of bed.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure it was free from a medication error rate greater than 5% when one of two nurses observed during medication pass made four errors out of 29 opportunities, resulting in a 13.79% medication error rate. The errors affected two residents and involved administration of medications that were not given as ordered, medications that were crushed despite being ordered to be swallowed whole, and a medication that was signed off on the MAR without being poured or administered. For one resident with orders for a puree diet with nectar thick liquids and medications including Amlodipine 10 mg, Aspirin EC 81 mg, Clonazepam 0.5 mg, Omeprazole 20 mg, and Plavix 75 mg, the nurse poured several medications into pudding, crushed Clonazepam and Plavix, opened Omeprazole capsules and poured the contents into the pudding, and placed EC Aspirin whole into the pudding. The nurse also signed off Amlodipine on the MAR even though it was not poured or administered. The record showed no order specifically authorizing crushing of Clonazepam or Plavix, and the pharmacy card for Clonazepam indicated it should be swallowed whole with water. For another resident, the nurse poured multiple medications including Acetaminophen, Aspirin, Colace, Baclofen, Benztropine, Depakote solution, Toprol XL, Lexapro, Protonix, Risperidone, Lidoderm patch, Salonpas patch, and Iron, but Eliquis 5 mg was marked not available and not administered. The progress notes did not show that the provider was notified that Eliquis was unavailable. During interview, the nurse stated she did not call the provider about the missing Eliquis and that she knew medications that are coated should not be crushed, while the DON stated medications should be administered per physician orders and double checked when signing off the MAR.
Incomplete Resident Evaluations
Penalty
Summary
The facility failed to maintain completed medical records for two residents by allowing required evaluations to remain in an In Progress status for an extended period of time. For one resident, the Self Administration of Medication evaluation and the Elopement & Wandering evaluation, both initiated on 6/2/25, remained incomplete for 59 days. For another resident, seven evaluations initiated on 5/19/25, including Substance and/or Alcohol Abuse, Side Rail, Self Administration of Medication, Pain, Norton Plus, Fall Risk, and Elopement & Wandering, remained incomplete for 73 days. During interview, staff explained that the MDS nurse initiated resident evaluations in the electronic health record as prompts for nursing to complete, and that once opened, the evaluations stayed in In Progress status until nursing finished the documentation. The DON stated nurses were responsible for completing all necessary resident evaluations in a timely manner and confirmed that the evaluations for the two residents were incomplete and should not have remained unfinished for 59 and 73 days, respectively.
Nonfunctional Bathroom Call Light
Penalty
Summary
The facility failed to ensure that a working call system was available in one resident’s bathroom and bathing area. Resident #80 was admitted in May 2025 with diagnoses including cerebral infarct (stroke) and muscle weakness, and the MDS dated 5/8/25 indicated the resident was cognitively intact with a BIMS score of 14 out of 15 and was dependent for toilet transfers. During interview, Resident #80 stated the bathroom call light had not been working for two to three weeks and that when the cord was pulled nothing happened, requiring the resident to wait for someone to come in and help in the bathroom. During observation and interview, CNA #1 pulled the call light cord in Resident #80’s bathroom and confirmed it was not working, then left the room without notifying maintenance. Unit Manager #1 also tested the bathroom call light, confirmed it was not working, and found that the broken call light had not been documented in the maintenance logbook. The facility policy required residents to have a call light or alternative communication device within reach when unattended and required defective call lights to be reported in the maintenance log. The DON and Director of Maintenance both stated that all residents must have a working call light or alternative way to call for assistance and that broken call lights must be reported right away.
Failure to Report Change in DON to State Agency
Penalty
Summary
The facility failed to report a change in DON in June 2025 to the state agency in the Health Care Facility Reporting System as required. On entry to the facility on 7/23/25, surveyors were provided the name of the current DON, but review of the HCFRS report did not show that the current DON had been reported to the state agency. During interview, the Administrator said he thought he had 90 days to report the change in DON, and the DON stated she did not have access to HCFRS and did not do the reporting, although she said the change in DON should have been reported.
Weekend Package Delivery Restricted by Administration
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when it did not deliver packages mailed to residents on Saturdays and Sundays. On 7/23/25, the surveyor observed a sign posted in the lobby stating that there would be no more package delivery on weekends per the Administrator's request, and the sign remained posted throughout the survey. During the resident group meeting, 17 out of 17 residents stated that activities staff delivered mail Monday through Friday, but if a package arrived on the weekend, administration had to review it before it was delivered to the resident. Several residents said they were frustrated and disappointed with not receiving their packages timely. During interviews, the Activities Director stated that the activities department was responsible for delivering mail seven days a week and that paper mail was delivered every day, but she was aware of the administrator's sign and an incident involving a resident package containing items the resident was not allowed to have. The Administrator acknowledged creating and signing the posting and said packages needed to be reviewed by management to determine which resident ordered the package because some residents were ordering contraband. He stated that some residents had to open their packages in front of him to ensure resident safety and that certain residents could come ask for their packages on the weekend. The DON stated that mail should be delivered every day, including packages, and that the sign should not have been posted.
Missed Timely Physician Visits for One Resident
Penalty
Summary
The facility failed to ensure timely physician visits for one resident out of a sample of 39. Resident #97, who was admitted in January 2021 with diagnoses including atherosclerosis, peripheral vascular disease, seizures, traumatic brain injury, and major depressive disorder, had a June 2025 MDS showing cognitive intactness with a BIMS score of 15 out of 15. During an interview, the resident said he/she was unsure when the last doctor visit occurred and stated it had been many months since seeing the doctor. Review of the medical record showed the resident was not visited and assessed by a physician for 164 days. The documented practitioner visits included NP visits on 6/24/25, 5/27/25, and 5/19/25, and a PA visit on 2/17/25, but no physician assessments were found. Nursing staff and leadership interviews confirmed they could not locate physician visit notes in the record, and the DON stated physician visits should occur according to Medicare guidelines but was unsure why only NP notes were present.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure annual performance reviews were completed for three of four CNA employee records reviewed. The facility policy titled Employee Performance Appraisals, revised 6/2023, stated that employee job performance is to be evaluated on a periodic basis and that department heads and supervisors will complete performance appraisals by the end of the first three months of employment, prior to the anniversary date of employment, and six months after transfer or promotion to a new job. Review of the employee files for CNA #12, CNA #13, and CNA #14 showed hire dates of 10/1/15, 9/20/21, and 9/24/14, respectively, and each file lacked a performance review dated within the past 12 months. During interviews, the Human Resource Director stated the appropriate department managers were responsible for completing the annual appraisals and that she had not received the documents to place in the files. The DON stated either the DON or ADON would complete CNA performance reviews, but she was unable to provide the requested appraisals and said the documentation could not be located.
Failure to Reconcile Medications on Readmission Leads to Significant Errors
Penalty
Summary
A deficiency occurred when a resident was readmitted to the facility and their medications were not accurately reconciled, resulting in multiple significant medication errors. The facility's policies required medication reconciliation upon admission and readmission, to be completed by two nurses and verified by nursing management. However, upon the resident's readmission, there was no documentation that a Medication Reconciliation Form was completed, nor evidence that nursing staff clarified or obtained new physician orders for the resident's medications. As a result, discrepancies arose between the hospital discharge summary and the facility's physician orders, particularly regarding the administration and discontinuation of Eliquis, Buspar, and Gabapentin. The resident, who had a history of subarachnoid hemorrhage, bilateral femoral DVTs, and an IVC filter, experienced missed doses and incorrect administration of critical medications. Eliquis was not administered for 48 days due to lack of order clarification, Buspar was given at an incorrect frequency before being increased, and Gabapentin was omitted entirely for 83 days. Interviews with nursing staff and management revealed a lack of awareness regarding the missed reconciliation, and the required documentation could not be located. The failure to follow established medication reconciliation procedures directly led to these significant medication errors.
Sanitation and Food Safety Deficiencies in Kitchen and Kitchenettes
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, as observed by surveyors. There was a persistent musty, pungent odor in the main hallway and kitchen, with water leaking from various areas, including the handwashing sink and the two-bay sink. A black substance was noted leaking from the wall, and a mop head was used to catch water, indicating ongoing plumbing issues. The kitchen floor was wet, and debris, including trash and food remnants, was found under the prep table and in the dry storage room. Food storage practices were inadequate, with several items in the main kitchen refrigerator not labeled or dated, including desserts, chicken fingers, and grated cheese. Some items were uncovered or improperly wrapped, and a container of cottage cheese was dated well beyond the facility's policy of discarding potentially hazardous foods within three days. The FSM acknowledged that all food should be labeled and dated, and discarded after three days. The facility also failed to adhere to proper hand hygiene and glove use during food preparation. A Cook/Dietary Aide was observed using the same pair of gloves for multiple tasks, including plating food and handling various kitchen surfaces, without changing them. This practice was repeated on another occasion by a different staff member. Additionally, resident kitchenettes were found with unlabeled and undated food items, such as a half-eaten pie and a grilled cheese sandwich, despite the FSM stating that staff check these areas twice daily.
Deficiencies in Medical Record Maintenance and Security
Penalty
Summary
The facility failed to maintain medical records securely and accurately, as evidenced by the lack of documentation for physician visits and improper handling of medical record disposal. Specifically, the facility did not have documentation of physician visits for a resident admitted in January 2021. The medical records showed that all visits since August 2023 were conducted by Nurse Practitioners, and there was a delay in obtaining the physician's progress notes. The Director of Nurses confirmed that the facility only had Nurse Practitioner notes and was in the process of obtaining the missing physician notes. The Medical Record Staff indicated that there was no system in place to ensure all physician progress notes were received, leading to gaps in the resident's medical records. Additionally, the facility failed to maintain secure medical record shredding bins on the resident units and by staff offices. Observations revealed that the secure medical record trash receptacles were full-to-capacity, with resident medical records easily accessible to unauthorized individuals. The Corporate Nurse acknowledged the lack of a policy for securely discarding resident medical records and noted that a cardboard box was being used for overflow, which was not an acceptable practice. The facility had not been serviced by the consultant shredding company since February 2024 due to billing issues, contributing to the overflow problem. Interviews with facility staff, including the Administrator and Front Desk Receptionist, revealed a lack of awareness and communication regarding the billing issues with the shredding company. The facility was a high-volume site scheduled for bi-weekly shredding services, but the service had been interrupted, leading to the accumulation of unsecured medical records. This situation posed a risk to the confidentiality and security of resident information, as the disposed records were accessible to residents, visitors, and staff.
Facility Fails to Maintain Safe Equipment and Sanitation Standards
Penalty
Summary
The facility failed to maintain essential equipment in safe working order, as observed by surveyors. Three out of four microwaves located in the resident kitchenettes on the 200, 300, and 400 units were found to have significant rust and damage. The microwave on the 300 Unit had a large rusted area and flaking rust on the inside ceiling. The microwave on the 200 Unit also had flaking rust on the ceiling. The microwave on the 400 Unit had a large rusted area on the rear wall, rusted holes in the ceiling, and a broken front door handle and leg. The Food Service Manager (FSM) acknowledged the need for replacement microwaves, which had not been ordered by the Maintenance Director. Additionally, the milk refrigerator unit in the dry storage room was not maintaining the required temperature, with internal thermometers reading 48 degrees Fahrenheit and a milk carton at 49 degrees Fahrenheit. The FSM confirmed the unit was not functioning properly. Furthermore, a persistent musty, pungent odor was detected in the main hallway near the kitchen, attributed to an inadequately serviced grease trap. The Maintenance Director admitted that the grease trap had not been fully pumped since August 2023 due to financial issues, despite a recommendation for additional servicing.
Plumbing Issues in Kitchen Lead to Sanitation Concerns
Penalty
Summary
The facility failed to maintain the plumbing in the main kitchen, leading to a buildup of pungent odors, water puddling on the kitchen floor, and a black substance leaching from the wall between the dish machine and the prep sink. The drainpipes within the wall were not maintained, resulting in leakage of water or sewage into the main kitchen, a buildup of a black substance oozing from the door jamb, and a foul odor permeating the main hallway. The issue was reported by dietary staff and observed by surveyors, but no corrective action was taken by the maintenance director or the previous food service manager. Additionally, the facility did not maintain the drain servicing the hand washing sink and the overflow valve to the ice machine, which resulted in water draining directly onto the kitchen floor. Despite the malfunction, the hand washing sink remained in service, contributing to the wastewater on the kitchen floor. The issue was known to the food service manager and the maintenance director, but a plumber was not contacted until the surveyors' visit. The water pipes for the dish machine were also not maintained, with a red plastic container placed under the dishwasher to catch leaking water. This container was observed to be overflowing onto the floor. The consultant plumber, contacted only after the surveyors' visit, confirmed that the pipes under the dishwasher and the prep sink were rotted and leaking, indicating a sanitation issue with grease from the pipes seeping onto the kitchen floor.
Lack of Dignified Dining Experience for Residents
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents in one of its dining rooms, as observed by surveyors. During multiple dining observations, it was noted that residents seated at the same tables were not served meals simultaneously, resulting in some residents having to watch others eat or be fed by staff. This delay in meal service was observed on several occasions, with some residents waiting up to 26 minutes for their meals. Additionally, staff members were observed standing while assisting residents with eating, which is against the facility's policy for providing a pleasant dining experience. The surveyor also noted that staff did not wash residents' hands or wipe down tables prior to meal delivery, which is a basic hygiene practice expected in meal service. On one occasion, a resident reached out and took food from another resident's tray, indicating a lack of supervision and coordination during meal times. Furthermore, a staff member was observed feeding a resident in a recliner chair while standing, holding the meal plate in one hand, which does not align with the facility's standards for a dignified dining experience. Interviews with staff, including a Unit Manager and a Nurse, revealed an acknowledgment of the issues observed. The Unit Manager admitted that it was challenging to serve all residents at the same time but agreed that it would be ideal for residents seated together to receive meals simultaneously. The Nurse admitted to standing while assisting a resident due to personal discomfort, despite knowing the expectation to be seated. The Administrator confirmed that staff should be seated when assisting residents and that all residents should have a dignified and homelike dining experience.
Failure to Obtain Proper Consent for Treatment
Penalty
Summary
The facility failed to ensure that a resident, who was responsible for their own care, was fully informed and involved in decisions regarding their treatment, specifically concerning the administration of psychotropic medication. The resident, identified as cognitively intact with a BIMS score of 13 out of 15, did not sign the necessary consent forms for treatment and psychotropic medication upon admission. Instead, the facility obtained consent from the resident's family, despite the absence of an Invocation of the Health Care Proxy or a physician's order to invoke it. Interviews with the resident and facility staff revealed that the resident could not recall signing any admission paperwork, and the Director of Social Services confirmed the lack of documentation for an Invocation of the Health Care Proxy. The Administrator acknowledged that the expectation was for the resident to sign all consents unless a Health Care Proxy was activated, which was not the case. This oversight led to the resident not being properly informed or involved in their care decisions.
Failure to Ensure Proper Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that medications were not self-administered without a physician's order and an assessment for self-administration for a resident. The facility's policy on self-administration of medications requires an evaluation of the resident's cognitive, physical, and visual ability to self-administer medications safely, followed by obtaining a physician's order if the resident is deemed capable. However, this process was not followed for a resident who was found to be self-administering Mupirocin ointment without the necessary assessments or orders. The resident, who was admitted with diagnoses including schizophrenia and metabolic encephalopathy, was observed to have a BIMS score indicating cognitive intactness. Despite this, the resident was given antibiotic ointment for a thumb wound and was applying it independently without supervision or a physician's order. The resident expressed a preference for self-administration and was not aware of the correct frequency for applying the ointment, indicating a lack of proper education and assessment by the facility. Interviews with nursing staff revealed that the required procedures for self-administration were not followed. The nurse responsible for the resident's care was unaware of how the resident obtained the ointment and confirmed that no self-administration assessment or physician's order was in place. The Director of Nursing acknowledged that the facility failed to complete the necessary assessments and education for the resident, resulting in a deficiency in medication management protocols.
Inadequate PPE Use in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to protocols for personal protective equipment (PPE) use. Specifically, staff did not consistently wear gowns and gloves when providing care to a resident on Enhanced Barrier Precautions, which is required to prevent the transmission of multi-drug resistant organisms. Observations revealed that staff members, including nurses and a certified nursing assistant, engaged in high-contact care activities such as touching bed linens, repositioning the resident, and changing the resident's gown without wearing the appropriate PPE. The resident involved had significant medical conditions, including urinary retention, an indwelling urinary catheter, and two Stage III pressure ulcers. Despite the presence of a CDC Enhanced Barrier Precaution sign at the entrance of the resident's room, staff were observed not following the required infection control measures. Interviews with staff, including Nurse #2, the Director of Nursing, and the Infection Control Nurse, confirmed that they were aware of the requirement to wear gowns and gloves during high-contact care activities but failed to consistently implement these precautions.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the lack of necessary protocols and monitoring of antibiotic use. Specifically, the facility did not ensure that antibiotics prescribed were necessary for one resident, and failed to reassess antibiotics 48-72 hours after initiation for five residents. The facility's policy on antibiotic stewardship, revised in April 2023, mandates that antibiotics should only be prescribed for symptomatic infections meeting specific criteria, and that they should be reassessed within 48-72 hours to ensure continued appropriateness. However, these protocols were not followed, leading to potential risks of adverse drug events and antibiotic resistance. Resident #114 was prescribed Keflex for right hand cellulitis, despite not meeting the criteria for appropriate antimicrobial use according to the facility's Revised McGeer Criteria. The medical record lacked a clinical rationale for initiating the antibiotic, and there was no documentation of reassessment 48-72 hours after the antibiotic was started. Similarly, other residents, including those with urinary tract infections and dental abscesses, were prescribed antibiotics without documented reassessment within the required timeframe. This oversight indicates a systemic failure in monitoring and reassessing antibiotic use as per the facility's policy. Interviews with the Director of Nurses (DON) and the Infection Preventionist (IP) revealed that the facility did not complete audit sheets to monitor antibiotic usage, and reassessment documentation was not located for any of the sampled residents. The DON acknowledged the difficulty in ensuring providers adhere to the criteria for prescribing antibiotics. The IP confirmed that audits were not conducted to ensure orders were complete and reassessments were performed, highlighting a significant gap in the facility's antibiotic stewardship efforts.
Failure to Implement Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures regarding the education, consent, and administration of influenza and pneumococcal vaccinations for three residents. For Resident #45, the facility did not provide education on the benefits and potential side effects of the vaccines, nor did it document consent or refusal in the medical record. The resident's immunization record indicated historical vaccinations, but there was no follow-up to confirm the administration of the current influenza vaccine or to assess eligibility for the pneumococcal vaccine. Resident #106, who was admitted with a diagnosis of diabetes mellitus type 2, also did not receive the necessary education or documentation regarding the pneumococcal vaccine. The medical record lacked evidence of consent or refusal, and there was no follow-up to ensure the resident was up to date with the recommended pneumococcal vaccination schedule. The facility's failure to document and follow up on the resident's vaccination status was confirmed during interviews with the Infection Preventionist (IP) and Director of Nursing (DON). Similarly, Resident #8's medical record did not include documentation of education, consent, or administration of the influenza and pneumococcal vaccines. Although the resident had a legal guardian, there was no follow-up after leaving messages regarding the influenza vaccine. The resident's immunization record showed previous doses of PCV13, but there was no evidence of offering or administering the recommended PCV20 or PPSV15 dose. Interviews with the IP and DON revealed that the facility did not adhere to its vaccination policies, resulting in the residents not being up to date with their vaccinations.
Failure to Provide COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to provide education, assess eligibility, and offer the COVID-19 vaccination to two residents, as per CDC recommendations and facility policy. The CDC guidance recommends updated COVID-19 vaccines for individuals 5 years and older to protect against serious illness. The facility's policy mandates offering immunization to residents, documenting education, consent, and vaccination status in the medical record. However, for Resident #8, there was no documentation of follow-up screening, eligibility assessment, or education related to the COVID-19 vaccine. The resident's legal guardian was contacted, but no further action was taken, and the resident was not up to date with the COVID-19 vaccination. Similarly, Resident #107's records lacked documentation of follow-up screening, eligibility assessment, and education regarding the COVID-19 vaccine. Although the resident had received previous COVID-19 boosters, there was no recent consent for the updated booster, and no documentation of discussion with the resident. The facility's immunization tracking log did not indicate that the resident had received the most up-to-date vaccination, and the resident was not up to date with the COVID-19 vaccination. Interviews with the Infection Preventionist (IP) and Director of Nursing (DON) revealed that the facility did not follow its immunization program process. The IP and DON acknowledged that education should be provided before vaccine administration and that residents should be screened each time a vaccine is given. Despite a COVID-19 booster clinic conducted by the partnered pharmacy, not all residents, including Residents #8 and #107, received the vaccine. The DON admitted to not following up with the pharmacy or requesting a supply of vaccines for in-house administration, resulting in a failure to protect residents in accordance with national standards of practice.
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What surveyors actually found near you
We read the 1,023 citations issued within 25 miles in the last 12 months — including the 12 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.
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Nursing homes near North Easton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Copley At Stoughton Nursing Care Center | 3.6 mi | ★★★★★ | 11 | 0 |
| Alliance Health At West Acres | 3.8 mi | ★★★★★ | 6 | 0 |
| The Center At Blue Hills | 3.8 mi | ★★★★★ | 4 | 0 |
| Brockton Post Acute Care | 4.4 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of West Bridgewater | 5.1 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.