Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Southshore Health Care Center during CMS and state inspections, most recent first.
The facility failed to provide timely access to medical records for multiple residents’ legal representatives, despite a policy stating residents have the right to inspect and obtain copies of their PHI. In one case, a guardian for a resident with schizoaffective disorder and intact cognition requested medication and treatment sheets but did not receive them for seven working days. In another, a resident with bipolar disorder and intact cognition had a health care agent and attorney who submitted written and faxed requests, including a required form, yet the facility never supplied the requested records and the DON was unaware of any response. A third resident with Parkinson’s disease, bipolar disorder, Hepatitis C, repeated falls, and severe cognitive impairment had an invoked HCP whose health care agent completed required paperwork and repeatedly requested records but never received copies, only assurances that staff would look into it.
The facility failed to provide necessary behavioral health services to two residents with psychiatric diagnoses after the contracted therapist left and was not replaced. Both residents had intact cognition and care plans calling for psychological or one-to-one therapy, and one had physician orders for psychiatric consult and treatment as indicated. Counseling for both residents was terminated when the therapist from the psychiatric service agency left, and no subsequent counseling was arranged, despite the facility’s policy, facility assessment, and behavioral health services agreement indicating that such services should be provided. One resident and the resident’s guardian reported repeated, unmet requests for a therapist, the other resident expressed willingness to resume counseling, the case manager stated counseling would absolutely benefit the resident, and the psychiatric NP confirmed that ongoing weekly counseling would benefit a resident while acknowledging that no therapist had been available since the prior therapist’s departure.
Two residents with intact cognition and behavioral health diagnoses were unable to reliably communicate with external parties because the facility’s main telephone frequently went unanswered. A guardian and a health care agent reported that repeated calls to the facility rang continuously without staff answering, even when they needed staff assistance to reach the residents. A case manager also experienced unanswered calls when trying to speak with a resident or staff, and the administrator acknowledged receiving complaints about phones not being answered.
A resident with severe cognitive impairment and multiple chronic conditions was found to have a forehead bump with a skin split of unknown origin, which led to transfer to the ED where a small hematoma and laceration with increased somnolence and confusion were documented. Staff interviews indicated the bump was not present during morning care, was first noticed around lunchtime after an activity, and was reported to nursing, but the cause remained unknown. The DON stated she was informed of the incident days later and believed it should have been reported as an injury of unknown origin. Review of facility records showed no documentation that this injury of unknown origin was reported to the State Survey Agency as required by facility policy, resulting in a reporting deficiency.
A resident with severe cognitive impairment, multiple diagnoses, and a history of repeated falls was found with a new bump and laceration on the forehead after morning care, with no witnessed fall and subsequent transfer to the ED for evaluation. Staff, including the CNA who discovered the injury and the nurse notified after the resident returned from an activity, reported the injury to a unit manager, but no incident report was completed and no investigation into the injury of unknown origin was initiated or documented. The DON reported learning of the injury days later, despite facility policies requiring immediate reporting and investigation of all accidents, incidents, and injuries of unknown origin as potential abuse, neglect, or exploitation.
A nurse removed a full blister pack card of oxycodone 5 mg from the locked narcotic drawer to address a resident’s concerns about receiving the correct PRN pain medication and dose. Instead of preparing the dose at the med cart, the nurse brought the entire card into the room, showed it to the resident, dispensed two tablets into a cup, and placed the card on the bedside table, leaving 34 tablets remaining. After leaving the room, the nurse later discovered the card was missing from the narcotic drawer, searched the cart with another nurse, and then returned to the room, where the card was no longer present and the resident denied seeing it. Documentation in the narcotic log and video footage reviewed by the DON corroborated that the nurse entered the room with the medication card and exited without it, resulting in a controlled substance not being stored in a locked, double-locked compartment as required.
The facility did not maintain an effective pest control program, resulting in widespread reports and observations of mice, ants, and cockroaches in resident rooms and food storage areas. Multiple residents reported pest sightings and accessible food was left unprotected, while facility records showed a lapse in professional pest control services for several months.
Resident Council grievances were not consistently addressed or documented as resolved. Residents reported repeated missing laundry, mice and other pests in rooms, disrespectful and intimidating behavior by the ADON, and food temperature concerns, but the minutes and related records often lacked a facility response. During a council meeting, multiple residents said the same issues kept coming up and nothing changed, and several said the meetings were a waste of time.
Failure to Notify Physician of Changes in Condition: The facility failed to notify the attending physician and/or responsible party of changes in condition for two residents. One resident with cognitive impairment and psychiatric diagnoses exhibited hallucination-like statements, repeated 911 calls, and exit-seeking behavior, but the MD and HCP were not notified. Another resident with MS, DM, and hypothyroidism had a significant weight loss of more than 10% of body weight, but the attending physician was not notified promptly and no physician progress note was found in the record.
A facility failed to follow physician orders for several residents, including splints, glasses, lab work, enteral feeding, O2, and wound care. Surveyors observed a resident with dementia wearing only one palm roll despite bilateral orders, another resident without ordered glasses or a left UE splint, a dialysis resident whose ordered CBC was not completed, a readmitted resident whose TF and O2 orders were not in place right away, and a resident whose O2 flow was set above the MD order and whose wound treatments were not fully completed as ordered.
Inadequate fall prevention and elopement supervision: One resident with dementia and repeated falls had multiple unwitnessed falls, including one that caused a hip and elbow fracture, while the care plan and resident care card did not consistently reflect effective fall interventions such as floor mats. Another resident with cognitive impairment and a history of elopement was initially assessed as not at risk, then made repeated statements about needing to leave and was later found outside the building and eventually by police at a liquor store, with no documented reassessment or added safety interventions after the earlier elopement attempt.
Meals Served at Inadequate Temperatures and Poor Palatability: Residents complained that food was repetitive, not good, and that desserts were served frozen. Surveyor-observed test trays on the East Unit showed breakfast and lunch items served at unacceptable temperatures, including cool French toast, lukewarm coffee, and lukewarm vegetables, with multiple items described as bland, dry, or unappealing. The FSD acknowledged the temperatures and palatability were not acceptable.
Unsanitary food storage, improper thawing of raw chicken, and damaged kitchen flooring: The surveyor observed canned goods in dry storage with rust and mouse droppings, and the FSD acknowledged a mouse problem and that the cans needed replacement. The surveyor also observed raw chicken breasts submerged in stagnant water, and the FSM stated the chicken should have been thawed in the refrigerator. In addition, the main kitchen floor had missing tile, recessed areas exposing the subfloor, and pooling water, and the FSD said the flooring needed repair.
Infection prevention and control failures were identified involving COVID-19 isolation, Legionella water management, infection surveillance, medication handling, and EBP use. Staff entered COVID-positive rooms without the full PPE required by posted signage, the water management plan and temperature logs were incomplete, infection line lists had missing and inaccurate data, a nurse touched unit-dose meds during pass, and a CNA failed to wear gown and gloves while transferring and dressing a resident on EBP.
A resident with muscle weakness, gait abnormalities, and heart failure was repeatedly observed in bed with the call light tucked into a bedside drawer and not within reach. The resident said staff move the call light a lot and that it should be next to the resident so it can be reached. The care plan included call light within reach, and CNAs, an RN, and the DON all stated the call bell should always be left within the resident's reach.
Failure to report and investigate resident-to-resident altercation: A resident told staff that another resident made fun of him/her in the hallway, but the incident was not reported to management, documented in the grievance binder, or entered into HCFRS. The resident had metabolic encephalopathy and a BIMS score of 14/15, and staff interviews showed they understood such verbal altercations should be reported and investigated, but the DON confirmed the event was not reported or investigated.
Failure to report alleged resident-to-resident abuse: A cognitively intact resident told staff that another resident made fun of him/her in the hallway, and the nurse spoke with the accused resident, who denied it. The grievance binder and HCFRS had no record that the allegation was reported, and interviews with the DON, SW, and nursing staff confirmed the incident should have been reported under the facility abuse policy.
Failure to Investigate Resident-to-Resident Verbal Altercation: A resident with metabolic encephalopathy and a BIMS of 14 reported that another resident made fun of him/her in the hallway, and the nurse only spoke with the other resident, who denied it. The grievance binder and HCFRS did not show an investigation, and the DON stated the incident was not reported to management and was not investigated, despite staff acknowledging that such allegations should be investigated.
Failure to individualize care plans for three residents involved missing documentation for a resident’s change in mental status, statements about needing to leave, and an elopement attempt; another resident’s history of thoughts of self-harm after auditory hallucinations and hospital transfer; and a third resident’s continuous O2 therapy ordered at 2 L/min by NC. Staff and the DON acknowledged the care plans did not reflect these needs.
Failure to Assess Need for Foley Catheter and Document Clinical Rationale: A resident admitted with a Foley catheter was observed with the catheter in place and was unsure why it was present or how long it had been there. The record showed catheter care orders and a discharge summary noting a voiding trial should be initiated, but there was no documentation that a voiding trial was attempted, no supporting GU diagnosis, and no physician documentation explaining the ongoing need for the catheter or Urology follow-up.
A resident with Parkinson’s disease and COPD had an inhaler, topical gel, and allergy nasal spray left unsecured in the room during survey observations. The resident was cognitively intact but had no consent or current desire to self-administer medications. The DON stated inhalers and nasal spray should be kept in the locked med cart unless self-administration is assessed, and topical gels should be kept in the locked treatment cart.
Improper Garbage Storage and Debris Accumulation: Surveyors observed two dumpsters with closed lids, but one lid was bent and not tight fitting, leaving garbage exposed. The area around the dumpsters had a buildup of trash and debris, including cardboard, gloves, spoons, mattresses, furniture, doors, a TV, tubing, tables, and pallets. The Maintenance Director said the items had been there for a while and the trash vendor would only remove them one at a time.
Failure to complete and transmit discharge MDS assessments affected two residents. One resident was discharged to another facility and another was discharged home, but neither had a discharge MDS completed after discharge. During interview, the MDS Nurse stated the MDSs should have been completed within 7 days and transmitted within 14 days of discharge, and that she must have just missed these two.
A resident was subjected to a strip search by the ADON after being found with a vape pen, despite no facility policy requiring such action. The resident, with a history of substance abuse and PTSD, was upset during the incident. The ADON mistakenly believed a skin check was necessary, leading to a violation of the resident's dignity and respect.
A resident with an activated Health Care Proxy requested a change in attending physicians due to dissatisfaction with the current physician. Despite the request being made in early October, the facility did not facilitate the change until two months later. Staff interviews revealed a lack of awareness about the request, and the only other available physician was initially unable to take on more residents. The change was eventually made in December.
The facility failed to secure medications on two nursing units, with unlocked medication room doors observed by surveyors. Nurses were unaware of the security lapses, and issues with the door lock on Unit #2 were not reported to maintenance. The DON confirmed that medication rooms should always be locked.
The facility failed to reconcile medications accurately for three residents upon admission, leading to discrepancies between hospital discharge summaries and physician orders. Nursing staff did not adhere to the facility's medication reconciliation policy, resulting in incorrect medication administration. The absence of a Unit Manager contributed to the oversight.
The facility failed to control a persistent mouse infestation, with residents frequently seeing mice and droppings in rooms and common areas. Despite pest control efforts, sanitation issues and structural gaps allowed mice to enter. Staff interviews revealed a lack of coordinated action to address the problem, and the issue persisted despite quality assurance efforts.
The facility failed to document and address grievances from the Resident Council, leading to unresolved issues such as excessive noise, medication room stocking, mice infestations, and lack of washcloths. Despite repeated concerns, there was no evidence of follow-up or resolution from the nursing department, and the Recreation Director did not review resolutions with the Resident Council. The DON claimed to conduct staff education, but there was no documentation to support this.
The facility failed to maintain a clean, safe, and homelike environment, with observations of foul odors, stained carpets, and maintenance issues across two nursing units. Residents and staff reported persistent bad smells and environmental concerns, while the Maintenance Director admitted to a lack of a work order system. The Regional Director of Operations acknowledged the need for environmental rounds and audits to address these issues.
A resident with end-stage renal disease and diabetes mellitus experienced worsening of a non-pressure ulcer on the left heel due to the facility's failure to implement timely and appropriate wound care. The facility did not develop a care plan for skin breakdown until months after admission, and weekly skin checks and wound evaluations were not consistently completed. Interviews with staff revealed a lack of oversight and clarity in managing the resident's wound care, contributing to the deterioration of the resident's condition.
A resident with a history of falls and cognitive impairment experienced multiple falls, including one resulting in a hip fracture, due to inadequate supervision and failure to update care plans with effective interventions. The facility's fall risk evaluations were inaccurately coded, and staff interviews revealed confusion about updating care plans.
The facility failed to provide appropriate dialysis care for two residents, resulting in deficiencies in monitoring and communication. One resident's AV fistula site was not properly assessed, and a comprehensive care plan was not developed. Additionally, there was inconsistent documentation and communication with the dialysis center, leading to missed medication changes and lab results. Staff interviews revealed a lack of adherence to facility policies, contributing to the identified deficiencies.
The facility failed to manage medications properly for two residents. One resident received a double dose of Alendronate for five weeks due to unaddressed duplicate orders, while another resident on Apixaban lacked monitoring for adverse effects. The DON confirmed these oversights, highlighting a lapse in medication management and monitoring protocols.
The facility failed to maintain sanitary conditions in the main kitchen dry food storage area, with mouse droppings found on canned goods and dried potatoes, and a large dark stain on the floor. The Food Service Director was unaware of these issues until pointed out by a surveyor, and admitted to not cleaning behind water crates properly.
The facility failed to administer and document influenza and pneumococcal vaccinations for three residents as per CDC guidelines and facility policy. A resident's refusal of the influenza vaccine was not recorded, and two residents who consented to pneumococcal vaccines did not receive them, with no documentation explaining the omissions. Staff interviews revealed a lack of clarity and accountability in the vaccination process.
The facility failed to assess, educate, and document COVID-19 vaccination status for four residents, leading to deficiencies in their vaccination process. A resident with moderate cognitive impairment was not properly educated or offered the vaccine, and there was no documentation of consent or refusal. Another resident with severe cognitive impairment did not have documented consent or refusal, leaving the vaccination section blank. A cognitively intact resident consented to the vaccine, but it was not administered or documented. Additionally, a resident who declined the vaccine did not have this refusal documented. Staff interviews revealed a lack of clarity and follow-through regarding the vaccination process.
A facility restricted a resident's right to leave with their significant other, allowing them to leave only with family due to past substance use and safety concerns. Despite being cognitively intact and their own responsible person, the resident faced limitations based on positive toxicology reports and the significant other's behavior. The facility's team, including the physician and social worker, decided on these restrictions, impacting the resident's self-determination and communication rights.
A facility failed to inform a resident's legal guardian, who is responsible for healthcare decisions, before obtaining the resident's consent for a community program. The resident, diagnosed with schizoaffective disorder and declared incapacitated, signed a consent form without understanding it, leading to anxiety. The Social Worker, aware of the guardianship, did not initially consult the guardian, delaying the proper consent process by 12 days.
A resident with moderate cognitive impairment was not informed about a toxicology screen conducted at the facility. The resident, who was his/her own responsible party, expressed feeling that his/her rights were violated as he/she did not consent to the test. The facility lacked documentation explaining the reason for the screen, and the DON was unsure if consent was required, despite a physician's order being present.
A resident with moderate cognitive impairment reported that their room was searched twice without consent or explanation, and their belongings were left in disarray. Facility staff could not provide documentation or a clear rationale for the searches, indicating a failure to respect the resident's dignity and rights.
A resident reported a stolen wallet, including a debit card, but the LTC facility failed to investigate or report the incident as required by its policies. Despite the resident being cognitively intact and suspecting who might have stolen the wallet, the facility only issued a partial reimbursement without further investigation or notifying the state agency.
A resident reported a stolen wallet, including a debit card, which was not reported to the Department of Public Health within the required 24-hour period. The facility's policy mandates immediate reporting of such incidents, but this was not followed. The resident, who was cognitively intact, noted an attempted use of the debit card, yet the incident was not thoroughly investigated or reported by the social worker or the Director of Nurses.
A resident reported their wallet, containing a debit card and insurance cards, was stolen. Despite the facility's policy requiring investigation of such allegations, no comprehensive investigation was conducted. The resident later discovered an attempted use of their debit card, but the facility only reimbursed $30 without further inquiry.
A resident with end-stage renal disease receiving dialysis three times weekly was not accurately reflected in the MDS assessment. The MDS Nurse acknowledged the error, noting the dialysis treatments were not coded, despite the resident's regular dialysis schedule.
A resident with type 2 diabetes did not have a pharmacist's recommendation for an A1c test addressed or documented in their medical record. The facility's policy requires timely action on such recommendations, but the March 2024 recommendation was missed, and the necessary follow-up for diabetes management was not completed.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The deficiency involves the facility’s failure to provide timely access to or copies of medical records to residents’ legal representatives as required by federal regulations and the facility’s own policy. The facility’s January 2020 Medical Record Policy stated that residents have the right to inspect and obtain copies of their protected health information. For one resident with schizoaffective disorder and intact cognition, a court-appointed guardian requested copies of the resident’s medication and treatment sheets via email on 3/03/26. The facility’s internal investigation showed that these documents were not emailed to the guardian until 3/10/26, seven working days after the initial request, and the administrator acknowledged issues with the facility’s timely response to this guardian’s document requests. Another resident with bipolar disorder and intact cognition had a health care agent and an attorney who requested medical records needed for a disability application. The attorney faxed a written request for clinical documents on 12/01/25 and, after being told on 12/12/25 that a specific form was required, faxed the completed form as instructed. The facility did not respond further or provide the requested documents, and the DON later reported being unaware of these requests and unable to locate any documentation of a response. A third resident with Parkinson’s disease, bipolar disorder, Hepatitis C, repeated falls, and severe cognitive impairment had a health care proxy invoked in 12/2024. This resident’s health care agent reported requesting copies of the resident’s medical records in September 2025, completing the necessary paperwork, and making multiple subsequent requests, but only being told that the facility would “look into it” and never receiving any copies. These actions and inactions demonstrate repeated failures to honor requests for access to medical records within the required timeframe.
Failure to Provide Ongoing Behavioral Health Counseling After Loss of Therapist
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health services to residents with psychiatric diagnoses, despite policies and assessments indicating such services should be available. The facility’s Behavioral Management Guidelines policy required development of behavior plans and medication regimens to optimize residents’ functional abilities, and the facility assessment identified that residents with psychiatric/mood disorders were served and that consultant psychiatric services were provided. A behavioral health services agreement with a psychiatric service agency specified that psychotherapeutic services would be provided to residents. Resident #1, admitted with a diagnosis including schizoaffective disorder and with intact cognition, had a care plan intervention to investigate and monitor the need for psychological/psychiatric support and provide services as ordered. Physician orders included a psychiatric consult and treatment as indicated. However, psychological service notes documented that Resident #1 was terminated from ongoing counseling when the therapist left the agency in November 2025, and no replacement therapist was provided thereafter. Resident #3, admitted with a diagnosis including bipolar disorder and also cognitively intact, had a care plan for alteration in mood that included one-to-one therapy per recommendations. Psychological service notes similarly documented termination of ongoing counseling when the same therapist left the agency in November 2025. Interviews confirmed that both residents had previously been receiving counseling and that these services stopped when the therapist left. Resident #1 reported repeatedly asking staff for a mental health therapist without receiving one, and Resident #1’s legal guardian stated that the facility had not obtained a replacement therapist since the prior therapist’s departure. Resident #3 stated they would resume counseling if it were available, and the resident’s case manager reported that the resident would absolutely benefit from counseling and that the lack of counseling had been a point of contention with the facility. The psychiatric NP, who continued to see Resident #1 monthly for psychotropic medication monitoring, stated that the therapist left in November 2025, had not been replaced, and that Resident #1 would benefit from ongoing weekly counseling. The administrator confirmed that the psychiatric service agency had not been able to provide a therapist for residents, including these two residents, since November 2025.
Unanswered Facility Phones Impede Resident Communication Rights
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to protect and facilitate residents’ rights to communicate with individuals and entities outside the facility when staff did not consistently answer the facility telephone. Resident #1, admitted in July 2023 with schizoaffective disorder and intact cognitive patterns per a quarterly MDS dated 1/16/26, had a court-appointed legal guardian. The guardian reported that on multiple occasions when she called the facility, the main phone rang repeatedly without being answered. Although Resident #1 had a telephone in his/her room, when the resident did not answer, the guardian attempted to reach staff through the facility’s main line for assistance, but those calls often went unanswered despite repeated attempts. Resident #3, admitted in June 2025 with bipolar disorder and intact cognitive patterns per a quarterly MDS dated 1/09/26, also experienced similar issues through his/her representatives. A family member who served as Resident #3’s Health Care Agent reported difficulty reaching the resident because facility staff frequently did not answer the telephone, even when she called repeatedly and allowed it to ring continuously. Additionally, Resident #3’s case manager stated that on some occasions when she called to speak with the resident or with staff about the resident, the facility phone was not answered. The Administrator acknowledged receiving complaints on 2/24/26 from Resident #1’s guardian and other family members about the facility’s telephones not being answered, confirming a pattern of unanswered calls that interfered with residents’ external communication.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency as required by its abuse, neglect, and exploitation policy. The policy, dated 2023, requires reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specific time frames, including within two hours if abuse or serious bodily injury is involved, and within 24 hours if not. A resident admitted in November 2021 with diagnoses including Parkinson's disease, bipolar disorder, Hepatitis C, and repeated falls had a Quarterly MDS showing a BIMS score of 3, indicating severe cognitive impairment, and the resident’s health care proxy had been invoked in December 2024. On a March date in 2026, the Unit Manager documented a red bump with a split in the skin on the resident’s forehead, with no witnessed fall, and the resident was transferred to the hospital ED for evaluation. The ED discharge summary documented a small hematoma and laceration on the forehead with increased somnolence and confusion. Interviews and record review showed that staff were unaware of how or when the injury occurred and that it was not reported to the State Survey Agency. The resident’s health care agent reported being notified by a nurse that the resident had a bump on the forehead of unknown cause and was being sent to the ED. The CNA assigned to the resident stated the bump was not present during morning care but was noticed around lunchtime and reported to the nurse. Another nurse reported that the resident had been at an activity and returned with a bump on the head, prompting transfer for evaluation because the cause was unknown. The Unit Manager stated the bump was noted and the resident was sent to the ED, and the DON reported she was not informed of the injury until days later and that it should have been reported as an injury of unknown origin. Review of the medical record confirmed there was no documentation that the injury of unknown origin was reported to the State Survey Agency, constituting the deficiency.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to investigate and document an injury of unknown origin for one resident. Facility policies on Accidents/Incidents and Abuse, Neglect, and Exploitation require staff to report all accidents and incidents to a supervisor, complete appropriate documentation, and make every attempt to ascertain the cause of the occurrence, including immediate investigation of injuries of unknown origin as potential abuse, neglect, or exploitation. The resident involved had diagnoses including Parkinson’s disease, bipolar disorder, Hepatitis C, and a history of repeated falls, with a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment, and a health care proxy invoked. The resident was sent to the hospital emergency department with a small hematoma and laceration on the forehead, increased somnolence, and confusion, but the facility was unable to provide any documentation that an investigation into the injury of unknown origin was conducted. On the date of the incident, the unit manager documented in a nurse progress note that a red bump with a split in the skin was observed on the resident’s forehead, there was no witnessed fall, and the resident was transferred to the emergency department. The resident’s health care agent reported being informed by a nurse that the resident had a bump on the forehead of unknown cause and was being sent out for evaluation. The CNA assigned to the resident stated the bump was not present during morning care and was first noticed around lunchtime, at which point it was reported to the nurse. Another nurse reported that after the resident returned from an activity, staff informed her of the bump, and she notified the unit manager but did not complete an incident report and did not believe an investigation was done. The unit manager confirmed he did not initiate an investigation or complete an incident report, and the DON stated she was not informed of the injury until days later, despite the facility’s expectation that injuries of unknown origin be immediately reported to the DON and administrator so an investigation could be conducted in a timely manner.
Unsecured Oxycodone Blister Pack Left Unattended in Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a controlled substance was properly secured and under direct supervision of nursing staff, in accordance with facility policy and professional standards. Facility policies on medication storage required that medications and biologicals be stored safely, securely, and properly, and that DEA schedule II–V controlled substances be stored in a permanently affixed, double-locked compartment separate from other medications. Despite these policies, a blister pack card containing oxycodone 5 mg tablets, a controlled substance, was removed from secure storage and left unattended in a resident’s room, after which it could not be located. The resident involved had been admitted with significant medical conditions including complete C1–C4 quadriplegia, muscle weakness, neuropathic bladder, seizures, and atrial fibrillation, and had a physician’s order for oxycodone 5 mg, two tablets (10 mg) by mouth every four hours PRN for severe pain. On the evening in question, the resident complained of overall body pain and requested oxycodone, specifically wanting assurance that the correct medication and dose would be given. In response, the assigned nurse unlocked the narcotic drawer, removed the entire blister pack card of oxycodone, and brought the whole card, along with a medication cup and water, into the resident’s room. She showed the resident the card, dispensed two tablets into the cup, and placed the blister pack card on the bedside table, leaving 34 tablets remaining. After administering the medication and leaving the room, the nurse later noticed that the oxycodone card was not in the narcotic drawer and informed another nurse. Both nurses searched the narcotic drawer and the entire medication cart without finding the card. The nurse then realized she had left the card in the resident’s room and returned to look for it, but it was no longer on the bedside table. The resident denied seeing the oxycodone card. The narcotic log documented that at 19:20 the amount on hand was 36 tablets, two were used, and 34 remained, consistent with the nurse’s account. Video footage reviewed by the DON showed the nurse entering the resident’s room with a medication card and exiting without it. The DON confirmed that it was not typical or best practice for nurses to bring an entire medication card into a resident’s room and stated that medications should be prepared at the cart and not left unattended at the bedside.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free of pests and rodents for its 79 residents. During a kitchen tour, surveyors observed a significant amount of mouse droppings on canned goods in the dry food storage area, which were identified as part of the emergency food supply. The Food Service Director acknowledged an ongoing mouse problem. Multiple residents reported seeing mice in their rooms, with observations of accessible food items not stored in sealed containers, making them vulnerable to pests. Residents also reported seeing ants and cockroaches in their rooms, and concerns about mice traveling through heating ducts and holes in bathroom tiles were documented. Resident Council meeting notes over several months reflected ongoing complaints about mice and other pests in various wings of the facility. A review of facility records revealed that there was no professional pest control service provided from April to August, leaving the facility without adequate pest management for several months. The Maintenance Director confirmed the absence of a pest control vendor during this period and was unaware of the reasons for the lapse. The Administrator, who began in July, was aware of the pest issues but could not explain why the previous administration failed to maintain pest control services. The lack of professional pest control and ongoing resident complaints and observations of pests directly contributed to the deficiency.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to ensure grievances brought forward through Resident Council were addressed and promptly resolved. Resident Council minutes documented repeated concerns, including missing clothing on the west unit, residents reporting that the ADON spoke disrespectfully and made them feel intimidated, food temperature concerns, mice seen in resident rooms and on beds, and ongoing reports of missing clothing. In multiple instances, the corresponding documentation did not show that the concerns had been addressed by the facility, and the Activities Director acknowledged that some issues should have had department head responses but did not. During a Resident Council meeting, 12 residents voiced that concerns were brought up repeatedly without being resolved, and several residents stated that nothing changed and the meetings felt pointless. Residents reported ongoing missing laundry, mice seen regularly in rooms, and that the ADON was degrading and had a bad attitude. One resident provided a written note describing a mouse traveling through a heating duct and room to room, keeping him/her awake for half the night, along with ants and a cockroach or two in the room. The Activities Director stated that department heads were expected to respond to concerns within three days, but the record showed repeated concerns without documented resolution, including the May complaint about the ADON and the recurring laundry and pest issues.
Failure to Notify Physician of Changes in Condition
Penalty
Summary
The facility failed to notify the attending physician and/or responsible party of changes in condition for two residents. Resident #83, admitted in August 2025 with diagnoses including alcohol dependence with withdrawal and major depressive disorder, had moderate cognitive impairment on MDS assessment with a BIMS score of 9 out of 15 and an activated health care proxy. Nursing notes documented that the resident called 911 on 8/17/25 and reported that somebody was playing in his/her back and that he/she did not belong at the facility and needed to leave, then called 911 again on 8/18/25 about something behind the window. On 8/23/25, the resident was found outside walking in the parking lot after being last seen in the TV room about 10 minutes earlier and was returned to the building after three attempts. The medical record did not show that the physician or HCP was notified of these changes in cognitive status and exit-seeking behavior. The facility also failed to notify the attending physician of a significant weight loss for Resident #8, who was admitted in July 2025 with diagnoses including multiple sclerosis, diabetes, and hypothyroidism and had moderate cognitive impairment with a BIMS score of 9 out of 15. The resident’s documented weights decreased from 162.4 lbs. on 7/29/25 to 145 lbs. on 8/20/25, a loss of 17.4 lbs. or 10.71% of body weight. The dietitian identified an 18.4-pound weight loss in two weeks and added yogurt and ice cream to meals twice daily, but the record did not show that the attending physician was notified of the significant weight loss until after the surveyor’s interview with Unit Manager #1. The record also did not include a physician progress note showing the resident had been seen by the attending physician from admission until 8/26/25.
Failure to Follow Physician Orders for Devices, Treatments, Oxygen, and Tube Feeding
Penalty
Summary
The facility failed to implement physician-ordered care and services for multiple residents, including splinting, glasses use, laboratory testing, tube feeding, oxygen therapy, and wound treatments. The report identified five residents out of a sample of 20 for whom ordered interventions were not consistently carried out or were not documented as carried out as ordered. Surveyors used observation, interview, and record review to identify that ordered treatments and devices were either missing, not applied, not reconciled after hospitalization, or not completed as ordered. For one resident with dementia, prior CVA, and hand contractures, the record showed orders for bilateral palm rolls, but surveyors repeatedly observed only the right-hand device in place while the left-hand palm roll was not worn and was found at the bedside. Staff interviews indicated the left device was not being used, and progress notes did not show refusal. For another resident with stroke-related left-sided weakness, orders were in place for glasses and left upper extremity splinting, but surveyors repeatedly observed the resident without the glasses or splint. Staff stated the resident should have been wearing both items, yet the record did not show refusals or consistent implementation. The report also found that a resident receiving dialysis had a verbal order for a CBC with differential after a critically low hemoglobin was communicated by the dialysis center, but the blood work was not found as completed on the next lab day. For a resident readmitted from the hospital with a feeding tube and oxygen use, the record did not show tube feeding or oxygen orders in place upon return, and the MAR did not show the continuous tube feeding or oxygen being administered until later orders were entered. In another resident, oxygen was observed running at settings higher than the physician’s order, and wound care was not fully completed as ordered: only three of five wound treatments were observed, one treatment used sterile water instead of the ordered wound wash, and two ordered wound areas were not observed being treated. The DON and other staff acknowledged that physician orders should have been followed and that the documentation and treatments did not match the ordered care.
Inadequate fall prevention and elopement supervision
Penalty
Summary
The facility failed to provide adequate supervision and effective interventions to prevent avoidable accidents for two residents. One resident had a history of dementia, psychotic disturbance, repeated falls, and Wernicke's encephalopathy, and the record showed multiple falls over the prior year. The resident's care plan included numerous fall-related interventions, including frequent checks, toileting, environmental adaptations, and floor mats while in bed, but the record also showed repeated falls without consistent new interventions being added after each event. Physician progress notes documented the falls but did not address fall risk or prevention measures. The resident experienced multiple unwitnessed or partially witnessed falls, including being found on the floor in the hallway, in another resident's room, beside the bed, and sitting on the floor next to the bed. One fall resulted in a left hip fracture and left olecranon fracture requiring hospital transfer and surgical repair. After several of the falls, the incident reports did not include staff statements or additional information about what occurred, and no new intervention was added to the fall prevention care plan. The resident's care card also failed to include the use of floor mats even though the care plan listed them, and survey observations found the resident in bed without floor mats in place. A second resident was admitted with alcohol dependence with withdrawal and major depressive disorder and had moderate cognitive impairment with an activated HCP. The initial elopement assessment indicated the resident was not at risk for wandering or elopement, despite hospital documentation showing poor insight, poor judgment, lack of capacity, a history of elopement from a previous facility, and an elopement from the hospital. After admission, the resident made statements to staff and police indicating confusion and a desire to leave, but the record did not show a reassessment of elopement risk or safety interventions after those behaviors. The resident was later found outside unaccompanied in the parking lot, refused to come back inside at first, and later was found by police one mile away at a liquor store and transported to the hospital. The DON stated the physician and HCP should have been notified after the earlier elopement attempt and that a reassessment and safety interventions should have been put into place, but they were not.
Meals Served at Inadequate Temperatures and Poor Palatability
Penalty
Summary
Meals and drinks were not consistently provided at palatable, attractive, and safe appetizing temperatures. Residents voiced complaints during the Resident Council Meeting that the food was not good, repetitive, and that desserts were served frozen. Additional resident interviews on the [NAME] Unit showed that four residents disliked the meals they were served. Food Committee Minutes also documented resident complaints that food temperature was only "so-so," and the Food Service Director stated dining services completed test trays at least twice a month and would do one weekly as follow-up. Review of test tray evaluations showed multiple meals served at inadequate temperatures, including noodles at 128 degrees, milk at 46 degrees, meatloaf at 128 degrees, asparagus at 119 degrees, roasted potatoes at 123 degrees, pudding at 48 degrees, and a waffle at 129 degrees. During surveyor-observed test trays on the East Unit, breakfast items included French toast at 80 degrees described as cool, dry, bland, and unappealing; cream of wheat at 120 degrees; orange juice at 48 degrees; whole milk at 45 degrees; and hot coffee at 114 degrees, which was lukewarm and unappealing. At lunch, baked chicken was 130 degrees, rice 140 degrees, mixed vegetables 112 degrees, melon 55 degrees, milk 42 degrees, and coffee 135 degrees; the FSD acknowledged the temperatures and palatability were not acceptable and stated the rice could use some salt.
Unsanitary food storage, improper thawing of raw chicken, and damaged kitchen flooring
Penalty
Summary
The facility failed to maintain the main kitchen dry food storage area in a sanitary condition. On 8/21/2025 at 7:56 A.M., the surveyor observed multiple shelves of canned goods in the dry storage area with rust encrusted along the can ends and a large amount of mouse droppings on top of the cans. During an interview at 8:20 A.M., the Food Service Director stated the cans were part of the emergency food supply, said the facility had a mouse problem for a while, and explained that staff used to sanitize the tops of the cans because of the mouse droppings, which he believed contributed to the rust. He also stated he was not aware of the rust and mouse droppings on the cans and needed to replace them. The facility also failed to follow proper sanitation and food handling practices while thawing raw chicken, and failed to maintain the main kitchen flooring in a sanitary and safe condition. On 8/21/2025 at 7:56 A.M., the surveyor observed a large stainless steel mixing bowl on a sink worktable containing approximately 10 raw chicken breasts submerged in stagnant water. During interview at 8:20 A.M., the FSM stated the chicken was intended to be served as an alternate meal that day and acknowledged the dietary staff should have placed the frozen chicken in the refrigerator to thaw instead of leaving it in standing water. The surveyor also observed several areas of compromised kitchen flooring with sections of tile missing, deeply recessed areas exposing the subfloor, and pooling water. On 8/27/25 at 11:26 A.M., the FSD stated the flooring needed repair and that maintenance was aware but had not fixed it yet.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to implement Transmission Based Precautions for residents who tested positive for COVID-19. Residents #28, #77, #52, and #39 had COVID-19 and were on isolation precautions, and the posted isolation sign required hand hygiene, gown, N95 respirator, eye protection, and gloves. During observations, multiple staff members entered these residents’ rooms without the full required PPE, including wearing a surgical mask instead of an N95, entering with no PPE, or using an N95 over a surgical mask. A laundry worker also delivered laundry into the rooms without the full PPE indicated on the sign. Staff interviews confirmed that the expected PPE for COVID-positive rooms included a gown, N95, face shield, and gloves, and that the N95 should not be placed over a surgical mask. The facility also failed to maintain and implement its Water Management Program for Legionella. The Water Management Plan binder contained an environmental assessment dated 2/27/18 and annual revisions dated 2/11/19 and 3/10/20, but no additional annual updates were provided. Weekly water temperature logs showed that from 3/2/24 through 11/30/24, temperatures were recorded for selected resident rooms, the kitchen, and laundry rooms, but from 12/7/24 through 8/15/25 the logs only showed four rooms on each unit and no longer included the kitchen or laundry areas. Interviews with the IP, DON, Maintenance Supervisor, Maintenance Director, and Administrator confirmed that the committee structure, annual updates, and full logging of sites were not being maintained as described in the facility’s plan. The infection surveillance line lists were incomplete and inaccurate. Review of monthly infection reports from January through July 2025 showed multiple entries with blank fields for infection symptoms, culture dates/results, comments, and whether the infection had cleared. Some infections were listed as ongoing even though they were not on the prior month’s line list, and several line items had the box for whether to count the infection left blank. The IP and DON stated that the line lists should be complete for tracking purposes, that ongoing infections should have been carried over from the prior month, and that missing culture results prevented pattern identification. The facility also failed to maintain sanitary medication administration practices and proper PPE use for Enhanced Barrier Precautions. During medication preparation for a resident with multiple oral medications, Nurse #2 was observed popping unit dose medications directly into his hands before placing them in a medication cup. The nurse acknowledged that he should not have touched the pills before administering them. In addition, Resident #1, who had a feeding tube, required assistance with ADLs and had EBP ordered. Although EBP signage and a PPE cart were posted outside the room, CNA #1 transferred the resident, re-entered the room, and exited with clothing without wearing the gown and gloves indicated on the signage. The CNA stated she did not wear a gown because she was not performing ADL care, while the ADON and IP stated that gowns and gloves should have been worn for transferring and undressing the resident.
Call light left out of reach for a cognitively intact resident
Penalty
Summary
The facility failed to ensure that Resident #5 had the call light accessible and within reach when unattended. Resident #5 was admitted in July 2025 with diagnoses including muscle weakness, abnormalities of gait and mobility, and heart failure, and the 8/5/25 MDS indicated the resident was cognitively intact with a BIMS score of 13 out of 15. The facility policy titled Call Light, Use of, dated April 2015, stated that residents will have a call light or alternative communication device within reach when unattended and that staff should position the call light conveniently and show the resident where it is located. Surveyors observed Resident #5 in bed on three occasions with the call light tucked into the second drawer of the bedside dresser, and each time it was not within reach. The resident stated that staff move the call light a lot and that he/she cannot get to it, and said the call light should be next to the resident so it can be reached. The care plan for falls included the intervention to provide environmental adaptations, including call light within reach. CNA #5, CNA #9, Nurse #5, and the DON all stated that call bells should always be left within the resident's reach, and the DON stated a call bell should never be left in a resident's drawer and out of reach.
Failure to Report and Investigate Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy when a resident-to-resident altercation involving Resident #51 was not reported to leadership, investigated, or documented in the grievance binder or HCFRS. The facility policy titled Abuse, Neglect and Exploitation stated that verbal abuse includes disparaging or derogatory communication within a resident’s hearing distance, that allegations require immediate investigation, and that reports must be made to the administrator, state agency, and other required agencies within specified timeframes. In this case, Resident #51, who was admitted in July 2023 and had diagnoses including metabolic encephalopathy, had a 7/18/25 MDS showing cognitive intactness with a BIMS score of 14 out of 15. The resident’s progress note stated that Resident #51 told staff Resident #14 made fun of him/her in the hallway, and a nurse spoke with Resident #14, who denied making fun of Resident #51. Interviews with CNA #7, Nurse #6, Nurse #5, Social Worker #1, and the DON indicated staff understood that resident-to-resident altercations, including verbal interactions, should be reported to management and investigated. However, the DON later stated she was still looking for an investigation related to the incident and then confirmed the nurse did not report the altercation to management and that it was not reported or investigated.
Failure to Report Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse was reported timely to the state agency for one resident. Resident #51, who was admitted in July 2023 and had diagnoses including metabolic encephalopathy, was assessed as cognitively intact on the 7/18/25 MDS with a BIMS score of 14 out of 15. A progress note dated 7/22/24 documented that Resident #51 told staff that Resident #14 made fun of him/her in the hallway, and a nurse spoke with Resident #14, who denied making fun of Resident #51. Review of the grievance binder and the HCFRS showed no documentation that the alleged resident-to-resident altercation was reported. The facility policy required alleged abuse to be reported to the administrator and state agency within specified timeframes, and interviews with nursing staff, the social worker, and the DON confirmed that resident-to-resident altercations and allegations of abuse should be reported. The DON stated the nurse did not report the 7/22/24 altercation to management and that it was not reported, and said the policy should have been followed.
Failure to Investigate Resident-to-Resident Verbal Altercation
Penalty
Summary
The facility failed to thoroughly investigate an allegation involving Resident #51 and a resident-to-resident verbal altercation. Resident #51 was admitted in July 2023 with metabolic encephalopathy and, on the 7/18/25 MDS, was documented as cognitively intact with a BIMS score of 14 out of 15. A progress note dated 7/22/24 stated that Resident #51 reported Resident #14 had made fun of him/her in the hallway, and the nurse spoke with Resident #14, who denied making fun of Resident #51. Review of the grievance binder and the HCFRS did not show that the alleged abuse had been investigated. During interviews, staff stated that resident-to-resident altercations and allegations of abuse should be reported, the residents should be kept safe, and the matter should be investigated. The DON later stated she was still looking for documentation of an investigation related to the 7/22/24 altercation and then said the nurse did not report the altercation to management and it was not investigated, adding that the policy should have been followed.
Failure to Individualize Care Plans for Mental Status, Self-Harm History, and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents with identified needs. Its policy stated that care plans should be individualized, based on resident data and interdisciplinary input, and include measurable objectives and timelines. Review of the records showed that the comprehensive care plans for the sampled residents did not reflect specific clinical or behavioral issues that were documented in progress notes and physician orders. For one resident with major depressive disorder and moderate cognitive impairment, nursing notes documented a change in mental status after the resident called 911, spoke with police about someone playing in his/her back and wanting to leave, and later was found outside walking in the parking lot before agreeing to return to the building. The record review showed no care plan addressing the resident’s change in mental status, verbalizations about leaving the facility, or the elopement attempt. The DON stated that care plans should have been developed and interventions put into place for the change in mental status and elopement risk, but they were not. For another resident with schizoaffective disorder and auditory hallucinations, progress notes documented auditory hallucinations of self-harm, one-to-one supervision, transfer to the hospital, and psychiatric clearance before return to the facility. The care plan did not include the resident’s history of thoughts of self-harm, and both nursing and social work staff stated the plan was not personalized to include that history. For a third resident with heart failure and hypertension, physician orders required continuous oxygen via nasal cannula at 2 L/min and tubing changes every Sunday, and surveyors observed the resident receiving oxygen on multiple occasions. The comprehensive care plan did not include oxygen therapy, and the DON stated the resident should have had a respiratory care plan related to oxygen use.
Failure to Assess Need for Foley Catheter and Document Clinical Rationale
Penalty
Summary
The facility failed to provide indwelling catheter care and management consistent with professional standards for one resident. Resident #5 was admitted in July 2025 with diagnoses including heart failure, muscle weakness, and diabetes. The resident’s MDS assessment dated 8/4/25 showed the resident was cognitively intact with a BIMS score of 13 out of 15 and indicated an indwelling catheter with no genitourinary diagnoses. During observation on 8/21/25, the resident was seen in bed with a Foley catheter hanging from the side of the bed and stated being unsure why the catheter was present or how long it had been in place. Review of the medical record showed physician orders for Foley catheter care, replacement if not draining after irrigation, insertion of a 16 Fr Foley catheter with a 10 mL balloon, and notification of the physician if the catheter did not drain after replacement. The hospital discharge summary indicated the resident had a Foley catheter and that a voiding trial should be initiated, with possible Urology consultation if the trial failed. The record did not show that a voiding trial had been attempted on admission, and it also did not contain a clinical rationale or supporting diagnosis for continued Foley catheter use. Physician progress notes likewise did not document medical reasoning for the catheter, a voiding trial, or follow-up with Urology. Nurse #1 stated that residents admitted with Foley catheters would have voiding trials if ordered, and the DON stated that a resident with a Foley catheter was expected to have a related diagnosis such as urinary retention or neurogenic bladder and that a voiding trial should have been completed unless contraindicated and documented.
Unsecured Medications Left in Resident Room
Penalty
Summary
The facility failed to ensure medications were stored in accordance with accepted professional standards for one resident. Resident #1 was admitted in July 2025 with diagnoses including Parkinson’s disease, muscle weakness, and COPD, and his/her MDS assessment dated 8/1/25 showed a BIMS score of 15 out of 15, indicating cognitive intactness. The resident’s physician orders included Albuterol Sulfate HFA inhalation aerosol, 2 puffs three times daily, and Diclofenac Sodium external gel 1% applied topically twice daily. The facility policy stated medications were to be stored in a locked mobile medication cart accessible only to licensed nursing personnel. During survey observations, the resident’s Albuterol Sulfate inhaler was found on the bedside table, and two Diclofenac Sodium gel tubes were observed on a dresser and windowsill. On later observations, the inhaler and gel tubes were again found unsecured in the room, and a Fluticasone Propionate nasal spray bottle was also on the bedside table. The resident’s self-administration evaluation dated 5/18/23 indicated he/she did not desire to self-administer medications, and the record did not contain consent for self-administration. The resident stated nurses generally left the inhaler in the room because it was used three times a day. Nurse #3 stated the inhaler and nasal spray had been removed from the room because they were supposed to be stored in the medication cart, and that the topical gels should be stored in the locked treatment cart. The DON stated inhalers and nasal spray should be kept in the locked medication cart unless a self-administration assessment had been completed, and topical gels should be kept in the locked treatment carts.
Improper Garbage Storage and Debris Accumulation
Penalty
Summary
The facility failed to ensure the garbage storage area was maintained in a sanitary condition to prevent the harborage and feeding of pests. During observation, two dumpsters were seen with their top lids closed, but the left dumpster had a bent cover that was not tight fitting, leaving garbage exposed. The surrounding area contained a buildup of trash and debris, including cardboard boxes, used blue gloves, plastic spoons, 11 mattresses, an overbed table, an office chair, bi-fold interior doors, a television, corrugated drainage tubing, folding tables, and multiple wooden pallets. The trash and debris were not properly contained in the dumpster. During interview, the Maintenance Director stated the mattresses and other items had been there for a while and that the trash vendor would only take them away one item at a time.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to encode and transmit discharge MDS assessments to the State within 7 days of assessment for two residents. Resident #33 was discharged to another facility on 3/25/25, and review of the medical record on 8/21/25 showed that no MDS had been completed since the discharge, leaving the assessment 133 days overdue. Resident #71 was discharged home on 3/26/25, and review of the medical record on 8/21/25 showed that no MDS had been completed since the discharge, leaving the assessment 134 days overdue. During interview on 8/22/25 at 7:32 A.M., the MDS Nurse reviewed both records and stated the MDSs should have been completed within seven days and transmitted within 14 days following the discharges, and that she must have just missed these two.
Resident Strip Searched Without Policy Support
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect when the Assistant Director of Nurses (ADON) conducted a strip search on the resident after finding a vape pen in their possession. The resident, who was alert and oriented, was asked to come to the ADON's office, accompanied by two other staff members, for a skin check. During this process, the resident was instructed to remove their upper body clothing, which was part of a strip search, despite the facility's policy not requiring such actions following room searches or the discovery of contraband. The resident, admitted for rehabilitation after a traffic accident, had a history of polysubstance abuse, PTSD, and anxiety disorder. The facility's Room Entry and Search Policy allowed room searches if illegal activity or a health and safety threat was suspected, but it did not mandate skin checks or strip searches. The ADON mistakenly believed that skin checks were required after room searches, leading to the inappropriate action of conducting a strip search in her office. Interviews with the ADON and CNA involved revealed that the resident was upset during the incident, and the ADON admitted to conducting the skin check under the false assumption that it was required by facility policy. The Director of Nursing and Administrator confirmed that there was no policy supporting the ADON's actions, indicating a failure to adhere to the facility's established procedures and resident rights policies.
Failure to Timely Honor Resident's Request to Change Physician
Penalty
Summary
The facility failed to honor a resident's right to choose their attending physician in a timely manner. The resident, who had an activated Health Care Proxy with a Health Care Agent (HCA) making medical decisions on their behalf, requested a change in attending physicians in early October 2024. However, the facility did not facilitate this change until two months later. The resident was admitted to the facility in July 2023 with diagnoses including metabolic encephalopathy, schizoaffective disorder, seizure disorder, and a history of urinary tract infections. The HCA expressed dissatisfaction with the current physician, citing rudeness and lack of familiarity with the resident. Despite a meeting held in early October 2024 with the resident, HCA, Nurse Manager, and Director of Social Services, there was no documentation in the medical record indicating an attempt to change the physician. Interviews with staff revealed a lack of awareness about the request, and the Unit Manager noted that the only other available physician was unable to take on additional residents. The Director of Nurses was unaware of the request until December 2024, at which point the change was facilitated.
Medication Security Lapses in Nursing Units
Penalty
Summary
The facility failed to ensure that medications were properly secured on two nursing units, Unit #1 and Unit #2. On December 9th, the surveyor observed that the medication room door on Unit #1 was open and unlocked, leaving medications unsecured. At the time of the observation, two nurses were working on the unit, but neither was present at the nurses' station or in the surrounding area for approximately 10 minutes. Nurse #1, when interviewed, stated she was unaware that the medication room door was open and did not have a key to the room. She acknowledged that the door should be closed and locked at all times. Similarly, on Unit #2, the medication room door was found to be unlocked, allowing access to unsecured medications. Nurse #3 indicated that there were difficulties with the key to the medication room door, which had been reported to facility maintenance. However, the Maintenance Director stated that no such issue had been reported to him. The Director of Nurses confirmed that it is the facility's expectation for all medication room doors to be locked and medications to be secured at all times.
Medication Reconciliation Deficiency
Penalty
Summary
The facility failed to ensure that nursing care and services met professional standards of practice for three residents upon their admission. The deficiency was identified through record reviews and interviews, revealing that the facility did not accurately reconcile medications and treatments as indicated on the hospital discharge summaries. This failure resulted in medications and treatments not being administered according to physician orders and facility policy. For one resident, the hospital discharge summary indicated the use of Lovenox, an incentive spirometer, and ice for pain relief, but there was no documentation in the medical record to support that these were reviewed with the attending physician. The nurse responsible for the admission evaluation admitted to not using medication reconciliation forms and only reading off the medications listed on the after-visit summary report to the physician. The Director of Nurses was unaware of the resident's medication needs and expected the nursing staff to clarify these with the physician. Another resident's discharge summary indicated a higher dosage of Prazosin than what was ordered by the facility's physician, and a third resident's medication was scheduled for daily administration instead of as needed, as per the discharge instructions. Interviews with nursing staff revealed a lack of adherence to the facility's medication reconciliation policy, with no formal process in place to ensure accuracy. The absence of a Unit Manager further contributed to the oversight, as the responsibility for double-checking new admissions fell to other staff members who did not consistently perform this task.
Persistent Mouse Infestation Due to Ineffective Pest Control
Penalty
Summary
The facility failed to implement an effective pest control program, resulting in significant sanitation concerns and a persistent mouse infestation. Observations and interviews revealed that mice were frequently seen in resident rooms, living areas, and the kitchen, with droppings found in various locations, including closets, drawers, and on beds. Residents consistently reported the presence of mice, and the issue was noted in Resident Council minutes over several months, indicating a lack of improvement despite pest control interventions. The pest control logs and service reports showed repeated attempts to address the problem by adding bait stations and traps in various areas, including resident rooms and the kitchen. However, these measures were insufficient, as evidenced by ongoing sightings and droppings. The pest control technician noted sanitation issues, such as food and trash on floors, and structural problems, like gaps around air conditioners and propped-open doors, which facilitated mouse entry. The technician also highlighted the need for better communication and documentation of pest sightings, which was lacking, as evidenced by the misplaced pest logbook. Interviews with staff, including the Maintenance Director and Housekeeping Manager, revealed a lack of coordinated efforts to address the infestation. The Maintenance Director acknowledged the severity of the problem and the need for repairs, such as sealing air conditioners and addressing holes in walls, but these actions had not been completed. The Housekeeping Manager noted challenges in maintaining cleanliness in cluttered areas, which contributed to the problem. The regional Administrator and DON confirmed that the mouse problem remained significant despite previous quality assurance efforts.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that grievances and concerns raised by the Resident Council were documented and addressed in a timely manner. During a Resident Group meeting, the Resident Council President and multiple residents expressed frustration that their concerns were repeatedly brought up without resolution. Concerns documented in the Resident Council minutes from March, April, and May 2024 included issues such as excessive noise from staff during the 3-11 shift, insufficient stocking of the medication room, persistent mice infestations, and a lack of washcloths and towels. Despite these recurring issues, there was no evidence of follow-up or resolution from the nursing department for the concerns raised in March, and the resolutions for April and May were repetitive and lacked documentation of completed actions. The Recreation Director stated that she distributes written concerns to the responsible department heads and expects them to update the resolution forms, but acknowledged that some forms lacked resolutions. She also admitted to not reviewing resolutions with the Resident Council Group. The Director of Nurses (DON) claimed to complete follow-up and resolution forms and conduct staff education as needed, but there was no documentation to support that education was completed in March, April, and May. This lack of documentation and follow-up indicates a failure in the facility's process to address and resolve resident grievances effectively.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean, safe, comfortable, and homelike environment for residents across two nursing units. Observations revealed foul, musty odors and stained carpets throughout the East and West Units. The East Unit had broken floor tiles, trash under baseboards, stained ceiling tiles, peeling wallpaper, and duct tape on frayed rugs. Resident rooms were found with soiled floors, dirty equipment, and reports of leaking ceilings. The West Unit also had a stale odor, stained carpets, and mouse droppings in a resident's bedside drawer. The shower room had peeling baseboards with black stains behind them. Interviews with residents, staff, and the Ombudsman confirmed the presence of strong odors, environmental concerns, and maintenance issues. Residents reported persistent bad smells, and the Director of Housekeeping acknowledged the carpets' age contributed to the odors and stains. Staff, including a CNA and a Hospice Aide, noted that the stains and odors did not improve despite cleaning efforts. The Maintenance Director admitted the lack of a work order system and reliance on word of mouth for maintenance requests, leading to unaddressed issues. The Regional Director of Operations recognized the need for environmental rounds and audits to identify and address these concerns. He acknowledged that staff might become accustomed to the facility's condition, overlooking issues such as odors, damaged carpets, and sanitation problems, which could exacerbate the pest problem. The report highlights the facility's failure to provide a functional, sanitary, and comfortable environment as per their preventative maintenance policy.
Failure to Provide Adequate Wound Care for Resident with Non-Pressure Ulcer
Penalty
Summary
The facility failed to provide quality care according to its protocols and professional standards for a resident with a non-pressure ulcer on the left heel. The resident, who was admitted with end-stage renal disease and diabetes mellitus, was identified as being at risk for skin breakdown. However, the facility did not develop or implement a care plan for skin breakdown until several months after admission. The resident's condition worsened from a split with slight darkness to unstable eschar, indicating a severe wound. Upon admission and re-admission, the facility identified skin impairments but failed to obtain appropriate treatment orders for the resident's right and left heel non-pressure wounds. The facility's policies required weekly skin checks and non-pressure wound evaluations, which were not consistently completed. Additionally, the facility did not ensure that the resident received diabetic foot care as per the house policy, and there were lapses in obtaining necessary physician orders for wound care and monitoring. Interviews with facility staff, including the Director of Nurses and the Assistant Director of Nursing, revealed a lack of clarity and oversight in managing the resident's wound care. The resident was not seen by the wound physician until several weeks after the need for a wound consult was identified. The facility's failure to adhere to its protocols and ensure timely and appropriate wound care contributed to the deterioration of the resident's condition.
Inadequate Fall Risk Management Leads to Multiple Falls
Penalty
Summary
The facility failed to provide adequate supervision to minimize the risk of falls for a resident, resulting in multiple falls over a five-month period. The resident, who was admitted with diagnoses including protein calorie malnutrition, muscle weakness, and a need for assistance with personal care, experienced six falls, one of which resulted in a left hip fracture and two skin tears. The facility's policy required a fall risk evaluation upon admission and after any significant change in status, but the evaluations were inaccurately coded, leading to an underestimation of the resident's fall risk. The facility did not thoroughly investigate the falls or develop and implement effective interventions to prevent future incidents. Despite the resident's history of falls and the presence of risk factors such as gait imbalance and improper footwear, the care plan was not updated with new interventions after each fall. The resident's falls were often related to transfers between a chair or wheelchair and the bed, and the facility failed to address these specific risks adequately. Interviews with staff revealed a lack of clarity regarding responsibility for updating care plans with new interventions. The Director of Nurses acknowledged that the care plan should have been updated after each fall, but it was not. The facility's failure to accurately assess the resident's fall risk and implement appropriate interventions contributed to the repeated falls and subsequent injuries.
Deficiencies in Dialysis Care and Communication
Penalty
Summary
The facility failed to provide appropriate dialysis care and services for two residents, leading to deficiencies in monitoring and communication. For one resident, the facility did not assess and monitor the left AV fistula site, failed to document assessments of the resident's condition, and did not develop a comprehensive care plan for dialysis. Additionally, there was a lack of ongoing communication between the nursing facility and the dialysis center, and weights for physician evaluation were not consistently obtained. The facility's policy on hemodialysis care was not followed, as evidenced by the lack of documentation and communication regarding the resident's dialysis treatments. The communication book, which was supposed to be used for exchanging vital information between the facility and the dialysis center, was not consistently filled out. This resulted in missed opportunities to address medication changes and lab results, as well as a failure to communicate the resident's medical leave of absence to the dialysis center. Interviews with staff revealed a lack of awareness and adherence to the facility's policies and procedures for dialysis care. The Director of Nurses and other staff members acknowledged that the necessary care plans and communication protocols were not implemented as required. This lack of compliance with established standards of practice contributed to the deficiencies identified during the survey.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that the medication regimen for two residents was free from unnecessary drugs and adequately monitored. For one resident, the facility did not act upon a pharmacy recommendation in a timely manner, resulting in the resident receiving a double dose of Alendronate, a medication used to treat osteoporosis, for five weeks. The resident had duplicate orders for the medication, which were not reviewed and discontinued as recommended by the consultant pharmacist. The Director of Nursing acknowledged that the error occurred because the nurse did not discontinue the duplicate order after the medication was unavailable on a scheduled day, leading to the resident receiving the medication twice weekly instead of once. For another resident, the facility failed to monitor for signs and symptoms of adverse consequences from an anticoagulant medication. The resident, who had a diagnosis of atrial fibrillation, was receiving Apixaban, an anticoagulant, but there was no documented order to monitor for bleeding or other side effects. The nurse confirmed that there should have been an order to monitor for such adverse effects every shift, but it was not present in the medical record. The Director of Nursing also confirmed the absence of the monitoring order and stated that monitoring should have been completed and documented every shift.
Sanitation Issues in Kitchen Dry Food Storage
Penalty
Summary
The facility failed to maintain the main kitchen dry food storage area in a sanitary condition, as observed by a surveyor. During the inspection, multiple shelves of canned goods were found with a large amount of mouse droppings on top of the cans. White containers of dried potatoes were also observed with mouse droppings and brown dried liquid stains. Additionally, there was dirt, debris, and a large amount of mouse droppings underneath the shelves. A large dark-colored stain, partially wet and surrounded by mice droppings, was noted on the floor between the last metal shelf of canned goods and the crates of water. Multiple small black flies were present on the walls and boxes. The Food Service Director (FSD) was unaware of the mice droppings in the dry food storage area until the surveyor pointed them out. Upon a follow-up observation, a small amount of mice droppings was still present on top of multiple cans, and water was leaking from the crates, leaving remnants of the previous large dark stain on the floor. The FSD admitted that the area where the crates of water were stored was not cleaned properly, as he did not pull out the crates to clean behind them.
Failure to Administer and Document Vaccinations
Penalty
Summary
The facility failed to adhere to CDC recommendations and its own policy regarding the administration and documentation of influenza and pneumococcal vaccinations for three residents. Resident #33, who had moderate cognitive impairment, refused the influenza vaccine, but this refusal was not documented in the electronic medical record. Resident #50, who was cognitively intact, consented to receive the pneumococcal PCV20 vaccine, yet there was no record of the vaccine being administered or any reason documented for its non-administration. Similarly, Resident #55, also cognitively intact, had consented through their legal representative to receive the pneumonia vaccines (PPSV23 and PCV13), but there was no documentation of these vaccines being administered or any explanation for their absence in the medical record. Interviews with facility staff, including the Unit Manager, Infection Preventionist (IP), and Director of Nurses (DON), revealed a lack of clarity and accountability regarding the vaccination process. The Unit Manager acknowledged that all vaccination-related consents and refusals should be documented in the electronic medical record but was unable to explain the omissions. The IP and DON also expressed uncertainty about why the vaccines were not administered or documented, despite the consents being obtained. The staff interviews highlighted a breakdown in communication and follow-up procedures, as the responsibility for vaccinations was deferred among staff members, leading to the deficiencies identified in the report.
Deficiencies in COVID-19 Vaccination Documentation and Administration
Penalty
Summary
The facility failed to properly assess, educate, and document the COVID-19 vaccination status for four residents, leading to deficiencies in their vaccination process. Resident #33, who had moderate cognitive impairment, was not properly educated or offered the COVID-19 vaccine, and there was no documentation of consent or refusal in the medical record. Similarly, Resident #76, with severe cognitive impairment and an invoked Health Care Proxy, did not have documented consent or refusal for the COVID-19 vaccine, leaving the vaccination section blank. Resident #79, who was cognitively intact, had consented to receive the COVID-19 vaccine, but the facility failed to administer it or document the reason for non-administration. Additionally, Resident #50, also cognitively intact, had declined the vaccine, but this refusal was not documented in the electronic medical record. These lapses in documentation and follow-up indicate a failure in the facility's vaccination policy implementation. Interviews with staff, including the Unit Manager, Infection Preventionist, and Director of Nurses, revealed a lack of clarity and follow-through regarding the vaccination process. The staff were unsure why the vaccines were not administered or why documentation was incomplete, despite the facility's policy requiring thorough documentation of consent, declination, and administration in the electronic medical record.
Facility Restricts Resident's Leave of Absence Rights
Penalty
Summary
The facility failed to uphold the rights of a resident, who was their own responsible person, by restricting their ability to leave the facility with individuals of their choice. The resident, who had a history of substance use disorder, was cognitively intact and had previously been allowed to leave the facility with their significant other to attend support meetings. However, the facility imposed restrictions based on the resident's past substance use, allowing them to leave only with family members. The facility's policy on leave of absence stated that residents who are their own responsible party may go on a leave of absence unattended. Despite this, the facility implemented a series of orders and restrictions that limited the resident's ability to leave with their significant other. These restrictions were based on the resident's positive toxicology reports and the significant other's behavior, which included an altercation and threats to staff. The facility's team, including the physician, social worker, and administrator, decided to restrict the resident's leave of absence to family members only, citing concerns about the resident's safety and decision-making. Interviews with staff and the resident revealed that the resident was dissatisfied with the restrictions, feeling that it negatively impacted their relationship with their significant other. The facility's actions were based on a team decision to ensure the resident's safety, but this resulted in a failure to honor the resident's right to self-determination and communication, as they were not allowed to leave the facility with their significant other, despite being their own responsible person.
Failure to Inform Legal Guardian for Consent
Penalty
Summary
The facility failed to ensure that the Resident Representative, who is the legal guardian, was fully informed in advance and given the necessary information to make healthcare decisions for a resident diagnosed with schizoaffective disorder. The resident had been declared incapacitated and had a guardian appointed by the court to make all healthcare decisions. Despite this, the facility's Social Worker had the resident sign a consent form for a community program without consulting the legal guardian. The incident occurred when the Social Worker, aware of the resident's legal guardianship, allowed the resident to sign a consent form for a program that assists with transitioning from a nursing home level of care and obtaining housing. The legal guardian was not informed until the resident expressed anxiety about the form they had signed. The guardian subsequently contacted the Social Worker to express concern and clarify that all consents should be obtained through her. The Social Worker later sent the consent form to the legal guardian for review and signature, 12 days after the resident had initially signed it.
Failure to Inform Resident of Toxicology Screen
Penalty
Summary
The facility failed to ensure that a resident was fully informed and understood their health status, care, and treatments. Specifically, the facility did not inform Resident #72 about a toxicology screen that was conducted. Resident #72, who was admitted with diagnoses including hypertension and chronic diastolic heart failure, was found to have moderate cognitive impairment but was still his/her own responsible party. During an interview, the resident expressed that he/she was unaware of the toxicology screen and did not consent to it, feeling that his/her rights were violated. The medical record showed that a toxicology screen was completed, resulting in negative findings for all substances. However, there was no documentation explaining why the screen was ordered, and the social worker confirmed that the resident was not followed by a substance use disorder counselor. The Director of Nurses acknowledged the lack of documentation and was unsure if consent was needed for the toxicology screen, despite there being a physician's order for it.
Failure to Respect Resident's Dignity During Room Searches
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect during room searches. The resident, who was admitted with diagnoses including hypertension and chronic diastolic heart failure, reported that their room was searched on two occasions without consent or explanation. The resident expressed that their personal belongings were disrespected during the searches, as items were removed from drawers and closets and not returned, leaving the room in disarray. The resident felt their rights were violated, and no rationale was provided for the searches, which were described as random. Interviews with facility staff revealed a lack of documentation and unclear reasoning for the room searches. The security staff member involved in the searches could not recall specific details about the resident's involvement, and the social worker confirmed that the resident was not followed by the substance use disorder counselor, questioning the necessity of the searches. The Director of Nursing acknowledged the absence of documentation to support the searches and could not recall the rationale behind them, indicating a failure in maintaining proper procedures and communication with the resident.
Failure to Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its policies and procedures regarding the potential misappropriation of resident property for one resident. Specifically, the facility did not investigate or report an allegation of a stolen wallet belonging to a resident. According to the facility's Grievance Policy and Abuse Prohibition Policy, any grievance involving misappropriation of property should be investigated and reported to the Administrator and the State Survey Agency within 24 hours. However, in this case, the grievance was not properly investigated or reported. The resident, who was cognitively intact, reported the loss of their wallet, which included a debit card and insurance cards. The grievance was logged, and a partial reimbursement was issued, but no further investigation was conducted. The resident later mentioned that someone attempted to use their debit card, and they suspected who might have stolen the wallet. Despite this, the Director of Nurses confirmed that no additional investigation or reporting to the state agency was carried out, which constitutes a failure to adhere to the facility's established policies.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report a potential misappropriation of property to the Department of Public Health within the required 24-hour timeframe, as mandated by federal guidelines. This deficiency involved a resident who reported a stolen wallet, which included a debit card and insurance cards. The grievance was filed on April 3, 2024, and was resolved on April 8, 2024, without being reported to the state agency. The facility's policy on abuse prohibition requires that any alleged violation involving misappropriation of resident property be reported immediately, but this protocol was not followed. The resident, who was cognitively intact, reported the incident to the social worker, who documented the grievance but did not conduct a thorough investigation or report the incident to the state agency. The Director of Nurses confirmed that the allegation was not reported. The resident mentioned that someone attempted to use their debit card for a charge, indicating potential misuse of the stolen property. Despite these details, the facility did not adhere to its policy of immediate reporting, resulting in a failure to comply with federal guidelines.
Failure to Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of property involving a resident's wallet. The resident, who was cognitively intact, reported the wallet missing, which contained a debit card and insurance cards. The grievance was logged by the Social Worker, and the Director of Nurses searched for the wallet but was unable to locate it. The facility's grievance policy requires that such allegations be investigated and reported, but no comprehensive investigation was conducted. The resident later reported that someone attempted to use their debit card, and they suspected they knew who stole the wallet. Despite this, the Social Worker and the Director of Nurses confirmed that no further investigation was carried out beyond the initial search and reimbursement of $30 to the resident. This lack of investigation is contrary to the facility's Abuse Prohibition Policy, which mandates a thorough investigation of such incidents.
Inaccurate MDS Assessment for Dialysis
Penalty
Summary
The facility failed to ensure that a Minimum Data Set (MDS) assessment was accurately completed for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, admitted in March 2024, was receiving dialysis treatments three times a week. However, the MDS assessment dated May 7, 2024, did not reflect that the resident was receiving these dialysis treatments. During an interview on June 27, 2024, the MDS Nurse acknowledged the oversight, stating she was unsure why the dialysis was not coded on the MDS, despite the resident's regular dialysis treatments. This was identified as an error, and a modification was needed to correct the MDS.
Failure to Address Pharmacist's Recommendation for A1c Test
Penalty
Summary
The facility failed to ensure that a monthly Medication Regimen Review (MRR) recommendation made by the pharmacy consultant was addressed in a timely manner and maintained as part of the permanent medical record for a resident with type 2 diabetes mellitus. The consultant pharmacist had recommended obtaining an A1c test to monitor the resident's blood sugar levels, but this recommendation was not acted upon or documented in the resident's medical record. The facility's policy requires that all findings and recommendations from the consultant pharmacist be reported to the Director of Nursing, the attending physician, the medical director, and the administrator, and that any resident-specific irregularities be documented in the resident's active record. The deficiency was identified during a survey when it was found that the recommendation made in March 2024 had not been addressed by the physician. The Nurse Manager stated that recommendations were placed in the physician's communication books for review, but the Director of Nursing confirmed that the recommendation had been missed and not addressed within the expected timeframe of one week. The resident was receiving medications Lantus and Jardiance for diabetes management, but the necessary follow-up to monitor therapy through an A1c test was not completed.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rockland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster Park Rehabilitation And Healthcare Center | 0.4 mi | ★★★★★ | 4 | 0 |
| Dwyer Home | 2.3 mi | ★★★★★ | 3 | 0 |
| Colony Center For Health And Rehabilitation | 2.6 mi | ★★★★★ | 1 | 0 |
| Southwood At Norwell Nursing Ctr | 3 mi | ★★★★★ | 9 | 0 |
| Queen Anne Nursing Home, Inc | 3.2 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.