Below average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Gardens At Cedarwood during CMS and state inspections, most recent first.
The facility did not submit required direct care staffing data to CMS for an entire quarter, as confirmed by review of policy, PBJ and CASPER reports, and multiple interviews with leadership. This resulted in no staffing data being reported, a one-star staffing rating, and documented gaps in RN and licensed nurse coverage.
A resident with schizophrenia and dementia, under legal guardianship, was administered antipsychotic medication without an active court-approved treatment plan, as required by facility policy. The expired treatment plan was not updated, and the resident continued to receive Clozapine without proper legal authorization.
A resident with a diagnosis of schizoaffective disorder was admitted after a psychiatric hospitalization without an accurate PASRR Level I screening, as the form failed to indicate the mental disorder and recent psychiatric stay, resulting in no Level II evaluation. The absence of a Social Worker overseeing the PASRR process contributed to the deficiency, as confirmed by the Administrator.
A resident with hypotension and dysphagia did not have pharmacy consultant recommendations regarding as-needed cough syrup and menthol lozenges addressed or documented in a timely manner. Recommendations made over two consecutive months were not communicated to the physician or acted upon until more than two months later, and the related reports were missing from the medical record.
A resident with a neurogenic bladder and indwelling Foley catheter was observed on multiple occasions with the catheter drainage bag lying directly on the floor, contrary to CDC guidelines and facility policy. Staff interviews confirmed knowledge that catheter bags should not touch the floor, yet the deficiency was observed during the survey.
The facility did not submit direct care staffing data to CMS for FY Quarter 1 2024. The CMS PBJ Staffing Data Report showed missing data for the quarter. Interviews revealed that the Nursing Staff Scheduler was unaware of the reporting responsibility, and Consulting Staff #5 identified missing data from October 1-15 due to previous owners' inaction. The Administrator was unaware of the issue before his employment, and Consulting Staff #4 confirmed the previous owners' failure to submit the data.
The facility failed to maintain an effective infection prevention and control program, lacking a system for tracking potential infections. A resident did not receive proper Enhanced Barrier Precautions (EBP) as staff failed to wear required PPE during high-contact care. Another resident was transferred without EBP, and staff were unaware of the necessary precautions. The facility had not fully implemented EBP despite receiving guidance.
The facility failed to maintain a clean and homelike environment, with surveyors observing broken heaters, stained curtains, and damaged windows across two care units. Interviews revealed a lack of awareness and systematic maintenance, with the Maintenance Director unaware of damages and the Administrator acknowledging inadequate rounding processes. The facility's policy on maintaining a safe environment was not effectively implemented, contributing to the deficiencies.
The facility failed to provide adequate supervision and an environment free from accidents for three residents. One resident experienced multiple falls without proper risk assessments or interventions. Another resident's care plan was not updated after falls, and a third resident was at risk for elopement due to incomplete assessments and expired wanderguard management.
The facility failed to provide proper respiratory care for four residents, including missing physician orders for oxygen therapy, lack of respiratory care plans, and improper storage and maintenance of nebulizer and oxygen equipment. Observations revealed outdated and unclean equipment, and interviews with staff confirmed these deficiencies.
The facility failed to address and document pharmacy consultant recommendations for three residents, leading to unaddressed medication regimen reviews. A resident's antipsychotic medication diagnosis was not updated timely, another resident did not receive a necessary AIMS assessment, and a third resident's medication dosages and PRN usage were not reviewed as recommended. The DON acknowledged the lack of a tracking system for these recommendations.
The facility failed to ensure proper medication administration and storage, leading to deficiencies. A resident with cognitive impairment had medications left unattended without an order to self-administer. Medication carts were observed unlocked and unattended, contrary to policy. Additionally, medications were improperly stored, with loose pills left uncovered and unlabeled. The DON confirmed these practices were against facility policy.
The facility failed to provide pneumococcal vaccinations to three residents as per policy and CDC guidelines. The residents' records lacked documentation of screening, eligibility assessment, and education, with consent forms left incomplete. An IPN confirmed these deficiencies, noting the residents were not up to date with their vaccinations.
The facility failed to provide timely and appropriate Medicare coverage notices to two residents, resulting in their health care proxies not being informed about the appeal process for services ending. Incorrect forms were issued, and notifications were inadequately communicated, leading to missed appeal opportunities.
The facility failed to develop and implement baseline care plans within 48 hours of admission for two residents, one with respiratory failure and another with PTSD. The first resident did not receive a written summary of their care plan, while the second resident's PTSD was not addressed in their care plan, leading to unmet needs and potential distress. Staff interviews revealed a lack of awareness and execution of care planning policies.
A resident with severe cognitive impairment and a history of falls did not receive the prescribed interventions from their Falls Care Plan. Observations showed missing non-skid strips and incorrect placement of Dycem on the wheelchair cushion. Staff interviews confirmed these oversights, attributing them to a room change, but acknowledged that interventions should have followed the resident.
A resident dependent on staff for ADLs and personal hygiene was found with long, dirty fingernails, indicating a failure in nail care provision. Despite being cognitively intact and expressing embarrassment over their nail condition, there was no documentation of recent nail care or refusal of such care. Interviews with CNAs and nursing staff revealed inconsistencies in nail care practices, with no specific schedule or documentation, leading to the deficiency.
The facility failed to provide proper catheter care for three residents, including not assessing the need for a Foley catheter, lacking physician orders for catheter care, and improperly positioning catheter bags above the bladder. These actions led to deficiencies in catheter management and increased risk of complications.
A resident with PTSD and depression did not receive trauma-informed care at the facility. The resident's PTSD was not documented in the Nursing Admission Assessment, and no PTSD Assessment was completed. Consequently, no care plan was developed to identify and mitigate trauma triggers. Interviews revealed that the resident was not asked about their trauma or potential triggers, and staff confirmed the absence of a care plan, failing to follow facility policy and guidelines.
A resident with severe cognitive impairment and anxiety was prescribed PRN Lorazepam without a stop or re-evaluation date, contrary to the facility's policy requiring re-evaluation after 14 days. The order was left open-ended, and the facility did not provide the full pharmacist recommendation. Interviews confirmed the need for clarification and re-evaluation.
The facility failed to ensure accurate MDS assessments for three residents. A resident's falls were not documented, another's hospice status was omitted, and a third resident's Foley catheter use was not recorded. MDS Nurse #1 acknowledged these inaccuracies during interviews.
A facility failed to maintain accurate medical records for a resident, as their electronic medical record contained documents not relevant to them. An informed consent document was scanned multiple times into the record, but it was actually a consent to treat for another resident. The DON and medical records staff confirmed the error.
A resident with a DVT did not receive the prescribed anticoagulant medication due to a pharmacy delay, and the Physician was not notified. The resident's condition worsened, leading to hospitalization and emergency surgery.
A resident with deep vein thrombosis (DVT) did not receive their prescribed anticoagulant medication, Eliquis, in a timely manner due to a nurse selecting the wrong pharmacy in the electronic medical record system. The error was not identified or corrected, resulting in the resident's hospitalization for increased pain and skin color changes in the affected leg.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing data to CMS for the entire reporting period of Fiscal Year Quarter 2 2025, as required by federal regulations. Review of the facility's policy indicated that it is their standard to submit timely and accurate staffing information, including agency and contract staff, in the format and schedule specified by CMS. However, the PBJ Staffing Report and CASPER Report 1705D for the relevant quarter showed that no data was submitted, resulting in a one-star staffing rating, excessively low weekend staffing, multiple days with no RN hours, and several days without 24-hour licensed nurse coverage. Interviews with facility leadership revealed that there was confusion and miscommunication regarding the submission of PBJ data. The Administrator initially believed the data had been reported but could not provide evidence of submission. The Director of Operations acknowledged an issue affecting all company buildings and stated that they were in contact with CMS. The Regional Clinical Nurse explained that the person responsible for PBJ submissions had been terminated about a month prior, and the company was under the impression that the data had been submitted. Ultimately, the Administrator confirmed that corporate was responsible for the submission, but it had not occurred for the specified quarter.
Antipsychotic Medication Administered Without Active Court-Approved Treatment Plan
Penalty
Summary
The facility failed to ensure that a court-approved treatment plan for the administration of antipsychotic medication was active and current for a resident with a legal guardian. The facility's policy requires that residents with guardians must have a valid court-approved treatment plan in place before antipsychotic medications can be administered. Record review showed that the resident, who had diagnoses including schizophrenia and dementia, was under guardianship and had previously been authorized to receive antipsychotic medication through a court-approved treatment plan. However, this treatment plan had expired, and there was no updated or current plan in the medical record. Despite the expiration of the treatment plan, the resident continued to receive Clozapine as ordered by the physician, as documented in the Medication Administration Records. Interviews with the Administrator confirmed that there was no active or updated court-approved treatment plan available, and the most recent plan had expired. The facility did not have a social worker at the time, and efforts to locate or update the necessary documentation were unsuccessful.
Failure to Accurately Complete PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a Preadmission Screening and Resident Review (PASRR) was accurately completed prior to the admission of a resident with a known mental disorder. The resident was admitted following a seven-week psychiatric hospitalization and had a diagnosis of schizoaffective disorder. However, the PASRR Level I screening form did not indicate the presence of this mental disorder, as the relevant box for schizoaffective disorder was not checked. Additionally, the form did not reflect the recent inpatient psychiatric hospitalization, and the screening results were marked as negative for serious mental illness (SMI), leading to no Level II PASRR evaluation being conducted. Further review revealed that there was no additional information in the PASRR electronic portal or with the PASRR office regarding the Level I screen for this resident, and no evidence of a Level II PASRR evaluation. During an interview, the Administrator confirmed the absence of a Social Worker responsible for PASRR oversight at the time, which contributed to the failure in the screening process. The deficiency was identified through record review and staff interview.
Failure to Timely Address Pharmacy Consultant Recommendations
Penalty
Summary
The facility failed to ensure that monthly medication regimen review (MRR) recommendations made by the pharmacy consultant were communicated to the physician and addressed in a timely manner for one resident. Specifically, recommendations made in August and September 2024 to evaluate the continued use of as-needed Geri-tussin (cough syrup) and menthol lozenge were not reviewed or responded to by the provider until November 4, 2024, which was 80 days after the initial recommendation. The pharmacy consultant's reports from August and September were also not found in the resident's medical record, indicating a lapse in documentation and follow-through with established policy requirements. The resident involved had a history of hypotension and dysphagia and had been prescribed Geri-tussin syrup and menthol lozenges on an as-needed basis, both of which were discontinued on November 4, 2024. Facility policy required that pharmacy consultant recommendations be acted upon within relevant time frames and documented in the resident's medical record. During an interview, the DON confirmed that the recommendations were not addressed in a timely manner and that the relevant reports could not be located in the resident's record.
Failure to Maintain Sanitary Foley Catheter Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program as required, specifically in the care of a resident with an indwelling Foley catheter. Observations on two separate dates revealed that the resident's catheter drainage bag was not attached to the bed and was lying directly on the floor without any protective barrier. This practice was not in accordance with both CDC guidelines and the facility's own policy, which require that catheter bags be kept off the floor and below the level of the bladder to prevent contamination. The resident involved had a history of urinary retention and neuromuscular dysfunction of the bladder, necessitating the use of an indwelling urinary catheter. Documentation confirmed the presence of physician orders and care plans for catheter care. Interviews with multiple staff members, including CNAs, a nurse, and the Director of Nurses, consistently indicated awareness that catheter bags should be hanging from the bed or wheelchair and not resting on the floor. Despite this, the deficiency was observed during the survey.
Failure to Submit Direct Care Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit direct care staffing data to the Centers for Medicare and Medicaid Services (CMS) for the entire reporting period of Fiscal Year Quarter 1 2024, which spans from October 1 to December 31. This deficiency was identified through a review of the CMS Payroll Based Journal (PBJ) Staffing Data Report, CASPER Report 1705D, which indicated that the facility did not submit the required data for the quarter. Interviews conducted on May 8, 2024, revealed that the Nursing Staff Scheduler was unaware of who was responsible for PBJ reporting. Consulting Staff #5 noted that data from October 1-15 was missing, likely due to the previous owners not filing it, which resulted in the data submission being incomplete. The Administrator, who was not aware of the reporting status before his employment, deferred questions to Consulting Staff #4, who confirmed that the previous owners should have submitted the data but was unsure why it was not done.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of a complete system of surveillance to identify trends of actual or potential infections. The Infection Preventionist (IP) admitted to not keeping a line listing of illnesses that do not require antibiotics, and there was no documentation of daily surveillance activities. This lack of documentation and tracking hindered the facility's ability to identify and address potential spreads of illnesses among residents, employees, and visitors. For Resident #36, the facility did not ensure that staff wore the required personal protective equipment (PPE) for Enhanced Barrier Precautions (EBP). A Certified Nursing Assistant (CNA) was observed providing high-contact care without wearing a gown, despite a sign indicating the need for both a gown and gloves. The CNA was unaware of the resident's precaution status, and the CNA care card did not reflect the necessary precautions. The Director of Nursing (DON) acknowledged the oversight and noted that staff education on EBP had not been completed. Resident #160 was also not provided with the necessary EBP, as staff members were observed transferring the resident without wearing gowns. There was no EBP sign or PPE available near the resident's room, and the comprehensive care plan did not include EBP. Interviews with staff revealed a lack of understanding and implementation of EBP, with the DON confirming that the facility had not yet rolled out the necessary precautions, despite receiving guidance from CMS and CDC.
Facility Fails to Maintain Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, comfortable, and homelike environment for its residents, as observed by surveyors. The surveyors noted multiple deficiencies across two resident care units, including broken baseboard heaters, dirty and stained window curtains, broken window blinds, and rust around bathroom fixtures. Additionally, there were instances of cracked and broken windows, scuffed walls, and damaged furniture, all of which contributed to an environment that was not well-kept or homelike. Interviews with facility staff revealed a lack of awareness and a systematic approach to addressing these issues. The Maintenance Director admitted to not having a schedule for routine maintenance rounds and was unaware of the damages until shown by the surveyor. The Administrator acknowledged that the facility's rounding process was inadequate and that the Maintenance Director was not involved in it. Furthermore, the Administrator noted that while department heads were assigned to check rooms and areas, there was no effective tracking process for these checks, resulting in unaddressed concerns. The facility's policy on maintaining a safe and homelike environment was not effectively implemented, as evidenced by the numerous environmental issues observed. The lack of a preventative maintenance policy and the absence of a structured process for identifying and addressing maintenance concerns contributed to the deficiencies. The Administrator recognized the need for improvement in the rounding process and acknowledged that the current state of the rooms was not homelike and posed safety concerns.
Failure to Prevent Falls and Elopement Risks
Penalty
Summary
The facility failed to provide adequate supervision and an environment free from accidents and hazards for three residents. For one resident, the facility did not follow its fall reduction policy by failing to investigate falls and implement fall prevention interventions. This resident experienced multiple falls, and the medical record did not show any completed fall risk assessments or interventions post-fall. The interdisciplinary care plan was not updated with new interventions after each fall, and the resident's health care proxy expressed concerns about the lack of communication and preventive measures. Another resident also experienced falls, and the facility did not develop or implement interventions to prevent recurrence. The medical record showed an incomplete fall risk assessment, and the interdisciplinary care plan was not updated with new interventions. Interviews with staff revealed that the expected procedures for updating care plans and implementing interventions were not followed, leaving the resident at risk for further falls. The facility also failed to follow its policy for managing elopement and wandering risks for a third resident. The resident had a history of elopement, but the facility did not complete an elopement risk screen upon the resident's return. The care plan lacked comprehensive interventions to prevent elopement, and the wanderguard device was not properly managed, as it was expired and not securely placed on the resident. Interviews with staff indicated that the necessary assessments and interventions were not completed, leaving the resident at risk for further elopement.
Deficiencies in Respiratory Care and Equipment Management
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for four residents. For Resident #53, there was no physician's order for oxygen therapy despite the resident receiving it since admission. The oxygen equipment was not changed according to the facility's policy, as observed by the surveyor. Interviews with the resident, a nurse, consulting staff, and the Director of Nurses (DON) confirmed the absence of a necessary physician's order for oxygen therapy. Resident #54 did not have a respiratory care plan developed, and the nebulizer equipment was not stored or changed per policy. The nebulizer face mask was observed hanging off the nightstand and later in a drawer with personal belongings, both times unbagged, and the tubing had not been changed since admission. The resident confirmed frequent use of the nebulizer and was unsure about the tubing change frequency. Interviews with the resident and staff highlighted the lack of equipment management and care plan. For Resident #34, the nebulizer equipment was not clean, and the mask and tubing were not stored per policy. The nebulizer machine was observed with dust and debris, and the mask and tubing were left unbagged. Nurse #1 acknowledged the improper storage of the equipment. Resident #1's oxygen equipment was not changed per policy, with tubing appearing old and dirty, and the humidifier bottle was unlabeled and empty. Nurse #1 confirmed the tubing was overdue for a change, posing an infection control risk. Interviews with staff, including the DON, revealed a lack of proper orders and adherence to equipment change schedules.
Failure to Address and Document Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for three residents. Specifically, the facility did not act upon or document the recommendations for Residents #21, #9, and #19, which included updating diagnoses, conducting necessary assessments, and reviewing medication dosages. The Director of Nursing (DON) acknowledged the absence of a tracking method to ensure recommendations were addressed and admitted that previous MRRs were not kept as part of the residents' medical records. For Resident #21, the facility did not address the consultant pharmacist's recommendations from January to March 2024 until May 2024. These recommendations included updating the diagnosis for the antipsychotic medication Seroquel and addressing the use of psychoactive PRN Trazodone. The recommendations were not signed by the physician until May 3, 2024, indicating a delay in addressing the pharmacist's suggestions. The DON confirmed that the recommendations were not scanned into the medical record or acted upon in a timely manner. Resident #9 was prescribed Olanzapine for mood disorder, and the pharmacy consultant recommended an AIMS assessment to monitor for tardive dyskinesia. However, the facility failed to include this recommendation in the resident's medical record, and the assessment was not completed. Similarly, for Resident #19, the facility did not act on recommendations to review the dosage of Escitalopram and the use of as-needed medications like Benadryl, Cepacol, and Mucinex. The recommendations were not documented or addressed, and the physician's response was incomplete.
Medication Administration and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper medication administration and storage practices, leading to several deficiencies. For Resident #50, medications were left at the bedside without direct supervision, despite the resident not having an order or assessment to self-administer medications. This resident, who has moderate cognitive impairment and a history of hepatic encephalopathy, was observed with medication cups containing lactulose left unattended in their room. The facility's policy requires that medications be administered under supervision, and there was no documentation supporting the resident's ability to self-administer, which was confirmed by the Director of Nurses (DON). Additionally, medication and treatment carts on Unit One were repeatedly observed unlocked and unattended, with residents roaming the halls. This occurred on multiple occasions, with carts left in hallways and common areas without staff supervision. The facility's policy mandates that medication carts be locked when not in use, a requirement that was not adhered to, as confirmed by interviews with nursing staff and the DON. Furthermore, medications were improperly stored on top of medication carts and within the carts themselves. Observations included loose pills left uncovered and unlabeled, both on top of and inside the carts. Nurses admitted to leaving medications unsecured and failing to destroy or properly document unused medications. The DON confirmed that medications should be administered immediately once prepared and that any unused medications should be destroyed and documented accordingly.
Failure to Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adhere to its policy and CDC recommendations regarding pneumococcal vaccinations for three residents. The policy required offering and administering the vaccine to eligible individuals, providing education, obtaining consent, and documenting the process. However, for Residents #9, #13, and #34, there was no documentation of screening, assessment for eligibility, or education provided. Additionally, the consent forms for these residents were blank and incomplete, indicating a lack of compliance with the facility's vaccination procedures. Resident #9, admitted in April 2024, had no record of receiving any pneumococcal vaccinations, and the medical record lacked necessary documentation. Resident #13, eligible for the PCV20 vaccine, also had incomplete documentation and no evidence of receiving the vaccine. Resident #34, with a diagnosis of COPD, similarly had no record of receiving the pneumococcal vaccine and incomplete documentation. The Infection Preventionist Nurse confirmed these deficiencies during an interview, acknowledging that the residents were not up to date with their vaccinations as per the facility's policy.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide timely and appropriate notifications regarding Medicare coverage and potential liability for services not covered, specifically for two residents. The facility did not issue the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, and failed to issue and explain the Notice of Medicare Non-Coverage (NOMNC), Form CMS 10123, in a timely manner. This resulted in the residents and their health care proxies (HCPs) not being informed about the appeal process for services that were ending. For Resident #21, the facility did not provide the SNF ABN and instead issued the incorrect form, ABN, Form CMS-R131. The NOMNC was communicated via a voicemail, and there was no evidence that a physical copy was mailed or that a discussion took place with the HCP. The HCP was not informed about the appeal rights and expressed a desire to appeal the decision, as the resident was previously walking and eating a regular diet. The facility later found proof that the forms were received via certified mail, but this was after the appeal window had closed. Similarly, for Resident #49, the facility failed to provide the correct SNF ABN and issued the ABN, Form CMS-R131 instead. The NOMNC was communicated through a phone call, and there was no documentation that the HCP was aware of the appeal rights. The HCP was not notified about the resident coming off skilled services and expressed interest in appealing, but was informed that the appeal window had closed. The facility did not have signed copies of the forms or evidence that the documents were mailed, indicating that the process was not followed correctly.
Failure to Develop Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement to ensure effective and person-centered care. For one resident, who was admitted with respiratory failure and required supplemental oxygen, the facility did not provide a written summary of the baseline care plan. The resident, who was cognitively intact, reported not having a meeting or receiving any documentation regarding their care plan. Interviews with facility staff revealed a lack of awareness and execution of the policy to provide residents with a copy of their baseline care plan. Another resident, admitted with PTSD and depression, did not have a baseline care plan developed for their PTSD. The facility's policy on trauma-informed care was not followed, as there was no assessment or identification of triggers that could re-traumatize the resident. The resident expressed that no one had discussed their PTSD or potential triggers, which caused them anxiety. Interviews with staff indicated that the necessary assessments and care plans were not completed, and there was a lack of understanding of the facility's policy and regulatory guidelines. The deficiencies highlight a failure in the facility's processes to ensure timely and appropriate care planning for new admissions. The lack of baseline care plans and communication with residents about their care needs and preferences resulted in unmet immediate needs and potential distress for the residents involved.
Failure to Implement Falls Care Plan Interventions
Penalty
Summary
The facility failed to implement interventions on the Falls Care Plan for a resident, leading to a deficiency in meeting the resident's physical, psychosocial, and functional needs. The resident, admitted in January 2024, had diagnoses including dementia, muscle weakness, unsteadiness on feet, and a history of a right hip traumatic fracture. The Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of recent falls. The care plan included interventions such as placing non-skid strips next to the bed and in front of the closet, and using Dycem on the wheelchair cushion to prevent falls. Observations by the surveyor revealed that these interventions were not implemented. On multiple occasions, the surveyor noted the absence of non-skid strips and the incorrect placement of Dycem under the wheelchair cushion instead of on top. Interviews with nursing staff and the Director of Nurses confirmed the lack of adherence to the care plan, with explanations suggesting a room change might have contributed to the oversight. However, the expectation was that interventions should follow the resident with any room changes, which did not occur in this case.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to provide adequate nail care for a resident who was dependent on staff for activities of daily living (ADLs) and personal hygiene. The resident, who was cognitively intact, expressed embarrassment over the condition of their long and dirty fingernails, which had not been trimmed or cleaned by staff. Despite being dependent on staff for grooming, the facility's documentation did not indicate when the resident last received nail care, nor did it document any refusal of such care by the resident. Interviews with Certified Nurse Assistants (CNAs) and nursing staff revealed inconsistencies in the provision of nail care. While CNAs acknowledged that nail care should be performed during shower days or as needed, there was no specific schedule or documentation of nail care being provided. The Director of Nursing (DON) confirmed that staff are expected to assess and address nail care needs during daily care and shower days, and any refusal of care should be documented. However, the lack of documentation and the resident's reports indicate that these procedures were not consistently followed, leading to the deficiency.
Deficiencies in Catheter Care and Management
Penalty
Summary
The facility failed to provide appropriate indwelling catheter care and management for three residents, leading to deficiencies in catheter assessment, care orders, and positioning. For one resident, the facility did not assess the necessity of a Foley catheter upon admission, nor did it attempt a voiding trial or consult with a urologist to determine the need for continued catheter use. The resident expressed a desire to have the catheter removed, but no explanation or action was taken by the facility staff. Another resident was admitted with a Foley catheter, but the facility failed to have physician orders for the catheter and its care. Observations showed that the catheter drainage bag was repeatedly positioned above the bladder, attached to the armrest of the resident's wheelchair, which is contrary to best practices for preventing urinary tract infections. Despite multiple interactions with staff, the improper positioning of the catheter bag was not corrected. A third resident also had a Foley catheter drainage bag improperly positioned above the bladder on the wheelchair armrest. This occurred multiple times, with various staff members failing to adjust the bag despite interacting with the resident. The resident indicated that staff placed the bag on the armrest, contradicting a staff member's claim that the resident did it independently. The facility's care plan did not reflect any resident preference for this positioning, indicating a lack of proper documentation and adherence to care protocols.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for Resident #109, who was diagnosed with post-traumatic stress disorder (PTSD) and depression. Upon admission in April 2024, the Nursing Admission Assessment did not indicate a diagnosis of PTSD, although the Minimum Data Set (MDS) assessment later confirmed it. The Social Services Assessment was incomplete, and there was no evidence of a PTSD Assessment being conducted. Consequently, the facility did not develop a baseline or comprehensive care plan to identify and mitigate potential trauma triggers for Resident #109. Interviews revealed that Resident #109 had not been asked about their PTSD, the nature of their trauma, or potential triggers. The resident expressed anxiety about being in closed spaces with males and indicated that no measures had been discussed to prevent re-traumatization. The Social Worker admitted to not completing a PTSD assessment and acknowledged the absence of a care plan for PTSD, which should have been in place to identify and avoid triggers. Nurse #1 confirmed the lack of a PTSD care plan in the resident's medical record, indicating a failure to adhere to facility policy and regulatory guidelines.
Failure to Re-evaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident's PRN psychotropic medication, Lorazepam, was re-evaluated 14 days after it was prescribed, as required by standard practice. The resident, who was admitted with diagnoses including dementia, mood disorder, anxiety, and epilepsy, had a severe cognitive impairment and anxiety. The physician's order for Lorazepam did not include a stop date or re-evaluation date, which is a requirement for PRN psychotropic medications. The facility's policy mandates that all psychotropic PRN medications should be written for 14 days only and then re-evaluated. However, the Lorazepam order was left open-ended, contrary to the policy. The Consultant Pharmacist's note indicated the need to evaluate the PRN Lorazepam, but the facility did not provide the full recommendation to the surveyor. Interviews with the DON and consulting staff confirmed that the order should have been clarified and re-evaluated after 14 days, as it was not intended for seizure management.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of three residents. For Resident #4, the MDS assessment did not document three falls that occurred within the facility, despite the resident's medical record indicating these incidents. MDS Nurse #1 acknowledged the oversight during an interview and confirmed that the falls should have been recorded in the MDS assessment. Resident #1's MDS assessment inaccurately reflected the resident's hospice status. Although the medical record showed that the resident was receiving hospice services with a prognosis of less than six months, the MDS assessment failed to document this information. Similarly, for Resident #160, the MDS assessment did not indicate the presence of an indwelling Foley catheter, which was noted in the resident's admission assessment and care plan. MDS Nurse #1 admitted that these details were not correctly documented and required modification for accuracy.
Inaccurate Medical Record Maintenance
Penalty
Summary
The facility failed to maintain medical records securely and accurately for one resident, leading to a deficiency. Specifically, the electronic medical record of a resident contained documents that were not relevant to them. An informed consent document for psychotropic medication was scanned into the resident's record 14 times, and upon review, it was found that the document was not an informed consent for psychotropics. Further examination revealed that the document was actually a consent to treat for another resident. During interviews, both the Director of Nurses and a medical records staff member acknowledged that these documents were incorrectly placed in the resident's medical record and should not have been there.
Failure to Notify Physician of Medication Unavailability
Penalty
Summary
The Facility failed to ensure that Resident #1's Physician was notified when the prescribed anticoagulant medication, Eliquis, was unavailable for administration. Resident #1, who had been diagnosed with a deep vein thrombosis (DVT) in the left lower extremity, did not receive the first scheduled dose of Eliquis due to a delay in delivery from the pharmacy. Nurse #1 documented the unavailability of the medication but did not inform the Physician, assuming the medication would arrive with the next scheduled delivery. On the following day, Resident #1 experienced increased pain, swelling, and discoloration in the left lower extremity. Despite the worsening condition, the Physician was still not notified. The MDS Coordinator assessed Resident #1 and recommended immediate transfer to the Hospital Emergency Department (ED) due to the absence of the necessary medication and the resident's deteriorating condition. The resident was subsequently diagnosed with an acute arterial thrombosis and underwent emergency surgery. Interviews with the Nurse Practitioner, MDS Coordinator, and Director of Nurses confirmed that the Physician was not informed about the unavailability of Eliquis. The Facility's policy mandates that significant changes in a resident's condition or treatment must be communicated to the Physician, which was not adhered to in this case. This lapse in communication and failure to administer the prescribed medication led to Resident #1's hospitalization and emergency surgical intervention.
Failure to Administer Anticoagulant Medication Timely
Penalty
Summary
The facility failed to ensure that a resident diagnosed with deep vein thrombosis (DVT) received their prescribed anticoagulant medication, Eliquis, in a timely manner. The Nurse Practitioner (NP) ordered Eliquis for the resident after an ultrasound confirmed the presence of a DVT. However, the nurse responsible for entering the medication order into the electronic medical record system (Point Click Care/PCC) mistakenly selected Pharmacy B instead of Pharmacy A, which the facility uses. This error resulted in the medication order being marked as 'profile only,' meaning it was not filled by the pharmacy. The nurse did not realize that the order had been sent to the wrong pharmacy and did not follow up to ensure the medication was delivered. As a result, the resident did not receive the first scheduled dose of Eliquis. The resident experienced increased pain and skin color changes in the affected leg, leading to their transfer to the hospital for evaluation. The Director of Nursing (DON) and the Chief Nursing Officer (CNO) later discovered the error during a review of the resident's medical record and communication with the pharmacy. Interviews with the nursing staff revealed that there was confusion about the pharmacy selection process in the PCC system. The nurse who entered the order was unaware that there were two pharmacies listed and did not know that selecting the wrong pharmacy would prevent the order from being filled. The facility's policies require timely notification and follow-up with the pharmacy for medication orders, but these steps were not adequately followed in this case, leading to the resident's hospitalization.
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Nursing homes near Franklin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alliance Health At Maples | 3.3 mi | ★★★★★ | 6 | 0 |
| Serenity Hill Nursing Center | 4 mi | ★★★★★ | 18 | 0 |
| Mount St Rita Health Centre | 4.8 mi | ★★★★★ | 8 | 0 |
| Medway Country Manor Skilled Nursing & Rehabilitat | 5.4 mi | — | 9 | 0 |
| Woonsocket Health Center | 7.3 mi | ★★★★★ | 0 | 0 |
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