Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Alamo Cove Rehab And Nursing Center during CMS and state inspections, most recent first.
Insufficient Nursing Staffing and Delayed Call Light Response: Residents reported long waits for help, delayed toileting and morning care, and repeated call light delays while the north hall was often staffed with only 2 CNAs for 24 to 28 residents and the shower aide was pulled to cover openings. A cognitively intact resident with MS, anxiety, and depression said she was often not gotten up until late morning, another resident who was legally blind reported sitting in stool or urine while waiting for help, and a third resident with diabetes and depression reported waiting more than 30 minutes and once 3 hours for bathroom assistance. Surveyors also observed active call lights left unanswered for extended periods, and 9 of 11 residents in a confidential council meeting reported regular waits of more than 30 minutes.
Facility assessment was not updated to reflect current staffing concerns. The assessment still contained staffing input from an earlier period and described staffing decisions based on census, resident acuity, transfer status, and hall location, but survey interviews with the DON, RNC, and RDO showed no updated staffing information could be identified from the most recent assessment meeting. The facility policy required the assessment to be reviewed and updated as necessary and at least annually.
Infection control practices were not maintained for residents on contact isolation and EBP, as staff entered rooms without proper PPE use, failed to perform hand hygiene, and mishandled PPE disposal. A resident’s nebulizer was stored improperly, an LPN gave insulin without gloves or hand hygiene, shared equipment was not cleaned between uses, oxygen tubing was left on the floor, and a water-pass ice cooler was left accessible for resident use with unsanitary handling of the scoop and cups.
Facility cleanliness and maintenance issues were observed throughout the building. A resident’s room had an open window with no screen, dirt on surfaces, and the resident reported grass and dirt on the bed after returning from an appointment. Staff observed strong urine odors in rooms and hallways, dusty pedestal fans blowing directly at residents, and a housekeeper mopping without placing wet floor signs. Broken or missing handrail parts, a broken bed in the hallway, debris near dumpsters, and missing window screens were also noted.
Delayed Response to Grievances for Call Lights and Missing Belongings: A cognitively intact resident with DM and depression reported repeated call light waits of more than 30 minutes, sometimes forcing her to toilet herself despite not feeling safe, and also reported missing clothing and personal items that had gone unresolved for months. A family member said she filed grievances about the call light delays and missing items without resolution, and most residents in a confidential meeting reported the same long wait times and prior grievances that had not improved.
Failure to Sustain Pressure Ulcer Prevention Monitoring: A resident who was dependent for mobility and at risk for pressure ulcers was repeatedly observed sitting in a broda chair without ordered heel protectors in place, with her heels directly contacting the chair foot cradle. The care plan required off-loading boots to both lower extremities at all times as tolerated, but staff and family reported the boots shifted or were not consistently on. The DON stated audits focused on wound tx orders and completion, and the facility was not using direct observation to monitor whether pressure ulcer prevention interventions were actually being implemented.
Delayed Response to Call Lights and Toileting Needs: Residents with cognitive impairment and incontinence reported long waits for call lights and assistance with toileting or brief changes. A resident with depression said he waited over an hour and soiled his brief while waiting; another resident with depression and anxiety said he waited an hour for a brief change and felt dirty; a third resident with legal blindness reported sitting in urine and feces while waiting for help, and family had also complained that staff did not respond to the call button.
Failure to Assess Residents for Self-Administration of Medications: Two residents were found with nasal spray medications left in their rooms and using them without documented self-administration assessments or orders. One cognitively intact resident with heart failure had ipratropium bromide nasal solution on her dresser and reported using both her own bottle and the facility’s bottle, while another resident with COPD had fluticasone nasal spray left on an over-the-bed table and reported nurses left it for her to use. Staff and the DON confirmed there was no assessment, care plan, or order for self-administration.
A cognitively intact resident with MS, anxiety, and depression reported that staff often did not help her get up by her preferred 10 AM time, with many mornings delayed until 11 AM or later. She said the unit was short-staffed, the shower aide was often pulled, and a grievance did not resolve the issue. Record review and interviews confirmed the delays were tied to staffing problems, despite the facility policy requiring flexibility for resident choices.
Failure to Notify Responsible Party of Change in Condition After Fall: A resident with cognitive impairment was found on the floor with left shoulder pain, and stat x-rays of the left hip and shoulder were ordered. The x-ray results showed no fracture or dislocation, but the resident’s representative was not documented as being notified of the results. The FM reported not being told what was wrong or whether the x-rays had been done, and the DON later said the FM was called after the fact. The resident’s care plan listed multiple fall risk factors, but no immediate safety intervention was added after the fall.
A resident with a Foley catheter and intact cognition had an EBP sign posted and an order for EBP every shift, but the care plan did not include EBP. The DON acknowledged the missing care plan, while the facility policy required the IDT to develop and revise a comprehensive care plan for each resident.
A resident with CHF and peripheral vascular disease had a care plan that still listed max assist for transfers and ambulation, even though the MDS and staff interviews showed the resident was cognitively intact and currently able to transfer and ambulate with standby assist. During observation, the resident walked in the hall with a wheeled walker while a therapy staff member provided no physical assistance. The ADON confirmed the care plan did not accurately reflect the resident’s current level of independence.
Failure to provide appropriate pressure ulcer care occurred when staff did not keep a resident's heel protectors in place as ordered. The resident had dementia, was dependent on staff for mobility, and was at risk for pressure ulcers; her care plan and order required heel protector boots at all times. She was observed multiple times sitting in a broda chair without the boots, with her heels directly contacting the chair foot cradle, while the MAR documented the intervention as completed and the DON stated nurses and CNAs were responsible for ensuring the boots were in place.
Two residents were involved in unsafe conditions that were observed by surveyors. One resident with CHF and PVD, who needed assistance for transfers and ambulation, was seen walking with a walker but without a gait belt, despite staff confirming that non-independent residents should use one. Another resident with HTN, CVA, vertigo, and severe cognitive impairment was left with her walker out of reach while a housekeeper mopped her room, no wet floor sign was placed, and the resident later walked into the hallway without her walker while the floor was still wet.
Dialysis communication and assessment were not consistently maintained for a resident receiving hemodialysis. The resident had diabetes and renal failure, with care plan instructions for dialysis transport, AV shunt monitoring, and reporting changes to the dialysis center. The dialysis communication form was only completed part of the time, one form was left blank by the facility, and the record lacked pre- and post-dialysis assessments. The resident and staff both reported gaps in the exchange of dialysis information, including missing return assessments and incomplete communication forms.
Missing Pharmacy Recommendation for Monthly MRR: The facility could not locate a pharmacy recommendation for a resident’s monthly MRR despite the pharmacist documenting that chart review was completed and recommendations were sent to the physician. The resident had multiple mental health diagnoses and was cognitively intact, and the DON and NHA both confirmed the recommendation could not be found in the chart.
Medication administration errors exceeded the allowed rate, with two residents involved. An LPN failed to correctly administer or document ordered meds during a med pass, including Lasix for one resident and lactated ringers and requested PRN pain medication for another resident; the MARs later showed conflicting documentation for the ordered treatments.
A resident admitted with intact skin, high risk for pressure injury, and total dependence for care was care planned for pressure ulcer prevention but did not consistently receive required assessments, skin checks, or q2h repositioning. Hospital records documented sacral/coccyx and heel pressure injuries that were not recorded on facility re‑admission assessments, and facility skin documentation initially described new gluteal abrasions later recognized as part of an unstageable coccyx pressure ulcer. Wound care orders for the coccyx and other pressure injuries were delayed or incompletely documented, with multiple missing entries on the treatment record. Staff interviews confirmed frequent missed showers, skin assessments, repositioning, and treatments due to staffing issues, while family reported never seeing staff reposition the resident and repeatedly raising concerns that were not effectively addressed, resulting in the development and worsening of multiple pressure ulcers.
Two residents experienced significant medication errors when ordered drugs were not administered in accordance with physician orders and facility policy. A resident with diabetes had insulin doses increased and then received short‑acting insulin late and only 2.5 hours apart, without the LPN confirming pre‑meal blood glucose or food intake, despite a prior severe hypoglycemic episode that was not brought to a provider for assessment or insulin adjustment. Another resident with epilepsy missed multiple doses of Keppra and valproic acid over several days due to refusal and dysphagia, with staff documenting lethargy, poor responsiveness, inability to swallow, and seizure activity, yet there was no documented provider notification about the repeated missed antiepileptic doses until an LPN, alerted by a CNA, assessed swallowing difficulty and arranged hospital transfer. These actions and omissions conflicted with the facility’s medication administration and change‑in‑condition policies, which required timely administration, documentation, and provider notification for missed doses and acute changes.
Multiple residents who required assistance with ADLs, including those with TBI, MS, dementia, chronic pain, and mobility deficits, did not consistently receive scheduled showers or bed baths, and refusals were not reliably documented. One resident was admitted to the hospital soaked in urine with crusting around the eye and mouth, while a family member reported the resident was frequently disheveled, in soiled or double briefs, and often missed scheduled showers despite repeated complaints to staff and management. Staff, including LPNs, CNAs, and the shower aide, reported that short staffing, frequent reassignment of the shower aide to the floor, and an excessive number of scheduled showers led to missed ADL care. Documentation for several residents showed fewer showers than scheduled, inconsistencies between task records and shower sheets, and missing progress notes for recorded refusals, despite a stated process requiring re‑approach and nurse documentation of refusals.
A resident with paranoid schizophrenia, dementia, and cognitive communication deficit had a care plan addressing behavioral concerns and the need for behavioral health interventions, but required PASRR Level I and Level II evaluations were not completed on time. A prior Level II determination allowed continued NF residence with potential specialized MH/DD services and specified a due date for the next Level II, which was not met. The SSD reported not having the current Level II and was unsure if the OBRA evaluator had assessed the resident, and the NHA confirmed that while a Level I and Level II had been completed the previous year, there was no Level I documented for the current year, resulting in noncompliance with PASRR requirements.
Surveyors found that staff did not implement care plan interventions for three residents, including fall-prevention measures and eating assistance. One resident with multiple sclerosis, dementia, and a history of falls was repeatedly observed leaning off the side of the bed without the prescribed pillow, blanket, or wedge in place. Another resident at high risk for falls, with dementia and MS, had a care plan requiring a non-slip dycem pad at the side of the bed after a fall, but the dycem was never present and staff were unaware of the intervention despite it being listed on the Kardex. A third resident with type 2 DM and an ADL self-care deficit had a care plan and progress notes indicating she required assistance with eating, yet documentation frequently recorded her as independent or needing only setup, staff reported she typically ate alone in her room without help, and she was observed struggling to feed herself without staff assistance.
A resident with a history of renal stones and a ureteral stent continued to have an indwelling Foley catheter for months after a urology visit, despite written instructions that it was acceptable to remove the catheter and only replace it if voiding problems occurred. The resident repeatedly complained of leaking and pain, and nursing notes documented multiple episodes of catheter leakage, resistance on reinsertion, and the presence of a blood clot, with several unsuccessful attempts to replace the catheter before allowing the resident to void without it. The resident stated he had asked staff several times to reassess the need for the catheter and felt the facility did not act promptly. The UM, MD, and PA each reported they had not assessed whether the catheter was still necessary after the urology visit, and the UM acknowledged that the urology instructions supported removal but could not explain why it was not done.
A resident with a history of CVA, malnutrition, dysphagia, and PEG-dependent enteral nutrition was care planned as NPO for all nutrition, hydration, and meds, yet staff were observed repeatedly providing water orally using sponge-tipped swabs. CNAs reported giving the resident water whenever he asked, despite acknowledging he was NPO and on fluid restriction, and that lemon swabs were supposed to be used instead. A full cup and jugs of water were found at the bedside, and a physician note documented the presence of bedside water for this NPO resident. The unit manager stated the resident should not have received water due to inability to swallow and acknowledged that oral care instructions in the Kardex and care plan were unclear, contributing to care that was inconsistent with professional standards for enteral nutrition management.
The facility failed to maintain complete and accurate medical records for three residents, including multiple missing entries on Treatment Administration Records for wound care, G-tube checks, catheter care, use of pressure-relieving boots, pulse oximetry assessments, and oxygen concentrator checks. For one resident with muscle weakness and personal care needs, several ordered wound and device-related treatments in a given month lacked documentation of completion or refusal. Another resident with DM2, pneumonia, and pressure injuries had undocumented wound treatments and respiratory monitoring tasks on several days. A third resident with MS, dementia, and a history of falls had no weekly skin assessments documented over multiple weeks, despite staff interviews confirming that weekly skin assessments and UAD alerts were expected and that missed treatments or refusals should be documented in the record.
A resident with a history of pressure ulcers and high risk for skin breakdown experienced worsening wounds due to inadequate care, including lack of regular repositioning, improper incontinence management, inconsistent application of barrier cream, and failure to maintain infection control precautions. Staff were unaware of the resident's wound status, did not follow care instructions, and did not consistently check on the resident, resulting in significant deterioration of the resident's pressure ulcer.
A resident was not provided with prescribed hospital discharge medications upon admission due to a delay in confirming and activating medication orders in the facility's system. The LPN entered the orders, but a required second check and activation were not completed, resulting in the pharmacy not receiving the orders until the following day. This led to the resident missing multiple scheduled doses of essential medications and ultimately being readmitted to the hospital.
Staff did not follow physician orders for Enhanced Barrier Precautions (EBP) when providing care to a resident with a pressure ulcer and urinary catheter. During observed care activities, including incontinence and wound care, a CNA, an LPN, and a unit manager did not wear gowns as required. The resident's wound had worsened, and EBP requirements were not posted at the door, leading to inconsistent use of infection control measures.
The facility failed to maintain proper sanitation and food safety standards, affecting 84 residents. Observations included a slow-draining sink, uncovered utensils, and soiled equipment. Food items lacked proper labeling and dating, with some past their best-by dates. Opened food packages were not securely sealed, and storage practices were inadequate, increasing the risk of contamination and foodborne illness.
The facility failed to maintain a clean and safe environment, affecting 84 residents. Observations revealed issues such as corroded appliances, missing laminate, loose fixtures, and heavily soiled ventilation grills. Maintenance aides indicated the use of the TELS program for work orders, but no related entries were found. The facility's policies for maintenance and housekeeping were not adhered to, leading to significant deficiencies.
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet needs in areas such as incontinence care, pressure ulcer prevention, and respiratory care. A resident at high risk for pressure sores lacked a care plan addressing this risk, while another receiving hospice services did not have these services reflected in their care plan. Additionally, a resident with obstructive sleep apnea had a CPAP machine that was not properly maintained, despite documentation indicating it had been cleaned.
The facility failed to maintain appropriate food temperatures and quality, affecting residents' meal satisfaction and nutritional intake. Observations showed food items were below required temperatures, and residents reported dissatisfaction with cold and undercooked meals. The Dietary Manager acknowledged these issues, and a group meeting confirmed widespread resident concerns.
The facility failed to honor resident food preferences, impacting several residents. A resident received food items listed as dislikes, while another received inappropriate food textures. A third resident experienced significant weight loss due to smaller portions than requested. Other residents reported frequent meal substitutions without notice and missing items on meal trays. These issues highlight the facility's failure to adhere to policies accommodating residents' dietary needs.
The facility failed to ensure proper glove use during incontinence care and injection administration, and sanitary storage of respiratory equipment, affecting three residents. A resident with cognitive impairment received incontinence care with improper glove use, while another resident with a brain injury experienced similar issues. Additionally, a resident with sleep apnea had a soiled CPAP machine, and an LPN administered an injection without gloves or hand hygiene, compromising infection control standards.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving a resident with wet pants and unmet incontinence needs, another resident ignored during care, and a third resident dismissed when seeking pain relief. A group meeting revealed widespread dissatisfaction with staff treatment, including unfamiliarity with resident needs and inadequate attention during night shifts.
The facility failed to assess two residents for safe self-administration of medications. One resident was found with a medication cup left by a nurse, and another was unsure about a pill's identity. The DON confirmed no residents were assessed for self-administration, and staff should supervise medication intake.
A facility failed to investigate abuse allegations for two residents. One resident reported thumb injuries caused by a staff member, but no investigation was conducted. Another resident, known to be combative, was reportedly restrained by a CNA during care. Witnesses described the CNA's actions as abusive, but the facility's investigation was incomplete and concluded no abuse occurred.
The facility failed to provide written bed hold notices to two residents and their representatives during hospital transfers, as required by policy. One resident, who was cognitively intact, was transferred twice without receiving the notice, and another resident was transferred at his wife's request without documentation of the notice. Interviews confirmed the requirement to provide the notice, but the facility could not locate the necessary documentation.
An LPN failed to follow professional standards during medication administration by not wearing gloves or performing hand hygiene after administering an insulin injection to a resident. The LPN then entered another resident's room and handled a meal tray without performing hand hygiene. The LPN believed gloves and hand hygiene were unnecessary as there was no exposure to blood or body fluids, contrary to CDC guidelines.
Two residents in a LTC facility did not receive adequate ADL care. A resident with edema was observed without prescribed ted hose, despite documentation indicating they were applied. The LPN admitted to not verifying their application. Another resident, cognitively intact, reported not receiving a shower for weeks and lacked basic hygiene assistance, resulting in an unkempt appearance. The facility failed to meet these residents' ADL needs.
Two residents at high risk for pressure ulcers did not receive adequate preventative care. One resident, cognitively impaired and dependent on staff, was left in a broda chair for extended periods without repositioning or incontinence care, leading to wetness and potential skin damage. Another resident, severely impaired and dependent, was also left in a broda chair without repositioning or offloading pressure, and was found with a bulging incontinence brief and wet pants. The facility failed to implement necessary preventative measures, risking the development of avoidable pressure ulcers.
A facility failed to ensure safe transport and transfer practices for residents, leading to potential injury risks. A resident with a history of falls was transported in a wheelchair without foot pedals, and transfers were conducted without a gait belt. Another resident experienced a fall when a new CNA did not use a gait belt during a transfer. Staff interviews confirmed that gait belts should be used for all non-mechanical lift transfers, and foot pedals should be in place when pushing a wheelchair.
Two residents in a LTC facility were left in wet incontinence briefs for extended periods, with staff failing to provide timely care and adhere to infection control practices. One resident, who was cognitively impaired, was observed in a wet brief without being checked or changed, and proper hygiene was not followed during care. Another resident, severely impaired, was also left in a wet brief, with staff neglecting to provide care until a family member intervened. These deficiencies pose risks for skin breakdown and UTIs.
A facility failed to maintain and store CPAP equipment in a sanitary manner for a resident with obstructive sleep apnea, leading to potential respiratory risks. The resident's CPAP machine, hose, and mask were heavily soiled, and the water container was empty with residue. Despite orders for daily cleaning, the equipment was not maintained, and the resident's care plan did not reflect the use of a CPAP machine.
A facility failed to limit a resident's PRN psychotropic medication to 14 days, as required by policy, without a documented rationale from the physician. The resident, with diagnoses including PTSD and anxiety disorder, was receiving Xanax and Ativan. The physician's order for Xanax as needed did not include a 14-day limit or a stop date, and there was no documented rationale for extending the PRN order.
A resident with Alzheimer's who was known to resist care was physically restrained and verbally intimidated by a CNA during incontinence care, despite a care plan directing staff to use de-escalation and re-approach strategies. Other CNAs present objected to the treatment and reported it as abusive, but the accused CNA continued working until facility leadership intervened. The incident highlights a failure to follow the care plan and protect the resident from abuse.
A resident with kidney failure alleged being kicked by staff, resulting in cracked ribs and hospital admission. Despite being informed of the abuse allegation at 1:00 AM, the NHA delayed submitting the Facility Reported Incident until 10:39 AM, about 10 hours later, leading to a potential delay in investigation and further abuse.
A facility failed to provide adequate supervision for three residents at high risk for falls, resulting in repeated falls and injuries. One resident sustained cervical and rib fractures, another experienced multiple falls despite being monitored in common areas, and a third resident with dementia was left unsupervised, leading to several falls. Staffing issues and insufficient interventions contributed to these deficiencies.
The facility failed to provide sufficient staffing, resulting in multiple falls for residents at risk. A resident on the rehab hall experienced several falls due to inadequate supervision, suffering a significant injury. Another resident, who was restless and frequently attempted to get out of bed, also fell multiple times due to insufficient monitoring. The facility's reliance on agency nurses and reduction in staff numbers exacerbated the situation, making it difficult for staff to provide necessary care and supervision.
The facility failed to provide evening snacks consistently, leading to dissatisfaction among residents. Staff reported that snacks were primarily available for diabetic residents, and non-diabetic residents often had to rely on staff purchasing snacks externally. The Dietary Manager cited reduced evening kitchen staff as a contributing factor, and the Director of Nursing was unaware of the issue.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and to have a licensed nurse in charge on each shift. Surveyors observed and documented repeated delays in care on the north hall, where residents and staff reported that only 2 CNAs were often assigned for 24 to 28 residents, the shower aide was frequently pulled to cover staffing gaps, and residents waited long periods for assistance. During observation, multiple call lights were seen active for extended periods, including one that remained on for 35 minutes, and an LPN was observed turning off call lights without meeting the residents’ needs. Resident #3, who was cognitively intact and had diagnoses including multiple sclerosis, anxiety, and depression, reported that she often was not gotten up until 11:00 AM to 11:30 AM or later even though she wanted to get up at 10:00 AM. She stated that at night it was hard to get help and that she could wait up to an hour for assistance. Her grievance records also described incomplete morning care, delayed getting up for meals, and staff stating there was not enough time to complete all tasks. A regional nurse consultant acknowledged that the resident regularly experienced delays in getting up and attributed this to staffing. Resident #74, who was legally blind and had moderately impaired cognition, reported waiting a long time for help and sitting in stool or urine before staff assisted him. His daughter also reported that repeated call light use did not bring timely help and that he had urinated on himself multiple times because no one came to assist him. Resident #5, who was cognitively intact and required substantial assistance with transfers and toileting, reported waiting more than 30 minutes for bathroom help and once waiting 3 hours, which led her to take herself to the bathroom despite knowing it was unsafe. A family member confirmed seeing call light response times greater than 30 minutes and reported the resident had been worried about low blood sugar while waiting for help. In a confidential resident council meeting, 9 of 11 residents reported regular call light response times greater than 30 minutes.
Facility Assessment Not Updated for Staffing Concerns
Penalty
Summary
The facility failed to update its facility-wide assessment to reflect current staffing concerns. Review of the Quality Assessment and Assurance Committee and Facility Assessment Sheet dated 8/28/2025 showed staffing input from 9/26/2024, including statements that resident council meetings had no staffing concerns, family input at care conferences had no staffing concerns, and staffing decisions were based on transfer status, resident acuity, and hall location. The assessment also noted that residents were reviewed for transfer status, special needs, behavioral needs, acuity, and the number of residents on each hall, with individual care or staffing issues investigated and corrected as they occurred. During the survey, the surveyor discussed staffing concerns with the DON, RNC, and RDO. The RDO and RNC stated they thought staffing was good in the building, but they could not identify any updated staffing information from the facility assessment meeting. The RDO later stated he could not find any updated staffing information from the last facility assessment meeting, and the DON stated she was new to the building when she attended the meeting and could not remember what was discussed. The facility policy required the assessment to be reviewed and updated as necessary and at least annually, and to address the resident population, including care needs related to disease, conditions, physical and cognitive disabilities, overall acuity, and other pertinent facts.
Infection control practices were not maintained for precautions, equipment, medication administration, and resident supplies
Penalty
Summary
The facility failed to maintain proper infection control practices for residents on transmission-based precautions and enhanced barrier precautions. Resident #59 had diagnoses including ileostomy, ulcerative colitis, peritoneal abscess, dehydration, and MRSA contact isolation orders, with enhanced barrier precautions also ordered for an ileostomy, biliary drainage tube, and abscess. Although signage outside the room indicated contact precautions and required PPE, an agency LPN entered the room with a gown left untied and open in the front, donned gloves while already in contact with the resident, and exited without performing hand hygiene. Later, another agency LPN removed PPE and placed it into the roommate’s garbage can, then touched the roommate’s arm and moved a straw between cups before leaving the room without hand hygiene. The care plan did not document contact isolation or transmission-based precautions, and the DON stated no residents were in transmission-based precautions while the IP stated Resident #59 was in contact isolation for MRSA. Resident #88 had dementia, a history of falling, and a pressure wound on the foot with enhanced barrier precautions ordered. Signage outside the room indicated a gown and gloves were required, but two CNAs entered the room to position a dependent lift sling and transfer the resident without gowns, and they only donned gloves after already inside the room. One CNA later acknowledged the signage indicated gown and gloves were required and that she had not worn them. The care plan for Resident #88 did not note enhanced barrier precautions, while the IP stated the precautions were related to a wound on the right foot and expected PPE during high-contact care activities including transfers. The facility also failed to maintain proper storage and handling of resident equipment and supplies. Resident #34’s nebulizer was repeatedly observed stored under a pillow and in a wheelchair basket rather than in a plastic bag when not in use. Resident #90 received insulin from an agency LPN who did not wear gloves and did not perform hand hygiene before or after the injection, despite the facility policy requiring handwashing, gloves, and handwashing after glove removal. Shared equipment was not cleaned between uses when a vital machine and mechanical lift were used for multiple residents, and staff observed the lift left uncleaned in the hallway. Oxygen tubing for Resident #43 was repeatedly observed on the floor with shoes on top of it and the storage bag on the ground, despite the oxygen policy stating tubing should be kept off the floor. In addition, a blue ice cooler used for resident water pass was left accessible in the hallway, and a resident was observed using the scoop and cooler without hand hygiene and with a previously used cup, while staff reported residents could access the cooler even though only staff were supposed to touch the scoop and cooler.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the environment. On 4/28/26, a window was observed open in Resident #11’s room with no screen present, and dirt was seen on the over-the-bed table, floor, and foot of the bed while the resident was sleeping. The next day, Resident #11 stated she was upset that she could not have a screen on her window and reported that when she returned from an appointment, her bed had grass and dirt on it. She also stated she did not want bugs coming into her room when the window was open. Multiple rooms and hall areas were observed with cleanliness concerns. A strong odor of urine was noted in one room and later along the 100 hall near rooms 111 through 114. Pedestal fans in resident rooms were observed with dust and debris on the protective cage and base, and one fan was blowing directly at a resident’s pillow while another was blowing directly at a resident’s face. Housekeeping staff were observed mopping a room and leaving without placing a wet floor sign, while the floor remained visibly wet. During interview, the housekeeper stated she did not use wet floor signs when mopping and that she did not clean residents’ personal items, only dusting about once a week. The facility also had environmental maintenance issues. A mattress was observed on the sidewalk at the back of the building, and a broken adjustable bed was observed in the hallway in front of the basement door. Missing plastic corner covers were observed on handrails on the 600 hall, 500 hall, and 100 hall, and a loose handrail with a missing end cap was observed next to a room with a trash can blocking most of the handrail. The maintenance supervisor stated the broken bed was waiting to be moved outside, was aware of the missing end caps and broken or loose handrails, and had ordered parts for repairs. Several windows were missing screens, and the maintenance supervisor stated some screens had been removed to prepare for air conditioner window units. Equipment and debris were also observed near the outbuildings and dumpsters, and the maintenance supervisor stated there had been issues with mice in the facility.
Delayed Response to Grievances for Call Lights and Missing Belongings
Penalty
Summary
The facility failed to take prompt efforts to resolve resident grievances related to call light response times and missing personal items. Resident #5, who was cognitively intact with a BIMS score of 13/15 and had diagnoses including diabetes mellitus and adjustment disorder with depression, reported that she often waited more than 30 minutes for staff to answer her call light. She stated that because of the long waits, she sometimes took herself to the bathroom even though she knew she was not safe to do so, and she felt frustrated and anxious when she believed she had no choice but to risk injury to avoid incontinence. Resident #5 also reported that she had informed the facility about several missing belongings, including clothing items, scissors, and socks, but nothing had been done. She stated the items had been missing for more than 2 months and that she was frustrated by the lack of response. Family Member EEE reported witnessing call light response times greater than 30 minutes and said Resident #5 had called her once because she was concerned her blood sugar was dropping while waiting for her call light to be answered for more than 30 minutes. Family Member EEE reported filing 2 grievance forms before 4/29/26 and said there was no resolution to the concerns about long call light wait times and missing items. The nursing home administrator stated the facility could not locate the grievance forms related to the missing items and that the social worker asked Family Member EEE to file a new grievance. In a confidential meeting, 9 of 11 residents reported regular call light waits of more than 30 minutes, and 9 of 11 said they had previously filed a grievance about the issue and felt it had not improved. A grievance form from the resident council documented long call lights on the north, basic, and south halls on 1st and 3rd shift, with the resolution section noting only that the concern would be addressed at a staff meeting.
Failure to Sustain Pressure Ulcer Prevention Monitoring
Penalty
Summary
The facility failed to sustain a system to ensure corrective measures related to pressure ulcers for a resident who was dependent on staff for mobility and identified on MDS as at risk for developing pressure ulcers. The resident had diagnoses including dementia, a history of falling, and a history of/healed fracture. Her care plan directed that off-loading boot cushions be used on both lower extremities at all times as tolerated to protect skin integrity. During observations, the resident was repeatedly found sitting in a broda chair without her heel protectors in place. On one occasion, the heel protectors were dislodged and around her legs, and the family member reported concern that the boots shifted when she moved and that she continued to get wounds. A CNA stated the resident should wear the boots on her feet all the time. Additional observations showed the resident sitting in the broda chair in the dining room and in her room without heel protectors, with her heels directly in contact with the foot cradle of the chair. The DON stated that the facility’s audits were focused on treatment orders, treatment completion, and wound vacs, and that the nurses and CNAs were responsible for ensuring heel protectors were in place as ordered. The DON also stated the facility was not monitoring through direct observation whether pressure ulcer prevention interventions were implemented. The NHA and RDO described weekly rounds and review of wound-related documents, but there was no discussion of observations to ensure care-planned pressure ulcer prevention interventions were consistently in place for residents with skin breakdown or at risk for skin breakdown.
Delayed Response to Call Lights and Toileting Needs
Penalty
Summary
The facility failed to treat residents with dignity and respect and failed to provide an environment that promoted and enhanced resident quality of life for 3 of 4 residents reviewed for dignity. The deficiency was based on repeated reports of long call light wait times and delayed assistance with toileting and brief changes for residents who were cognitively impaired and dependent on staff for care. The report states these delays resulted in residents remaining in soiled briefs or urine and feces for extended periods, with residents describing feelings of frustration, feeling dirty, and feeling bad about soiling themselves while waiting for help. Resident #1 had diagnoses including weakness and major depressive disorder, a BIMS score of 12, and was documented as occasionally incontinent of bladder and always incontinent of bowel. His care plan identified a need for maximum to moderate assistance with toileting. He reported that he had to wait a long time for his call light to be answered, that he had soiled his brief many times while waiting for staff, and that he had waited longer than an hour for his call light to be answered. An LPN confirmed that he did use his call light. Resident #6 had diagnoses including adjustment disorder with depression and anxiety disorder, a BIMS score of 10, and was always incontinent of bladder and bowel. His care plan identified a need for maximum assistance by one staff member for toileting. He reported that it took forever for things to get done, including changing his pants, and that he had waited an hour for a brief change, which made him feel dirty. Resident #74 had legal blindness and depression, a BIMS score of 12, and reported that he had to wait for help, sat in poop for a while, and questioned the point of having a call light when staff did not come. His daughter had previously emailed concerns that nobody came when he used the call button and that he had peed his pants multiple times because nobody helped him to the bathroom. The grievance record also documented that he had waited up to around 30 minutes on two responses, and multiple staff members stated they were unaware of his complaints until the survey process.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure residents were assessed as appropriate for self-administration of medications for two residents reviewed for medication administration. One resident, who had a history of acute diastolic heart failure and a BIMS score of 13/15, was observed with a white bottle of ipratropium bromide nasal solution on the bedside dresser and stated she used it every day, sometimes using that bottle and other times using the facility’s bottle. The resident reported staff knew she had it, but there was no assessment or order in the medical record for self-administration of medications. Facility staff gave conflicting statements, with one LPN reporting only one resident was known to self-administer medications and the ADON and DON stating residents needed an assessment, provider agreement, and an order before self-administration. Another resident, who had COPD and a BIMS score of 12/15, was observed with a bottle of nasal spray on the over-the-bed table in the room. The resident stated the night nurse had left it there after use and had not returned to retrieve it, and that nurses would give her the nasal spray and then come back to get it when she was done. A later observation found a brown bottle of nasal spray labeled with the resident’s name on the over-the-bed table while the resident was sleeping. The medical record contained an order for fluticasone propionate nasal suspension, but there was no noted assessment or order for self-administration of medications, and the DON stated the resident had not been assessed, did not have a care plan, and did not have an order to self-administer medications.
Failure to Honor Resident Morning Routine Choice
Penalty
Summary
The facility failed to honor a resident's choice to get up by 10 AM for one cognitively intact resident with multiple sclerosis, anxiety, and depression. The resident stated during interviews that she wanted to get up at 10 AM every day, but she was often not assisted out of bed until 11 AM or later, and she reported that this was a daily occurrence. She also stated that the unit had only 2 CNAs for 24 residents and that the shower aide was frequently pulled, making it difficult for staff to meet residents' needs. Record review showed the resident filed a grievance after not being up at her desired time, and the grievance investigation noted that she had not been able to get up at her desired time for the last two days because staffing issues affected care delivery. The regional nurse consultant documented that the resident regularly received her shower on second shift but still experienced delays in getting up for the day, which she attributed to staffing. The RNM stated the resident had not been up by 10 AM because the shower aide was pulled and staffing was bad that morning, and the DON stated she was unaware of the resident's concerns until that week. The facility policy stated that daily schedules should allow maximum flexibility for residents to exercise choices about what they will do and when they will do it.
Failure to Notify Responsible Party of Change in Condition After Fall
Penalty
Summary
The facility failed to notify the resident’s responsible party of a change in condition after the resident was found on the floor lying on the left side with the head raised off the floor and the left hip and left shoulder resting on the footrest. The resident stated the left shoulder hurt, and a stat left hip and left shoulder x-ray was ordered. The resident had cognitive impairment, with an MDS BIMS score of 8/15, and the resident’s family member was present at the facility after the fall. The x-ray results later showed no fracture or dislocation of the left shoulder or left hip, but the resident’s representative was not documented as being contacted regarding the radiology results. During interview, the family member stated no one had told them the x-ray results and that they had been told they would be called with the results. The DON later reported the family member had been called and an apology was made for not notifying her earlier. The resident’s care plan identified multiple fall risk factors, including dementia, muscle wasting, acute kidney failure, Parkinson’s disease, physical debility, diabetes mellitus, cardiomyopathy, repeated falls, atrial fibrillation, and a prior head injury, but no intervention was placed in the care plan for immediate safety measures for the fall.
Failure to Develop EBP Care Plan for Resident with Foley Catheter
Penalty
Summary
The facility failed to develop a comprehensive resident-specific treatment plan for Enhanced Barrier Precautions (EBP) for Resident #306, who was reviewed as one of four residents in the comprehensive care plan sample. Resident #306 was admitted with diagnoses including benign prostatic hyperplasia with lower urinary tract symptoms and had a BIMS score of 15 out of 15, indicating cognitive intactness. During observation, the resident was lying in bed with a urinary catheter in place, and an EBP sign was posted on the door stating that staff must clean their hands before entering and leaving the room and wear gloves and a gown for high-contact resident activities, including device care or use involving the urinary catheter. Review of the physician order showed EBP every shift for foley urinary catheter placement, with initials indicating precautions were maintained throughout the shift and a start date of 5/17/2026. However, the care plan did not include any plan for enhanced barrier precautions. During interview, the DON stated it was the expectation that when a resident was under EBP, the sign would be placed on the door, PPE would be available, an order would be entered in the chart, and a care plan would be developed, and acknowledged that Resident #306 did not have an EBP care plan in the chart. The facility policy stated the interdisciplinary team shall develop a comprehensive care plan for each resident and review and revise it after each assessment and as care needs change.
Care Plan Did Not Reflect Current Mobility Needs
Penalty
Summary
The facility failed to review and revise Resident #5’s care plan to accurately reflect current mobility needs. Resident #5 was admitted with diagnoses including CHF and peripheral vascular disease. The MDS assessment dated 2/27/26 showed the resident was cognitively intact with a BIMS score of 13/15, and Section GG indicated the resident required substantial/maximal assistance to transfer from bed to wheelchair and to and from the toilet. However, the care plan dated 1/18/26 still listed limited physical mobility related to CHF and stated the resident required maximum assistance with a four-wheeled walker for sit-to-stand transfers and surface transfers. During observation on 4/28/26, Resident #5 walked down the hall using a wheeled walker while an unknown therapy staff member walked beside her and provided no physical assistance. In interviews, the COTA reported that mobility changes were discussed in daily IDT meetings, the ADON stated the care plan did not accurately reflect the resident’s current level of independence and need for assistance with transferring and ambulation, and the Rehab Director stated the resident was currently able to transfer herself and ambulate with standby assistance. The facility policy stated the IDT shall develop a comprehensive care plan for each resident and review and revise it after each assessment and as care needs change.
Failure to Maintain Heel Protectors for a Resident at Risk for Pressure Ulcers
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was cited after staff failed to ensure heel protectors were in place for a resident at risk for skin breakdown. Resident #88 was a female with diagnoses including dementia, history of falling, and history of/healed fracture. Her MDS indicated she was dependent on staff for mobility and at risk for developing pressure ulcers. Her care plan directed off-loading boot cushions to both lower extremities at all times as tolerated, and the order summary directed heel protector boots on at all times every shift. During observation, the resident was seen sitting in a broda chair with her heel protectors dislodged and around her legs, and family reported the boots shifted when she moved and that she always had to wear them to prevent her wound from getting worse or developing others. A CNA stated the resident should wear the boots on her feet all the time. On multiple later observations, the resident was sitting in the broda chair without heel protectors, with her heels directly in contact with the chair foot cradle. Although the MAR documented the heel protector boots as completed each shift by an agency LPN, the DON stated nurses and CNAs were responsible for ensuring the heel protectors were in place as tolerated.
Failure to Maintain Safe Environment and Supervision During Ambulation and Housekeeping
Penalty
Summary
The facility failed to maintain an environment free from accident hazards and adequate supervision for two residents who were reviewed for accidents. Resident #5 had diagnoses including congestive heart failure and peripheral vascular disease, was cognitively intact with a BIMS score of 13/15, and required substantial to maximal assistance for transfers. Her care plan identified her as at risk for falls and directed staff to provide assistance as needed for mobility tasks and anticipate her needs. During observation, she was seen walking in the hall with a wheeled walker while accompanied by an unknown therapy staff member, but she was not wearing a gait belt. Staff interviews confirmed that residents who were not independent with ambulation should wear a gait belt, and the ADON confirmed Resident #5 had not been assessed as independent for ambulation. Resident #48 had diagnoses including hypertension, cerebral infarction, and vertigo, and her MDS showed severe cognitive impairment with a BIMS score of 3/15. Her care plan identified her as at risk for falls related to confusion, deconditioning, and being unaware of safety needs, and her fall risk assessment classified her as high risk. While a housekeeper was mopping the floor in Resident #48’s room, the resident was sitting with her overbed table in front of her and her walker across the room out of reach. After the housekeeper left, no wet floor sign was placed, and the floor remained visibly wet. Shortly afterward, Resident #48 was observed walking from her room into the hallway without her walker, and a CNA asked where her walker was and noted that the floor was wet. The housekeeper stated she did not use wet floor signs when mopping and believed the floor was not wet for long. The NHA stated she was acting as the director of housekeeping and reported her expectation was that wet floor signs be used every time.
Dialysis Communication and Assessment Not Maintained
Penalty
Summary
The facility failed to ensure pre- and post-dialysis treatment assessment and monitoring communication was maintained between the facility and the dialysis provider for one resident who required hemodialysis. The resident was a female with diagnoses including type 2 diabetes and dependence on renal dialysis, and her care plan directed dialysis on Tuesday, Thursday, and Saturday, with instructions to have her ready by 11:00 AM, send a meal with her, avoid the left arm for blood pressure or blood specimens, monitor the AV shunt site for bruit and thrill, and report changes to the dialysis center and/or physician. Review of the dialysis communication forms showed they were documented only 7 of 15 times from 3/26/26 through 4/28/26, and one form dated 4/2/26 was blank in the area to be completed by the facility. The resident's electronic record also had no documentation of pre- or post-dialysis assessment on 9/15 scheduled dialysis treatment days. The resident stated the nurses did an assessment before dialysis but did not assess her when she returned, and she reported the facility did not send the dialysis form as it should. Staff interviews confirmed the communication form was expected to include vital signs, weight, and medication changes before dialysis, and that the resident should have weight, vital signs, and an assessment, including visualization of the AV site, when she returned.
Missing Pharmacy Recommendation for Monthly MRR
Penalty
Summary
The facility failed to locate a pharmacy recommendation for one resident reviewed for medications, Resident #86. The resident was admitted with diagnoses including depression, psychotic disorder with delusions, agoraphobia, anxiety, and post-traumatic stress disorder, and the MDS indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact. Review of the resident’s Medication Regimen Review completed by the pharmacist on 11/25/2025 showed the comment, “Chart reviewed, recommendations sent to the physician,” but the resident’s chart did not contain a pharmacy recommendation for that review. During interviews, the Nursing Home Administrator stated the facility could not find the pharmacy recommendation from 11/25/2025. The DON stated the pharmacist reviews resident medications monthly, emails recommendations to the facility, and the recommendations are then dispersed to the appropriate department head or nurse manager for follow-up with the physician and later uploaded into the chart; however, she also stated the facility was unable to find the recommendation for Resident #86 from 11/25/2025. The facility’s MRR policy required a licensed pharmacist to review each resident’s drug regimen at least monthly and report irregularities to the attending physician, medical director, and DON, with reports acted upon and maintained in the medical record.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with a total error rate of 10%, based on observations, interviews, and record review for 2 of 8 sampled residents. Resident #48 had diagnoses including hypertension, cerebral infarction, and vertigo, and her MDS assessment showed a BIMS score of 3/15, indicating severe cognitive impairment. During a medication pass, an agency LPN did not dispense the ordered Lasix 40 mg by mouth in the morning and stated that the medication was on hold and not to be given. However, the MAR later documented that the LPN had administered Lasix 40 mg at 9:00 AM as ordered. Resident #59 had diagnoses including ileostomy, ulcerative colitis, peritoneal abscess, and dehydration, and her MDS assessment showed a BIMS score of 15/15, indicating cognitive intactness. During observation, the resident requested pain medication, and the agency LPN stated the resident was out of pain medications and that she did not have access to the backup narcotic box, requiring the DON to pull the medication. The LPN also did not dispense lactated ringers 125 mL during medication administration, yet the MAR later documented that lactated ringers 125 mL had been administered at 9:00 AM, and there was no documentation that the resident received the requested PRN pain medication two hours after requesting it.
Failure to Prevent and Properly Manage Pressure Ulcers in a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pressure ulcer prevention and care for a high‑risk resident, resulting in the development and worsening of pressure injuries. The resident was originally admitted with intact skin and diagnoses including need for assistance with personal care and muscle weakness, and was care planned as having potential for impaired skin integrity related to traumatic brain injury. Interventions on the care plan included an alternating pressure mattress, heel elevation, daily skin observation with reporting of changes, and monitoring and documentation of any skin injuries. A Braden Scale assessment showed the resident was at high risk for skin breakdown. Despite this, multiple nursing admission and re‑admission screenings documented the resident’s skin as intact or with only dry skin, and did not record sacral or coccygeal skin issues that were identified in hospital records. Hospital documentation showed that a sacral wound was identified during a sepsis workup, with a small sacral wound draining purulent fluid and later a Grade 1 pressure ulcer to the coccyx. A subsequent hospital wound consult documented multiple pressure injuries, including an unstageable pressure injury and deep tissue pressure injuries to both heels, present on admission. When the resident returned to the facility, nursing re‑admission screenings again failed to document the coccyx/sacral wound, and early facility skin documentation on 11/11 described new in‑house gluteal abrasions without correlating them to the previously identified coccyx/sacral wound. Facility orders for wound care to the left gluteal abrasion were initiated on 11/12, and later progress notes and wound care practitioner assessments documented an unstageable coccyx pressure ulcer with slough and eschar, multiple pressure injuries to the coccyx/buttocks, heels, and elbows, and a decline of the coccyx area while in the hospital. By mid‑December, the left and right gluteal abrasions had combined into one coccyx wound, and the coccyx wound remained unstageable with a high percentage of slough and ongoing drainage. Interviews and record review revealed systemic failures in assessment, documentation, and implementation of care. The unit manager acknowledged that the coccyx wound and elbow wounds were first identified by the facility on 11/12 and that nursing re‑admission assessments on 10/27 and 11/5 did not indicate a coccyx pressure ulcer, attributing this to missed documentation. She also confirmed missing weekly skin assessments and shower sheets, despite expectations that staff complete skin checks twice weekly during showers and weekly nursing skin assessments. Multiple LPNs reported that the resident was dependent on staff for all care, including repositioning, and that he was not receiving regular showers, skin checks, or q2h repositioning as required, often due to short staffing. One LPN stated that staff commonly skipped care and treatments, and another confirmed that residents, including this resident, frequently missed treatments and care. The January treatment administration record for coccyx wound care showed nine instances of missing documentation for ordered treatments. Family reported that the resident had no skin issues on admission, required total assistance, and was not observed being repositioned or receiving care during frequent visits, and that concerns voiced to nursing, unit management, the DON, and social work were not effectively addressed. The facility’s own pressure ulcer policy required prevention of avoidable pressure ulcers and necessary treatment and services for existing ulcers, but the documented omissions in assessment, monitoring, repositioning, and treatment led to the identified deficiency.
Significant Medication Errors Involving Insulin and Antiepileptic Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, specifically related to insulin administration for a resident with type 2 diabetes and antiepileptic medications for a resident with epilepsy. For the diabetic resident, the care plan identified a risk for blood sugar fluctuations and directed staff to administer medications as ordered, monitor blood glucose, follow hypoglycemia protocols, and report abnormal values to the physician. The resident’s insulin regimen was changed to include long-acting insulin at bedtime and scheduled short-acting insulin with meals plus a sliding scale. After this change, the resident experienced a first documented episode of severe hypoglycemia, during which an LPN found the resident non‑responsive with a critically low blood glucose and administered glucagon per protocol. The progress note for this event did not document that a provider was notified, and the medical director later confirmed he had not been made aware of this episode, nor had the insulin orders been reviewed or adjusted afterward. On a subsequent date, the same resident experienced another severe hypoglycemic episode. A CNA reported the resident felt hot, and when the LPN assessed the resident, she was diaphoretic and unresponsive with a blood glucose of 29. Multiple glucagon injections and oral glucose were administered with assistance from other nurses and a nurse practitioner, and the resident was ultimately sent to the hospital. Hospital records documented that the resident had been receiving 10 units of long‑acting insulin at night and 2 units of insulin with meals, and noted that hypoglycemia could be due to an insulin dosing error or accurate dosing in a patient not eating adequately. Review of the resident’s orders and MAR showed that the short‑acting insulin lispro was ordered as 7 units with meals plus a sliding scale, and that on the day of the second hypoglycemic event, the LPN administered 7 units of lispro at 10:32 a.m. for a blood glucose of 140 and then again at 1:05 p.m., giving 7 units plus 2 units per sliding scale for a blood glucose of 177. The LPN later acknowledged she was behind on medications, gave the morning and lunch insulin doses 2.5 hours apart, did not know whether the resident had eaten breakfast or lunch or how much was consumed, and did not realize the doses were so close together. The DON confirmed the insulin doses were given late and that nurses were expected to administer insulin with meals, check blood glucose before eating, and assess intake, while the medical director, PA, and pharmacist all stated they would be concerned about lispro being given 2.5 hours apart without knowledge of food intake. The second resident had a diagnosis of epilepsy and a care plan goal to remain free from injury related to seizure activity, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. MAR review showed that this resident missed multiple doses of Keppra and valproic acid over several days, including missed morning doses of Keppra and multiple missed doses of valproic acid on consecutive days. Progress notes documented that the resident refused morning medications on one day, that the nurse reapproached and the resident took only part of the medications, and that the resident’s family member expressed concern about lethargy, abnormal responsiveness, and the possibility of seizure, requesting hospital evaluation. The resident was sent to the hospital and returned with an increased Keppra dose, but subsequent notes indicated ongoing lethargy, refusal of meals, and refusal of medications. The resident later had seizure activity at the facility, and days afterward, staff documented that the resident had been unable to swallow food and medications for several days and that valproic acid was not given for this reason, leading to a provider notification and transfer to the emergency department. Hospital records for this resident described a history of TBI, epilepsy, and nonverbal status, with presentation for failure to thrive and significant dysphagia over 24–48 hours, during which the resident was unable to take medicines or oral intake. The family reported being told that oral antiepileptic medications drooled out of the resident’s mouth and could not be swallowed, and that the last seizure a few days prior was believed to be due to inability to take oral medications. The hospitalization summary noted status epilepticus and an acute ischemic infarction, and the attending physician stated that due to dysphagia the resident frequently missed antiepileptic doses, making breakthrough seizures unsurprising. Interviews with facility staff revealed that the LPN caring for the resident on one of the key days could not recall whether the provider was notified about missed Keppra and valproic acid doses, and the unit manager acknowledged she did not further investigate family concerns and confirmed multiple missed doses without documentation of provider notification. Another LPN reported being told by a CNA that the resident had been having swallowing issues and missing medications for days before she assessed the resident, notified the provider, and arranged hospital transfer. The DON and PA both stated that nurses were expected to notify providers whenever medications were missed or there was a change in condition, and review of records showed no documentation that providers were notified of the repeated missed antiepileptic doses due to dysphagia. Facility policies on medication administration required medications to be given as prescribed, within one hour before or after scheduled times, with before/after meal orders followed as written, and required explanatory notes and notification of the DON and physician when two doses of a medication were refused or withheld. The change in condition policy required that sudden or serious changes in condition be communicated to the physician with a request for prompt evaluation, and that all nursing actions be documented in progress notes. In both residents’ cases, the documented findings show that medications were not administered in accordance with physician orders and facility policy, that critical changes in condition and missed doses were not consistently communicated to providers, and that documentation of provider notification was lacking despite repeated episodes of hypoglycemia and missed antiepileptic doses associated with dysphagia and seizure activity.
Failure to Provide and Document Scheduled Showers and ADL Care for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and appropriate ADL care, particularly bathing and showering, to multiple dependent residents, and to accurately document refusals and care provided. One resident with a history of traumatic brain injury and total dependence for care was care planned as totally dependent on two staff for baths or showers twice weekly and as needed. Hospital records later documented that this resident was admitted soaked in urine, with a crusted right eye and crusting around the mouth. A family member reported visiting frequently for several hours at a time and never seeing staff assist with care, describing the resident as often disheveled, with peeling skin, soiled briefs, double briefs, and saliva on the mouth and face, and stated that scheduled showers were often missed despite repeated complaints to nursing staff, the unit manager, DON, and social worker. Review of shower sheets for a two‑month period showed only seven documented showers or bed baths when fourteen should have been provided or refusals documented. Staff interviews confirmed that showers and bed baths were frequently missed, especially when the facility was short staffed or when the designated shower aide was pulled to work the floor. Multiple LPNs reported that residents were missing showers due to staffing issues and that the shower aide was often reassigned, resulting in missed showers. A CNA stated it was very common to skip ADL care such as showers and bed baths because there was not enough time. The unit manager acknowledged awareness of the family member’s concerns, admitted that shower sheets were not consistently completed, and confirmed that she had not conducted follow‑up on ADL care after the resident’s hospital admission in soiled condition. The DON stated she was not aware of the family member’s concerns and indicated that unit managers were supposed to review shower sheets and care tasks daily. For other residents reviewed, records and interviews showed additional failures to provide scheduled showers and to document refusals. One male resident with multiple sclerosis, dementia, and weakness was care planned to receive showers twice weekly with assistance; task documentation showed a shower as given on a date when the shower sheet recorded a refusal, and there were no progress notes documenting refusals on that or another refusal date, despite multiple missed shower opportunities over 30 days. Another male resident with chronic pain, muscle weakness, wheelchair dependence, and long hair reported he did not get a shower every week and sometimes only every other week, especially when the shower aide was off; documentation across several months showed fewer showers than the scheduled opportunities, substitution of bed baths in some months, and missing progress notes for documented refusals. A female resident requiring setup and moderate to maximum assistance for bathing was scheduled for twice‑weekly showers but, over a 30‑day period, had only two showers and one refusal documented, with no corresponding refusal note in the progress notes despite nine scheduled opportunities. Another female resident with multiple sclerosis and overactive bladder reported that staffing ratios affected care, that it was difficult to get assistance, and that when the shower aide called in, floor CNAs did not complete scheduled showers; she also reported that the shower aide had too many showers scheduled to complete. The shower aide confirmed starting work very early, being pulled to the floor at least three times per week, and being unable to complete the high number of scheduled showers, resulting in residents not receiving showers on those days. The unit manager stated that when the shower aide was pulled, the assigned CNA was responsible for the shower and that refusals were to be re‑approached and documented with a nurse progress note, but the documentation reviewed did not consistently reflect this process.
Failure to Complete Timely PASRR Level I and II Evaluations for Resident With Serious Mental Illness
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely completion of PASRR (Preadmission Screening/Annual Resident Review) Level I and Level II evaluations for a resident with serious mental illness. The resident was a female with diagnoses including paranoid schizophrenia, dementia, and cognitive communication deficit. Her care plan, revised on 6/14/25, identified a behavior concern related to paranoid schizophrenia, noting that she might be paranoid about money and others’ opinions, potentially leading her to intrude on others’ privacy. Interventions included assisting her to develop appropriate coping and interaction methods, encouraging appropriate expression of feelings, anticipating and meeting needs, obtaining behavioral health consults as needed, and administering and monitoring psychotropic medications. Record review showed a Level II evaluation letter dated 1/5/25 stating that the resident could continue to reside in the nursing facility and may choose to receive specialized mental health/developmental disability services, with specialized services to be planned by the local community mental health agency. The letter indicated that a subsequent Level II evaluation would need to be completed by 1/4/26. During an interview, the Social Services Director reported that the Level II evaluation due by 1/4/26 was not available and that she was unsure whether the OBRA evaluator, who had been in the facility on 2/19/26, had seen this resident. She also stated that Level I evaluations were completed yearly and with changes in condition. Electronic correspondence from the Nursing Home Administrator confirmed that a Level I was completed on 12/5/24 and a Level II on 1/5/25, but there was no Level I documented for 2025, demonstrating that required PASRR evaluations were not completed timely for this resident.
Failure to Implement Care Plan Interventions for Fall Prevention and Eating Assistance
Penalty
Summary
Surveyors identified a failure to implement comprehensive care plan interventions for multiple residents, resulting in care not being provided as planned. One male resident with multiple sclerosis, dementia, anxiety, weakness, a history of repeated falls, and other psychiatric diagnoses had a care plan focus on limited physical mobility and fall risk, with specific interventions including use of a pillow or rolled blanket to define bed borders and a wedge or body pillow to prevent him from leaning or falling from the bed. On multiple observations over several days, the resident was seen lying in bed leaning to the right side without any pillow, blanket, or wedge in place, and at one point his right arm and shoulder were off the side of the mattress while a blue wedge was observed on the bedside table instead of in use on the bed. Another female resident with dementia, osteoporosis, and multiple sclerosis had a care plan identifying her as at risk for falls due to a high desire for independence, challenged balance and coordination, low safety awareness, and a tendency to lean forward when propelling herself in a wheelchair. Following an incident where she was found sitting on the floor after sliding while attempting to transfer from bed to wheelchair without staff assistance, the plan of care was updated to include a non-slip dycem pad to the side of her bed. However, during multiple observations, no dycem was found on or under the sheets on the exit side of the bed. The resident stated she did not know what a dycem was and that there was none on her bed. A CNA and an LPN both reported they had not seen a dycem on the bed and were unaware of the intervention, despite the Kardex indicating its use, and staff interviews confirmed that the dycem was not being implemented as planned. A third resident with type 2 diabetes mellitus had a care plan indicating an ADL self-care performance deficit, with a goal to improve self-care and an intervention specifying that she required assistance with eating. Progress notes documented that she required assistance with feeding and was only eating bites of her meals. Despite this, facility documentation for multiple dates recorded her as independent with eating or needing only setup assistance. Several LPNs and a CNA reported that the resident always ate in her room and generally did not receive assistance with eating, although some staff had noticed she did not eat well and seemed to need help. One LPN stated she did not know the care plan required assistance with eating and another reported the resident did not require such assistance. During observation, the resident was seen in her room attempting to eat independently, struggling to scoop food onto her fork and unable to cut her chicken, with no staff present to assist her, contrary to the care plan intervention.
Failure to Assess Ongoing Need for Indwelling Foley Catheter
Penalty
Summary
The deficiency involves the facility’s failure to assess and act on the continued need for an indwelling Foley catheter for one resident following a urology visit. The resident was originally admitted with diagnoses including essential hypertension and had a history of renal stones and a ureteral stent. A urology After Visit Summary dated 6/25/25 documented instructions that it was acceptable to remove the Foley catheter and to replace it only if the resident was unable to void after six hours or had a post-void residual greater than 250. Despite these written instructions, the catheter remained in place for months, and there is no documentation that facility providers assessed whether the catheter was still necessary after the June 2025 appointment. During the months following the urology visit, the resident repeatedly experienced problems with the catheter, including leaking and pain. Progress notes show that on 9/29/25 the resident complained of leaking around the Foley, with the bed noted to be wet with urine; the nurse removed the old Foley, encountered resistance and a blood clot during reinsertion, and then placed a new catheter, after which the resident reported feeling better. On 10/1/25, the resident again reported leaking from the insertion site, and the nurse flushed the catheter and adjusted the balloon to stop the leaking. On 10/6/25, the resident again reported leaking; the nurse deflated and repositioned the balloon, flushed the line, and observed all saline leaking from the insertion site. Multiple attempts by two nurses to reinsert a new catheter were unsuccessful due to resistance, and the resident was then allowed to void without a catheter, using briefs while staff monitored output and possible retention. Interviews confirmed that key staff and providers did not assess the ongoing need for the catheter after the June 2025 urology visit. The resident reported that he had the Foley catheter for months after the appointment, had asked staff several times to see if he still needed it, and felt the facility did not act promptly, causing frustration and pain from frequent leaking and discomfort. The Unit Manager stated she was unsure whether the catheter was supposed to be removed after the June visit, acknowledged that the urology note indicated removal was acceptable, and could not recall why the facility had not removed it or whether facility providers had assessed the need for continuation. The Medical Director reported he had not assessed the resident to determine if the Foley was still needed and did not see the resident often enough to comment on why it remained in place. The PA believed the resident had urinary retention, had not assessed whether the catheter could be removed, and was unaware that the catheter had already been discontinued until informed during the interview.
Improper Oral Water Administration to NPO PEG-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide care consistent with professional standards for a resident receiving enteral nutrition who was ordered NPO with PEG tube feeding for all nutrition, hydration, and medications. The resident had a history of stroke, malnutrition, dehydration, GERD, dysphagia, aphasia, anemia, and failure to thrive, with a speech evaluation documenting moderate oral dysphagia and clinical signs of pharyngeal dysphagia. The care plan identified swallowing and nutritional problems, including use of enteral feedings via PEG and an NPO status, with interventions specifying tube feeding as ordered and diet to be followed as prescribed. Despite these orders and assessments, staff were observed providing water orally to the resident using sponge-tipped mouth swabs. A CNA repeatedly dipped a mouth swab into a Styrofoam cup of water and placed it into the resident’s mouth multiple times without squeezing out excess water, while the resident sucked water from the sponge. The CNA stated that the resident had requested water several times that morning and that she had given him water with the swab each time he asked. Another CNA reported that the resident was on a fluid restriction, was NPO, and received water via his feeding tube, and that staff were supposed to use lemon mouth swabs to keep his mouth moist because he could not have anything by mouth. Additional observations and interviews showed that the resident continued to request water, that lemon swabs were intended to be used in place of water due to his NPO status, and that there was no specific order for mouth swabs, with oral care treated as a standard of care. A physician progress note documented that a full cup of water had been found at the bedside of this NPO resident with a PEG tube, with nursing staff reporting it was for oral care. Another progress note described the resident with brown-colored emesis on his gown and linens, with tube feeding held pending evaluation for possible obstruction. The unit manager confirmed the resident should not have received water because he was not swallowing and that oral care directions in the Kardex and care plan were unclear, noting that brushing his teeth and rinsing could result in aspiration.
Failure to Maintain Complete and Accurate Treatment and Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records and treatment documentation for multiple residents, as required by its own charting and documentation policy. For one resident with muscle weakness and a need for assistance with personal care, the January 2026 Treatment Administration Record (TAR) showed missing documentation for several ordered treatments. These included wound care to a ruptured blister on the left inner knee with no documentation on one date, wound care for a right forearm skin tear with missing entries on two dates, use of bilateral pressure-relieving boots with no entry on one date, catheter care with no entry on one date, G-tube placement checks with no entry on one date, and coccyx wound care with missing documentation on five separate dates. The TAR did not indicate whether these treatments were completed or refused on the listed dates. Another resident with type 2 diabetes mellitus and pneumonia had incomplete documentation on the February 2026 TAR. There was no recorded entry for a morning pulse oximetry assessment on one date, despite an order related to pneumonia. Wound care orders for a right medial gluteal community-acquired stage 3 (now unstageable) pressure injury, requiring cleansing with normal saline, application of hydrogel, and border gauze every shift, lacked documentation on three dates. Additionally, ordered betadine application to a community-acquired unstageable deep tissue injury (DTI) on the left heel was not documented on two dates, and required checks of the oxygen concentrator for proper function and flow rate every shift were not documented on one date. The TAR did not show whether these treatments and checks were completed or refused. A third resident with repeated falls, multiple sclerosis, dementia, anxiety, and weakness had no weekly skin assessments documented for multiple specified weeks in November and December 2025. Interviews with nursing staff indicated that weekly skin assessments were expected to be completed to identify changes in skin condition, and that these assessments appeared in the electronic record as UADs (assessments) to be completed by nurses. Staff reported that UADs could be skipped and reassigned, and that if not completed within 24 hours they would disappear from the alert system. The DON stated that unit managers were supposed to review shower sheets and resident care tasks daily and follow up on missed documentation or care, and that nurses were expected to document any missed treatment with an explanation in a progress note, but such documentation was not present for the missed treatments and assessments identified.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
A resident with a history of a sacral pressure ulcer and high risk for skin breakdown was not provided with adequate care to prevent the worsening of pressure ulcers. The resident was observed lying flat on her back with her heels pressed against the bed surface, despite care instructions to elevate her heels and reposition every two hours. The resident reported pain and burning from a wound on her buttocks, and stated that staff did not always have the necessary cream available during care. Documentation showed a significant increase in the size of a right gluteal Stage 3 pressure ulcer over a short period, with the wound progressing from a small, stable area to a much larger, fragile, and declining wound with eschar and active bleeding. Staff interviews and observations revealed multiple lapses in care. Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were unaware of the resident's wounds, did not consistently check on the resident, and failed to maintain enhanced barrier precautions as required for infection control. The resident's wound was not covered with a bandage as ordered, and barrier cream was not always available or applied as needed. Incontinence care was not performed properly, with the resident experiencing repeated episodes of catheter leakage that left her clothing and bedding wet. Staff were observed pulling linens out from under the resident, which can cause shearing and further skin breakdown, and did not consistently use gowns and gloves as required. Further, there was a lack of communication and awareness among staff regarding the resident's wound status and care needs. Some staff had not seen the wound, and wound care orders were not consistently followed. The resident, who was cognitively intact, reported ongoing pain and inadequate care. The failure to provide proper wound care, repositioning, incontinence management, and infection control measures resulted in actual skin breakdown and worsening of the resident's pressure ulcers.
Failure to Timely Implement Hospital Discharge Medication Orders on Admission
Penalty
Summary
Nursing staff failed to ensure that a newly admitted resident received care in accordance with professional standards by not implementing hospital discharge medication orders in a timely manner. The resident, who had diagnoses including gastroparesis, returned from the hospital with a comprehensive list of prescribed medications for various conditions such as nausea, vomiting, pain, and heartburn. Upon admission, the responsible LPN entered the medication orders into the computer system but did not complete the process required to transmit these orders to the pharmacy, as a second nurse was expected to confirm and activate the orders. As a result, the pharmacy did not receive the medication orders on the day of admission. The delay in confirming and activating the medication orders led to the resident missing multiple scheduled doses of essential medications, including those for nausea, pain, and other chronic conditions. The resident reported not receiving her prescribed medications for nausea and vomiting, which resulted in her being readmitted to the hospital two days after her initial return to the facility. Documentation confirmed that several doses of medications were missed during this period, as the pharmacy only received the orders the following morning after another nurse discovered the oversight and activated the orders. Interviews with nursing staff and pharmacy personnel revealed that the facility's process required a double-check and activation of new medication orders before they could be sent to the pharmacy. However, this step was not completed by the night shift nurse, leading to a significant delay in medication administration. The resident's care was compromised due to the failure to follow established procedures for timely medication order processing and administration upon admission.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
Facility staff failed to implement physician orders for Enhanced Barrier Precautions (EBP) for a resident with a pressure ulcer and a urinary catheter. The resident's medical record indicated the need for gloves and gowns during high-contact care activities such as dressing, bathing, toileting, personal hygiene, transferring, changing linens, and wound care. Despite these orders, observations revealed that a CNA and an LPN provided direct care, including incontinence care and wound care, without donning gowns as required by EBP protocols. Additionally, the unit manager assisted with repositioning the resident without wearing a gown, even though she acknowledged the resident required EBP due to wounds and catheter use. The need for EBP was not posted at the resident's door. The resident was found with a large, non-blanchable area and an open wound on the buttocks, and the wound had significantly worsened between assessments. The resident also experienced issues with catheter placement, resulting in urine backflow and soiled clothing and bedding. Staff failed to maintain EBP during these care activities, as observed by surveyors, and the required precautions were not consistently communicated or posted for staff awareness.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to maintain proper sanitation and food safety standards in its kitchen and food service areas, affecting 84 residents. During a comprehensive tour of the kitchen, it was observed that one of the hand sink basins was draining slowly, and several plastic utensils were stored uncovered, exposing them to potential contamination. Additionally, food transportation carts, a coffee machine, and a refrigerator door gasket were found to be soiled with accumulated food residue, indicating a lack of effective cleaning and maintenance of food service equipment. Further inspection revealed that several food items were not properly labeled or dated, increasing the risk of foodborne illness. Two containers of sour cream and a gallon of milk were found without effective open or discard dates, and some items were past their best-by dates. The facility's policy on date marking for food safety was not adhered to, as evidenced by the presence of expired and improperly labeled food items in the walk-in cooler and nourishment room. Additional deficiencies were noted in the storage and handling of food products. Opened bags of chocolate chips, cake mix, and spaghetti pasta were not securely sealed, and a case of bread was stored on the freezer floor. In the walk-in cooler, an uncovered plate with a half-eaten piece of cheesecake and a container of cut-up lettuce without labels or dates were found. The facility's failure to follow its policies on food receiving, storage, and sanitation contributed to the increased potential for cross-contamination and bacterial harborage, posing a risk to resident health and safety.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain a clean and safe environment, affecting 84 residents, as observed during an environmental tour. Several areas, including service corridors, janitor closets, and common rooms, were found to be in disrepair and unclean. Specific issues included corroded and soiled appliances in the staff break room, missing laminate on countertops, loose fixtures, and heavily soiled ventilation grills. Additionally, the flooring in multiple janitor closets and the oxygen supply closet was soiled with dust and dirt deposits, and several pieces of furniture were damaged or dirty. Interviews with maintenance aides revealed that the facility uses the TELS program for maintenance work orders, but no specific entries related to the observed maintenance concerns were found in the records for the last 60 days. The facility's policies and procedures for preventative maintenance and housekeeping were reviewed, indicating a lack of adherence to established guidelines for maintaining a safe and sanitary environment. The deficiencies noted during the survey highlight a significant lapse in the facility's environmental services and maintenance practices.
Failure to Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for four residents, leading to unmet needs in areas such as incontinence care, pressure ulcer prevention, skin integrity, respiratory care, and overall wellness. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was at high risk for pressure sores but lacked a care plan addressing this risk. Observations revealed that Resident #13 was not repositioned regularly, and incontinence care was not provided timely, resulting in prolonged periods of wetness and potential skin damage. Resident #38, who was receiving hospice services, did not have these services reflected in their care plan, indicating a lack of coordination between hospice care and the facility's care planning. This oversight could lead to inadequate end-of-life care and support for the resident and their family. Similarly, Resident #44, who was at very high risk for pressure sores and had a history of traumatic brain injury and aphasia, did not have a care plan addressing their high risk for pressure sores or the use of palm protectors and arm elevation for contracture prevention. Resident #76, who had obstructive sleep apnea and used a CPAP machine, did not have a care plan that included the use and maintenance of the CPAP machine. Observations showed that the CPAP equipment was heavily soiled and not properly maintained, despite documentation indicating it had been cleaned. This discrepancy suggests a failure in the facility's processes for ensuring the proper care and maintenance of medical equipment, potentially compromising the resident's respiratory health.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled food to its residents, as evidenced by observations and interviews. During a survey, it was noted that food trays were delivered to various halls and dining areas, with the Main Dining Room being served last. Food temperatures were recorded using a digital thermometer, revealing that several food items, such as pork fritters, mashed potatoes, and peas, were below the required temperature of 135°F, as per the 2022 FDA Model Food Code. Additionally, beverages like coffee and milk were not maintained at safe temperatures, potentially affecting the residents' food acceptance and nutritional status. Interviews with residents and staff highlighted ongoing issues with food quality and temperature. Resident #17, who is cognitively intact, reported that the food, especially during evening meals, was not hot enough and mentioned an incident where an egg sandwich was undercooked. The Dietary Manager confirmed the complaint and acknowledged that residents have raised concerns about food temperatures. Similarly, Resident #45, also cognitively intact, expressed dissatisfaction with the cold food served in her room and had previously communicated these concerns to the Dietary Manager. The facility's policies on maintaining sanitary tray lines and proper food portioning and plating were reviewed, indicating a commitment to safe food handling and appealing presentation. However, the lack of plate warmers and a food committee for residents to voice their concerns were noted as contributing factors to the deficiency. A confidential group meeting with 11 residents further corroborated the issue, with unanimous agreement that the food was not served hot enough, was of poor quality, and often had missing items.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor resident food choice preferences, impacting several residents. Resident #63 expressed dissatisfaction with receiving food items listed as dislikes on her meal card, such as gravy and peas. The facility's policy mandates that food served should accommodate residents' allergies, intolerances, and preferences, with alternative options available. However, this policy was not adhered to, as evidenced by the meal card review and resident interviews. Resident #44, who has a traumatic brain injury and aphasia, received food items that were not consistent with her dietary preferences, such as whole peas and applesauce, despite her meal tray ticket indicating these as dislikes. Additionally, Resident #73, who is mildly cognitively impaired, reported receiving smaller portions than requested, leading to significant unintentional weight loss. The resident's meal ticket indicated a preference for large portions, which was not consistently honored. Other residents, such as Resident #17 and Resident #21, also experienced issues with meal preferences not being met. Resident #17 reported frequent substitutions without prior notice, and Resident #21 did not receive requested items like grapes, with no alternatives offered. The facility's failure to provide meals according to residents' preferences and dietary needs was further corroborated by a confidential group meeting where residents reported missing items on their meal trays.
Infection Control Deficiencies in Glove Use and Equipment Sanitation
Penalty
Summary
The facility failed to ensure proper glove use during incontinence care and injection administration, and sanitary storage of respiratory equipment, affecting three residents. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was observed receiving incontinence care with improper glove use. CNA P used soiled gloves to apply barrier cream and wash the resident's peri area, violating standard infection control practices. Additionally, the resident's urine test results were pending, and there was a history of severe UTIs. Resident #44, diagnosed with traumatic brain injury and aphasia, was also subject to improper glove use. CNA Q was observed handling clean objects and opening the door while still wearing soiled gloves after providing peri care. This action posed a risk of cross-contamination and did not adhere to proper infection control protocols. Resident #76, with obstructive sleep apnea, had a CPAP machine that was heavily soiled and improperly stored. The machine was observed running with the hose on the ground and the mask on the bed, contrary to the facility's cleaning and storage orders. The resident reported that the machine was not cleaned, and the Director of Nursing confirmed the equipment's poor condition. Additionally, an LPN was observed administering an insulin injection without gloves and failed to perform hand hygiene, further compromising infection control standards.
Failure to Uphold Resident Dignity and Respect
Penalty
Summary
The facility failed to uphold the dignity and respect of its residents, as evidenced by multiple observations and interviews. Resident #13, who was cognitively impaired and dependent on staff for personal hygiene, was observed with wet pants and crumbs on his shirt. Despite his non-verbal cues indicating discomfort, staff members, including a CNA and the Director of Nursing, failed to address his needs promptly. The resident's use of a pocket talker for hearing was overlooked, and his incontinence was not managed in a timely manner, leading to prolonged discomfort. Resident #44, who had a traumatic brain injury and aphasia, was also subjected to a lack of dignity during care. While being transferred and receiving incontinence care, CNAs conversed with each other rather than engaging with the resident, who could hear but not speak. This behavior was noted as disrespectful, as the staff did not acknowledge the resident's presence or attempt to communicate with him during care. Resident #54 reported experiencing pain and difficulty sleeping, and when seeking assistance, was met with a dismissive attitude from a nurse. The nurse expressed frustration about her workload before addressing the resident's request for pain medication. Additionally, a group meeting with 11 residents revealed widespread dissatisfaction with the staff's treatment, citing issues such as unfamiliarity with resident needs, personal phone use, and inadequate attention during night shifts.
Failure to Assess Residents for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents did not self-administer medications without a proper assessment of their ability to do so safely. During an observation, Resident #28 was found with a medication cup containing five pills left on their tray table, which the resident reported was left by a nurse for later consumption. There was no assessment or orders in the record for Resident #28's self-administration of medications. Similarly, Resident #69 was observed with a medication cup in the hall and was unsure about one of the pills, which was identified by an LPN as a pancreatic enzyme pill. The LPN mentioned that Resident #69 was alert and could self-administer medications, but there was no assessment or orders in the record to support this. The Director of Nursing confirmed that no residents in the facility were assessed to self-administer medications, and staff were expected to supervise medication intake to ensure compliance.
Failure to Investigate Abuse Allegations
Penalty
Summary
The facility failed to investigate an allegation of abuse for Resident #37, who reported that a staff member bent his thumbs backward, causing ongoing pain and difficulty in gripping objects. Despite the resident informing management, there was no documentation or investigation into the incident. Interviews with staff revealed a lack of awareness and communication regarding the allegation, with the Director of Nursing (DON) unable to locate any records or statements related to the incident. For Resident #49, the facility did not provide an accurate investigation into an allegation of abuse involving a CNA potentially restraining the resident during care. The resident, who was known to be combative due to Alzheimer's, was reportedly held down by a CNA while other staff assisted with incontinence care. Witnesses described the CNA's actions as abusive, including holding the resident's arms and covering his face with a soiled sheet. Despite these reports, the facility's investigation summary did not include all witness statements and concluded that the event was not a result of abuse or neglect. The facility's failure to thoroughly investigate these allegations and accurately document witness accounts resulted in the potential for further abuse. The lack of communication and proper documentation among staff, as well as the incomplete investigation, highlights deficiencies in the facility's handling of abuse allegations.
Failure to Provide Bed Hold Notices During Hospital Transfers
Penalty
Summary
The facility failed to notify two residents and their representatives of the bed hold policy in writing upon their transfer to a hospital, as required by the facility's policy. Resident #37, who was cognitively intact, was transferred to the hospital on two occasions, once for a headache due to a fall and another time for lethargy and difficulty maintaining oxygen levels. However, there was no documentation that Resident #37 received a written bed hold notice on either occasion. Interviews with the Director of Nursing and Licensed Practical Nurses confirmed that a bed hold form should be provided at each hospital transfer, but the Nursing Home Administrator admitted that the documentation could not be located for the specified dates. Similarly, Resident #43 was transferred to an acute care hospital at the request of his wife due to his lack of appetite and failure to return to his baseline condition. The facility's records did not contain any documentation of a bed hold notice being provided to Resident #43 or his representative prior to the transfer. An email inquiry to the Nursing Home Administrator confirmed that the documentation could not be found. The facility's bed hold policy, revised in 2019, mandates that a copy of the policy be provided to the resident and their representative before and during transfers for hospitalization or therapeutic leave.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards for medication administration, specifically during an insulin injection for Resident #332. During an observation, an LPN was seen administering an insulin injection without wearing gloves and subsequently did not perform hand hygiene after the procedure. The LPN then proceeded to another resident's room without performing hand hygiene, where she discussed pain medication and handled a meal tray. In an interview, the LPN stated that she did not wear gloves or perform hand hygiene because she believed there was no exposure to blood or body fluids. According to the Centers for Disease Control, gloves should be worn during procedures involving potential exposure to blood or body fluids, and hand hygiene should be performed immediately after glove removal and before touching other medical supplies intended for use on other persons.
Failure to Provide Adequate ADL Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care to two residents, resulting in unmet care needs and an unkempt appearance. Resident #19, who was admitted with diagnoses including localized edema and aphasia following a cerebral infarct, was observed multiple times without her prescribed ted hose, which were ordered to be worn every morning and removed at night. Despite documentation in the medication administration record (MAR) indicating that the ted hose were applied, observations and interviews confirmed that they were not. The Licensed Practical Nurse (LPN) responsible for documentation admitted to not verifying the application of the ted hose, relying instead on the Certified Nurse Assistants (CNAs) to perform this task. Resident #76, who was cognitively intact and required substantial assistance for personal hygiene, reported not receiving a shower for approximately 2-3 weeks and had not been assisted with shaving during that time. Observations noted that Resident #76 had a soiled shirt, messy hair, and overgrown facial hair. The resident expressed a desire for regular showers and basic hygiene assistance, such as washcloths for daily cleaning. Despite being scheduled for a shower, the resident reportedly refused due to the early timing, and the Shower Aide (SA) did not have a shaver available during previous showers. The facility's failure to ensure the application of ted hose for Resident #19 and to provide regular showers and hygiene assistance for Resident #76 highlights a deficiency in meeting the residents' ADL needs. The Director of Nursing (DON) confirmed the expectation that nurses should verify and document the application of ted hose, which was not adhered to in this case. Additionally, the lack of consistent hygiene care for Resident #76 was evident, as the resident had not received regular showers or basic hygiene support, leading to an unkempt appearance.
Failure to Prevent Pressure Ulcers in At-Risk Residents
Penalty
Summary
The facility failed to provide preventative care consistent with professional standards for two residents at risk of developing pressure injuries. Resident #13, who was cognitively impaired and dependent on staff for all toileting and personal hygiene needs, was identified as being at high risk for pressure sores with a Braden Scale score of 11. Despite this, there was no care plan developed for pressure sore risk or preventative interventions. Observations revealed that Resident #13 was left in a broda chair for extended periods without repositioning, and staff failed to check or change the resident's incontinence brief, resulting in wetness and potential skin damage. Resident #44, who was severely impaired and completely dependent on staff for mobility and hygiene, had a Braden Scale score of 9, indicating a very high risk for pressure sores. However, the care plan lacked information related to pressure sore prevention. Observations showed that Resident #44 was left in a broda chair for prolonged periods without repositioning or offloading pressure from the heels, contrary to the facility's protocol of repositioning every two hours. The resident was also found with a bulging incontinence brief and wet pants, indicating a lack of timely incontinence care. Interviews with staff, including the Director of Nursing, confirmed that both residents should have been repositioned every two hours and checked for incontinence regularly. The facility's failure to implement these preventative measures and adhere to care plans for pressure sore prevention resulted in the potential for the development of avoidable pressure ulcers, infection, and overall deterioration in health status for both residents.
Failure to Use Gait Belts and Wheelchair Foot Pedals
Penalty
Summary
The facility failed to ensure safe transport and transfer practices for residents, leading to potential injury risks. Resident #63, who was cognitively intact and had a history of repeated falls and weakness, was observed being transported in a wheelchair without foot pedals, requiring her to hold her feet off the floor. Additionally, during transfers to and from the commode, the Certified Nurse Assistant (CNA) did not use a gait belt, despite the facility's policy and the presence of gait belts in the resident's room. Interviews with various staff members, including the CNA, Licensed Practical Nurse (LPN), Registered Nurse/Unit Manager (RN/UM), and Director of Nursing (DON), confirmed that gait belts should be used for all transfers that do not require a mechanical lift, and foot pedals should be in place when pushing a wheelchair. Resident #37, who had multiple diagnoses including acute respiratory failure and COPD, experienced a fall when a new CNA did not use a gait belt during a transfer. The incident report indicated that the resident was found on the floor after attempting to sit down before the CNA had finished changing his brief. The CNA, who was recently hired, had received education on the use of gait belts following the incident. Interviews with the DON confirmed that the CNA should have used a gait belt during the transfer, as per facility policy.
Failure in Timely Incontinence Care and Infection Control
Penalty
Summary
The facility failed to provide timely incontinence care and perform hand hygiene according to standard infection control practices for two residents, resulting in potential risks for skin breakdown and urinary tract infections. Resident #13, who was cognitively impaired and dependent on staff for all toileting and personal hygiene needs, was observed in a wet incontinence brief for an extended period. Despite multiple observations and interactions with staff, the resident's needs were not addressed promptly. The resident was left in a broda chair for long periods without being checked or changed, and staff failed to reposition him as required. Additionally, when incontinence care was eventually provided, proper hygiene practices were not followed, as gloves were not changed between tasks, and the resident was not cleaned from front to back. Resident #44, who was severely impaired and completely dependent on staff for toileting and personal hygiene, was also left in a wet incontinence brief for an extended period. Observations revealed that the resident remained in the same position for hours without being checked or changed. Despite the presence of staff on the hall, no care was provided to the resident until a family member expressed concern about the resident being soaking wet. The facility's failure to adhere to the care plan, which required checking and changing the resident every two hours, contributed to the deficiency. The report highlights the facility's failure to provide adequate incontinence care and adhere to infection control practices, as evidenced by the prolonged periods during which both residents were left in wet briefs. The lack of timely care and proper hygiene practices poses a risk for skin breakdown and urinary tract infections, particularly for residents with a history of severe UTIs, like Resident #13. The observations and interviews with staff and family members underscore the facility's shortcomings in meeting the residents' needs and following established care protocols.
Failure to Maintain Sanitary CPAP Equipment
Penalty
Summary
The facility failed to maintain and store CPAP equipment in a sanitary manner for a resident with obstructive sleep apnea, leading to an increased potential for respiratory infection and distress. The resident, who was cognitively intact, had a CPAP machine upon admission, with orders for daily cleaning and maintenance. However, observations revealed that the CPAP machine, hose, and mask were heavily soiled with dirt and grime, and the water container was empty with a dried white substance. The resident reported that the CPAP machine was not being cleaned, and a registered nurse did not address the running machine or offer assistance during a medication administration. The Director of Nursing confirmed that the CPAP machine should be cleaned weekly by nursing staff and that there were orders to ensure proper use and storage of the equipment. Despite these orders, the resident's care plan did not indicate the use of a CPAP machine or the presence of sleep apnea. The Director of Nursing observed the soiled equipment and acknowledged the inability to clean it, indicating a need for replacement by the durable medical equipment company.
Failure to Limit PRN Psychotropic Medication to 14 Days
Penalty
Summary
The facility failed to ensure that PRN psychotropic medications were limited to 14 days unless a documented rationale by the physician was present in the medical record. This deficiency was identified in the case of a resident who was admitted with diagnoses including PTSD, bipolar disorder, anxiety disorder, and dementia. The resident was cognitively intact, as indicated by a BIMS score of 15/15. The resident was receiving Xanax twice daily and Ativan at night. A physician's recommendation suggested treating the resident's anxiety with a single medication and attempting a gradual dose reduction or discontinuation of Xanax. However, the physician's order dated 12/30/2024 for Xanax as needed did not include a 14-day limit or a stop date, and there was no documented rationale for extending the PRN order beyond 14 days. The facility's policy requires that PRN psychotropic medications be limited to 14 days unless the attending physician documents a reason for extension in the resident's medical record. The Social Services Director confirmed that the order did not comply with this policy, as it lacked a stop date and documented rationale for the extended use.
Failure to Protect Resident from Abuse During Care
Penalty
Summary
A resident with Alzheimer's disease, who was known to be resistant and combative during activities of daily living (ADL) care, was subjected to inappropriate handling by staff during incontinence care. The resident's care plan specified that if the resident resisted care, staff should reassure the resident, ensure a safe environment, leave, and return later to try again. Despite these instructions, three CNAs proceeded with care while the resident was combative, with one CNA holding the resident's hands to his chest while the others performed care. This action was not in accordance with the care plan's de-escalation strategies. Multiple staff interviews revealed that the CNA at the head of the bed pinned the resident's arms down, verbally engaged with the resident in a confrontational manner, and covered the resident's head and arms with a soiled sheet to facilitate rolling the resident. Other CNAs present objected to this treatment, repeatedly asking the CNA to stop, and one removed the sheet from the resident. Both CNAs who witnessed the incident reported the behavior as abusive to the charge nurse and subsequently felt threatened by the facility administrator, leading them to resign. The incident was reported to facility leadership, but the CNA accused of abuse continued to work on the floor until the Director of Nursing and the Nursing Home Administrator arrived and suspended her. The LPN on duty was unsure of the protocol for removing the accused CNA from resident care and did not intervene immediately. The actions taken by the staff during care, including physical restraint and verbal intimidation, were inconsistent with the resident's care plan and failed to protect the resident from abuse.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to implement its policies and procedures for reporting an allegation of abuse involving a resident, leading to a potential delay in investigation and further abuse. The incident involved a resident who was admitted to the facility with a diagnosis of kidney failure. The resident alleged that he had been kicked by a staff member, resulting in cracked ribs, and was subsequently admitted to the hospital. The resident's BIMS score indicated that he was cognitively intact, which supports the credibility of his allegation. The deficiency occurred when the Nursing Home Administrator (NHA) was informed of the abuse allegation at approximately 1:00 AM but did not submit the Facility Reported Incident (FRI) until 10:39 AM, about 10 hours later. This delay in reporting was despite the fact that the resident had already been discharged to the hospital and had sustained injuries. The Social Worker and Registered Nurse involved in the case reported the allegation to the NHA promptly, but the NHA's delayed action in submitting the FRI contributed to the deficiency.
Inadequate Supervision Leads to Repeated Falls and Injuries
Penalty
Summary
The facility failed to provide adequate supervision for three residents at risk for falls, resulting in repeated falls and injuries. Resident #114, who was admitted with diagnoses including kidney failure, experienced multiple falls within a short period. Despite being identified as high risk for falls, interventions such as medication review and room relocation were insufficient. The resident sustained a cervical fracture and later acute rib fractures, indicating a lack of effective supervision and timely intervention. Resident #108, with partial paralysis following a stroke, also experienced multiple falls. Despite being assessed as high risk for falls, the resident was found on the floor several times, including incidents where they were injured. The facility's response included relocating the resident to common areas for monitoring, but this did not prevent further falls, highlighting inadequate supervision and staffing issues. Resident #106, diagnosed with dementia, was identified as high risk for falls and experienced numerous falls. The interventions implemented, such as placing the resident in common areas and using gripper socks, were not sufficient to prevent falls. Observations revealed the resident was left unsupervised for extended periods, and interviews with staff indicated that staffing levels were inadequate to provide necessary supervision, contributing to the repeated falls.
Inadequate Staffing Leads to Multiple Resident Falls
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of residents, particularly those at risk for falls. The staffing issues were highlighted by the experiences of three residents who suffered multiple falls due to inadequate supervision. The facility's scheduler reported that staffing was based on census numbers, and there was a reliance on agency nurses, but not on Certified Nursing Assistants (CNAs). On the third shift, the facility was understaffed, with only one CNA assigned to each hall and a float CNA who was not always available. This resulted in CNAs being overwhelmed and unable to provide adequate supervision, especially for residents requiring two-person assistance. Resident #114, residing on the rehab hall, experienced several falls due to insufficient supervision. The rehab hall was not visible from other areas, and staff were often required to assist on other halls, leaving the rehab hall unsupervised. On multiple occasions, Resident #114 fell while staff were attending to other duties, and there was a delay in assistance. The resident suffered a significant injury, including a fracture of the cervical vertebrae, after one of the falls. Resident #108 was also affected by the staffing shortage, as he was restless and frequently attempted to get out of bed. With only one CNA on the south hall during the third shift, staff were unable to monitor him adequately, leading to several falls. Similarly, Resident #106, who was at risk of falling, was often left unsupervised due to the limited number of CNAs available to assist with residents requiring two-person assistance. The facility's reduction in staff numbers exacerbated the situation, making it difficult for staff to provide the necessary care and supervision to prevent falls.
Inadequate Provision of Evening Snacks
Penalty
Summary
The facility failed to consistently offer or provide hour of sleep (HS) snacks to two residents, resulting in dissatisfaction. Resident #102 reported the unavailability of snacks in the evening, while Resident #113 noted that snacks were limited and not offered unless a resident's name was on a list. Staff interviews revealed that sandwiches were unavailable after the kitchen closed at 8:00 PM, and snacks were primarily provided for diabetic residents. Staff sometimes resorted to purchasing snacks from vending machines or external sources to meet residents' requests. The Dietary Manager acknowledged a reduction in evening kitchen staff, which affected the timely delivery of meals and snacks. Observations of nourishment rooms showed limited availability of snacks, with some rooms being locked or used for personal food storage. The Director of Nursing was unaware of the issue, despite reports from multiple staff members indicating a lack of snacks for non-diabetic residents and insufficient stocking of nourishment rooms. This deficiency highlights a gap in the facility's ability to meet residents' needs for snacks outside of scheduled meal times.
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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.
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Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Plainwell | 4.8 mi | ★★★★★ | 20 | 0 |
| Medilodge Of Westwood | 6 mi | ★★★★★ | 2 | 0 |
| Friendship Village | 6.7 mi | ★★★★★ | 15 | 0 |
| Plainwell Pines Nursing And Rehabilitation Communi | 8.3 mi | ★★★★★ | 29 | 1 |
| Medilodge Of Kalamazoo | 8.5 mi | ★★★★★ | 4 | 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 August 2026) and official state health department websites.