Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bayside Village during CMS and state inspections, most recent first.
Failure to Identify High Fall Risk Residents: The facility did not document fall-risk status in the care plans for three residents with fall histories and related diagnoses, including one resident with severe cognitive impairment and a recent major injury. The DON stated the facility did not have a Fall Prevention Program, and staff reported there were no door or wheelchair indicators to identify high fall risk residents. CNA interviews confirmed they relied on the care plan for fall-risk identification, but the care plans did not show the residents’ risk level.
A resident with severe cognitive impairment, epilepsy, gait instability, and repeated falls sustained a pelvis fracture after standing outside a closed med room door while two LPNs were inside and not providing supervision. Video showed one LPN using a personal cell phone and the other also on a personal cell phone while the resident fell at the door. The resident had a fall care plan directing staff to leave the med room door open when the resident was looking for them, but that intervention was not followed.
A resident with severe cognitive impairment and a history of wandering was able to leave the facility unsupervised for about 30 minutes after staff failed to properly assess elopement risk, did not provide adequate supervision, and did not respond appropriately to exit door alarms. The resident exited through a malfunctioning delayed egress door, was found outside in a ditch with complaints of cold and pain, and required transfer to the ED. Staff were inattentive, did not update care plans or assessments in response to behavioral changes, and did not follow facility policies regarding supervision and alarm response.
A resident with cognitive and mobility impairment was left on the toilet, got up without staff present, and fell with later-discovered major injury; staff also moved the resident before documented vitals or neuro checks. Another resident with severe cognitive impairment accessed a razor left in the room and cut his tongue, and the injury was not reported with an incident form. A third resident with dementia attempted to elope, but the record lacked an elopement assessment, care plan update, or documented increased supervision.
The facility failed to ensure RN coverage for eight consecutive hours in a 24-hour period. PBJ staffing data and facility records showed no RN hours on multiple days, including a day with no RN coverage for the full 24-hour period. Interviews confirmed there was no RN scheduled or present for the required time, and the NHA acknowledged the lapse.
Failure to complete annual CNA performance review. The facility did not complete a performance evaluation for one CNA who had been hired the prior year, and the DON acknowledged there was no policy for performance evaluations or when they were due. The NHA also acknowledged the review was not completed and should have been done annually.
Pharmacist failed to provide written MMR recommendations to the physician for several residents reviewed, and facility leaders confirmed there were no written pharmacy recommendations from MMRs for any resident over the past year. The pharmacist said he often relied on physician notes about GDRs and sent concerns to the DON by email or correspondence rather than submitting written recommendations to the MD.
Failure to conduct QAPI PIPs: the NHA said the committee had been "putting out fires" and was unsure what projects had been done, and the DON stated no PIPs had been done in the last year because the former NHA said the facility was getting cited anyway. No PIPs were available for review, despite the facility policy requiring distinct PIPs, at least one annual project focused on high-risk or problem-prone areas, ongoing performance tracking, and an annual self-assessment.
QAA committee meetings were not held quarterly with all required members present. Record review showed only one QAA meeting in the quarter, and the Medical Director was absent from that meeting. The NHA stated there likely were no QA meetings in the other months of the quarter, and no additional sign-in sheets were provided.
The facility failed to ensure one CNA completed the required 12 hours of annual training. The HR Manager stated the annual training is based on the CNA hire date, and record review showed the CNA had only 9 hours of training in a year. The DON's Facility Assessment stated nurse aide in-service training must be sufficient to ensure continuing competence and no less than 12 hours per year, and the NHA acknowledged the annual training requirement.
Homelike Environment Not Maintained: Residents were served breakfast and lunch on institutional trays in the dining room, with meals distributed in no particular order and tablemates not served together. The Dietary Mgr stated the DON had questioned why trays were used and said it would be a better dining experience without them. The nurses’ station also had lifted and peeled paneling and missing or hanging wallpaper, and RN and SS staff described the area as rough, needing repair, and not very functional.
Failure to Provide Bed Hold and Transfer Notices: The facility did not provide written bed hold information for five residents and did not provide written transfer notices explaining the reason for hospitalization or the bed hold policy for four residents. Records for residents transferred to the ED or hospitalized did not show that the resident or representative received the required notices, and the NHA and DON acknowledged the notices were not being sent.
An RN left a medication cart unlocked and unattended while stepping away during med pass, and another medication cart in a common area was later found unlocked and unattended. In addition, a resident with intact cognition and no self-administration order or assessment had antacid medication left in a medicine cup at the bedside, and the resident stated staff sometimes leave medication there. The DON confirmed carts should be locked when not attended, and facility policy required medications to remain secured or under direct observation during administration.
Failure to Attempt GDR for Psychotropic Medications: A resident with dementia, depression, and aphasia was receiving quetiapine and escitalopram, but the record showed no documented GDR attempt despite no behaviors documented in the MDS or behavior logs. Surveyors found the resident was generally described as pleasant, stable, and without behavioral concerns in social services and physician notes, while the physician declined the GDR based on stability and past behaviors without a documented risk-versus-benefit review.
A resident with depression, hallucinations, psychotic disorder with delusions, anxiety, and Alzheimer's disease had severe cognitive impairment, behavioral symptoms toward others, and orders for quetiapine and sertraline. The EMR contained an older PASARR Level I annual resident review, but a current annual PASARR Level I could not be found. The DON reviewed the record and confirmed there was no current PASARR Level I on file.
Two residents with COPD had deficiencies in oxygen therapy management and respiratory equipment handling. One resident had supplemental O2 in use without a physician order, care plan, or physician documentation, and nebulizer and nasal cannula tubing were left unbagged, undated, and placed directly on equipment. Another resident had oxygen tubing that was not properly marked or stored, ordered SpO2 checks were missed on multiple occasions, and the care plan lacked interventions for O2 monitoring, tubing changes, and storage.
Missing Physician Visit Documentation: A resident with a history of DVT had no physician visit notes or assessment documentation in the EMR after the last available note, despite staff stating the physician had been in the facility and had been notified about repeated med errors. The DON and NHA both confirmed the record lacked documentation showing the physician reviewed the resident's care, condition, or current regimen.
Two residents did not receive required timely physician visits. One resident with generalized anxiety disorder had a gap of greater than 60 days between physician visits, and another resident with pulmonary embolism, pneumonia, and dementia did not receive the first physician visit until nearly 2 months after admission, with subsequent NP visits also occurring more than 2 months apart. The NHA and DON acknowledged the visits were not completed at 30-day intervals during the first 90 days after admission and noted difficulty with timely visits by the attending MD.
Wrong Medication Given to A Resident A nurse prepared two residents’ nighttime meds side by side and accidentally placed another resident’s Lopressor/metoprolol into a resident’s cup. The resident swallowed the pills before the error was recognized. The resident had Alzheimer’s disease with severe cognitive impairment and did not have HTN, HF, or angina. The chart documented the wrong-medication event and later vital checks, but the RN manager was not told until the next day, and the record lacked an incident report and documentation that the resident’s husband/DPOA was notified.
A resident had an unwitnessed fall with a forehead laceration requiring sutures, followed by repeat ER visits for continued bleeding and additional sutures. The care plan remained focused on an earlier fall with no injury and was not updated with new interventions after the injury, and a fall risk assessment was left blank despite prior documentation that the resident was at risk for falls.
A resident with acute embolism, atrial fibrillation, rheumatoid arthritis, and ASHD was repeatedly given Xeljanz XR instead of ordered Eliquis by evening nurses. An LPN identified the mix-up after noticing an unusual medication supply pattern, marked the blister packs, and reported the ongoing error to the DON; RN staff confirmed awareness, but the EMR and MAR did not document the errors, and the consultant pharmacist was not notified.
A resident with a Foley catheter experienced blood in the urine, swelling, and decreased urine output, with repeated findings of an overfilled catheter bag that was not emptied as required. Staff failed to document care accurately and in a timely manner, and significant changes in the resident's condition were not communicated to the physician. These deficiencies led to the resident developing a ruptured bladder, UTI, and septic shock, ultimately resulting in death.
A resident with moderate cognitive impairment and a history of falls was being assisted in a transfer by a CNA who failed to use a gait belt as required by the care plan and facility policy. Instead, the CNA held the resident by her pants and buttocks, resulting in the resident slipping, falling, and sustaining a head laceration and pelvic fracture. Documentation and interviews confirmed the care plan was not followed, leading to hospitalization for the resident.
A significant medication error occurred when an RN administered medications intended for another resident, due to improper labeling and storage of medication cups. The affected resident, with multiple chronic conditions, received several unprescribed medications and required hospital monitoring for potential adverse effects. Family notification was not documented, and facility policy regarding medication handling was not followed.
The facility failed to provide adequate staffing, resulting in unmet care needs for residents. Interviews revealed that residents experienced delays in receiving medications and assistance, with one resident falling and being left on the floor due to insufficient staff. Staff confirmed frequent understaffing, particularly during night shifts and weekends, which compromised care. The facility's staffing schedule did not meet the requirements outlined in its Facility Assessment.
The facility failed to ensure that three CNAs had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. The CNAs, hired at different times, lacked dated competency skills after their respective hire dates. The DON and NHA acknowledged the absence of dated competency skills, and the Facility Assessment indicated annual evaluations on 23 areas, but the surveyor received an incomplete and undated list of training on 13 areas.
The facility did not conduct annual performance reviews for three CNAs, as required by their policy. CNAs hired in 2021, 2022, and 2023 had not received reviews, confirmed by the DON and HR staff. This lapse was acknowledged by the NHA and DON, indicating non-compliance with the facility's policy.
The facility failed to maintain food safety standards, with staff not washing hands between handling soiled and clean dishes, improper cleaning of cooling collars, and incorrect sanitizer testing. Ice buildup in the freezer and dust on a fan were noted, along with splash contamination risk in the dining room. Staff U did not follow hand hygiene protocols, posing a risk to residents.
The facility failed to ensure the QAPI committee met quarterly with required members, including the Medical Director and DON, leading to potential quality-of-care concerns for all 57 residents. Several meetings lacked attendance by the Medical Director, and no meetings were held in November and December 2023, violating CMS regulations.
The facility failed to provide three CNAs with the required 12 hours of annual in-service training, as confirmed by interviews and record reviews. CNA P, S, and T did not meet the training requirement based on their hire dates, with only 9.5, 5, and 10.25 hours completed, respectively. The facility's policy mandates at least 12 hours of training annually to ensure CNA competence, a requirement acknowledged as unmet by the DON and NHA.
The facility failed to provide behavioral health care training to two CNAs, as required by their policy. The training logs showed no record of such training for these staff members, and the Facility Assessment did not include a requirement for it. The NHA and DON acknowledged this absence, which could potentially affect all 57 residents.
The facility failed to update care plans after multiple falls for several residents, including those with Alzheimer's and Parkinson's disease. Despite falls occurring, care plans were not revised to include new interventions, as acknowledged by the DON. This oversight was contrary to the facility's policies on accident prevention and fall risk assessment.
The facility failed to ensure accurate physician visits and documentation for four residents, leading to potential gaps in comprehensive medical care. Physician K's notes often contained inaccuracies, such as incorrect medication dosages and diagnoses, and lacked thorough reviews of residents' conditions. The facility's policy on physician supervision and documentation was not followed, contributing to these deficiencies.
The facility failed to label opened inhalers and eye drops with the date they were opened, as required by policy. During audits of two medication carts, it was found that several medications for multiple residents were not labeled with opening dates, leading to the potential use of expired medications. Both a registered nurse and an LPN acknowledged the oversight, and the DON confirmed the policy requirement.
A resident with Alzheimer's Disease was observed in a wheelchair with a tray table and pommel cushion, which were used as restraints without proper assessments, physician orders, or care plan documentation. The facility did not provide education on restraint risks to the resident's representative, and no interventions were attempted before applying the restraints. The facility's policy on a restraint-free environment was not followed.
A resident receiving hospice services experienced a lack of proper coordination and communication between the LTC facility and the hospice provider. The facility did not have a physician order for hospice, nor a care plan or documentation of hospice visits in the resident's medical record. Interviews with the DON and an RN revealed uncertainty about the start date of hospice services and a lack of documentation on scheduled hospice visits. The facility's policy on hospice coordination was not followed, leading to this deficiency.
A resident with depression and other medical conditions expressed feelings of depression due to the recent loss of their son. The facility failed to provide supportive visits, grief counseling, or referrals to outside services, and did not include this issue in the resident's care plan. The Social Services Designee and Nursing Home Administrator acknowledged these oversights, which were contrary to the facility's policy on providing medically related social services.
A resident with pressure ulcers did not receive timely wound treatment medication due to the facility's failure to reorder Santyl. Despite physician orders, the medication was unavailable for seven days, and staff did not contact the physician for alternative orders. The facility's policies on medication cross-matching and reordering were not followed, leading to this deficiency.
The facility failed to attempt a gradual dose reduction (GDR) for a resident on Seroquel, despite recommendations, and did not ensure accurate antipsychotic medication dosage for another resident. Discrepancies in medication orders and lack of documentation were noted, with staff unable to explain the incorrect dosage administration.
The facility failed to implement a comprehensive Water Management Plan for Legionella control, as a humidifier used in the resident area was not assessed, and only one water sample was collected annually for testing. The Maintenance Supervisor was unaware of any Legionella discussions during QA or QAPI meetings, and there was no documentation of disinfectant levels or temperature control, exposing residents to potential Legionella infections.
A cognitively impaired resident eloped from the facility after a visitor allowed her to exit. Despite being identified as an elopement risk, the resident did not have a wander alarm due to a history of cutting them off. Staff were unaware of the exit until alerted by another visitor. The facility lacked adequate supervision, especially during weekends, and had no consistent policy for wander guard placement.
Failure to Identify and Document High Fall Risk Residents
Penalty
Summary
The facility failed to identify residents at high risk for falls, failed to implement a fall prevention program, and failed to document fall-risk status and related interventions in the care plans for three residents reviewed for falls. R1’s MDS dated 4/10/26 showed diagnoses including history of falling, unspecified dementia, nondisplaced intertrochanteric fracture of the right femur, repeated falls, and need for assistance with personal care. R1 also had a BIMS score of 4 of 15, indicating severe cognitive impairment. R1’s Fall Risk Evaluation completed on 4/13/26 scored 13, and the form stated that a score of 10 or greater indicated high risk and that prevention protocol should be initiated immediately and documented on the care plan. R1’s Fall Care Plan included interventions such as checking and assisting with toileting at specified times, a bed alarm added after a fall with major injury, and reminders to use the wheelchair, but it did not identify R1 as high fall risk. Review of R2 and R3’s Fall Care Plans also found no documentation of their level of fall risk. During interview, the DON stated she did not know the score that indicated high fall risk until she looked it up, and said the facility did not have a Fall Prevention Program. The DON also stated there were no stickers on doors or wheelchairs to identify high fall risk residents, and the BOM acknowledged the facility was not doing what it had indicated it would do for high fall risk residents. The facility’s list of residents who had fallen in the last 3 months identified 17 residents with 46 falls, including 37 unwitnessed falls, without high fall risk being identified in the care plan or staff education being provided to identify high risk residents. CNA interviews showed staff relied on the care plan to identify fall risk, but both CNAs stated R1’s care plan did not identify a fall risk and confirmed there were no symbols or stickers used anywhere in the facility. Both CNAs believed R2 and R3 may be high fall risk residents because they had alarms, but they had no other method to identify high fall risk residents. At exit conference, the NHA acknowledged that residents with high fall risks did not have documentation of such in their care plans and had no visual identification method such as door name plates or wheelchairs.
Failure to Follow Fall Care Plan and Maintain Supervision
Penalty
Summary
The facility failed to ensure supervision and to follow a resident’s care plan interventions intended to prevent falls for one resident with severe cognitive impairment, epilepsy, anoxic brain damage, gait instability, repeated falls, and wheelchair dependence. The resident’s MDS showed a BIMS score of 3 out of 15, and the admission record documented multiple mobility-related diagnoses, including unsteadiness on feet and abnormal gait and mobility. The resident also had a fall care plan intervention stating that if the resident was looking for staff in the medication room, the medication room door needed to be left open, and that the door should only be shut when staff were giving report and counting. Surveillance video of the fall showed that no staff were at the nurses’ station while two LPNs were in the medication room with the door closed. One LPN was observed using a personal cell phone, and the other was also observed on a personal cell phone and otherwise inactive. The resident was seen standing outside the closed medication room door and then fell to the floor. The post-fall assessment documented that the resident was high risk prior to the fall and that the resident believed the fall occurred while standing at the med room window. The interdisciplinary team later documented that the care plan was not being followed because the medication room door was closed with two nurses in the med room. The resident sustained a major injury from the fall, and the emergency room record documented left superior and inferior pubic rami fractures. The resident’s fall care plan was later updated to include a wheelchair pressure sensor alarm, but at the time of the incident the resident was still described as propelling independently throughout the facility. Interviews with nursing staff confirmed awareness of the instruction to leave the medication room door open on nights when staffing was reduced, and the facility’s personal cell phone policy prohibited use of personal cell phones on nursing units or in working areas.
Failure to Prevent Resident Elopement Due to Inadequate Assessment, Supervision, and Door Security
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of progressive neurological disease, diabetes, non-Alzheimer's dementia, anxiety, and depression was not properly assessed for elopement risk, nor adequately supervised, resulting in the resident eloping from the facility undetected for approximately 30 minutes. The resident, who had documented patterns of wandering, was able to exit the building through a 300 Hall door that did not function as intended, opening before the required 15-second delay. Staff failed to notice or respond appropriately to the resident's wandering behaviors, and the resident's care plan did not address wandering or elopement risk until after the incident occurred. Surveillance footage showed the resident wandering unsupervised throughout the facility for an extended period, including multiple attempts to exit the building. Staff were observed to be inattentive, with one LPN using a personal cell phone at the nurses' station and leaving the resident unsupervised. When the exit door alarm was triggered, staff did not conduct a head count or search outside, only resetting the alarm and looking out the window. The resident was later found outside in a ditch, inadequately dressed for the weather, complaining of cold and pain, and required transfer to the emergency department for evaluation. Documentation and interviews revealed that staff did not consistently review progress notes or update elopement risk assessments in response to changes in the resident's behavior. The resident's care plan lacked interventions for wandering prior to the incident, despite multiple documented episodes of nighttime wandering and exit-seeking. Staff were also not fully aware of or did not follow facility policies regarding supervision, response to exit alarms, and use of personal cell phones, contributing to the failure to prevent the elopement.
Removal Plan
- Elopement and Wandering Residents Policy reviewed and updated.
- All staff were made aware of mandatory all staff meeting regarding elopement policy and responsibilities during an elopement.
- Maintenance director inspected and tested 300 Hall exit door, accompanied by Surveyor.
- Additional education to all staff regarding proper functioning door alarms was initiated via text and in person.
Failure to Supervise Residents and Address Falls, Razor Access, and Elopement Risk
Penalty
Summary
The facility failed to provide adequate supervision and accident prevention for three residents. One resident with a pelvic fracture history, gait and mobility impairment, and moderate cognitive impairment was left on the toilet with limited-assist and gait-belt interventions in place, then got up without staff present and fell in the room. Staff interviews and surveillance review showed the resident was moved after the fall without documented vital signs or neurological checks before being transferred from the floor, and the fall was later linked to a right pubic fracture discovered during an emergency room evaluation. The record also showed no physician visit documented after the fall before the resident was sent to the hospital later for worsening anxiety, pain, and depression. A second resident with dementia and severe cognitive impairment cut his tongue with a razor that staff and family indicated had been left accessible in the room. The resident was not supposed to be shaving himself, and staff interviews confirmed he was not safe to have a razor. The tongue injury caused bleeding that required repeated treatment, and the facility did not complete an incident and accident report for the self-inflicted injury as required by policy. A third resident with dementia, hallucinations, and severe cognitive impairment attempted to elope from the facility, including trying to exit through doors and pushing on the front door until it came off the track. Review of the record showed no elopement assessment after the attempt, no care plan update addressing the event, and no documentation of increased supervision or interventions to reduce recurrence. Staff interviews also showed there was no resident list for elopement risk and that staff relied on WanderGuard bracelets to identify residents at risk, while this resident did not have one visible or documented.
RN Coverage Not Maintained
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was available for eight consecutive hours during a 24-hour period. Review of CMS Payroll Based Journal staffing data for FY Quarter 2 2025 showed the facility triggered for no RN hours on 3/16/25, 3/22/25, 3/23/25, and 3/29/25. Facility staffing documentation for Saturday 3/29/25 showed no RN coverage for the 24-hour period, and timesheets showed no RN in the facility from 3/28/25 at 7:11 p.m. through 3/30/25 at 7:15 a.m. During interviews, the Human Resources Manager reported there was not an RN working on the schedule for 3/29/25, and the Nursing Home Administrator acknowledged that on 3/29/25 there was not an RN in the facility for eight consecutive hours in a 24-hour period.
Failure to Complete Annual CNA Performance Review
Penalty
Summary
The facility failed to complete a performance review for one of five Certified Nurse's Aides, CNA O, at least every 12 months. Record review showed CNA O was hired on 4/16/24 and had no performance review completed. During an interview on 9/4/25 at approximately 10:55 a.m., the DON acknowledged that no performance evaluation had been completed for CNA O and stated the facility did not have a policy regarding performance evaluations or when they should be completed. During an interview on 9/5/25 at 7:52 a.m., the NHA acknowledged the performance review for CNA O was not completed and should have been completed annually.
Pharmacist Failed to Provide Written MMR Recommendations to Physician
Penalty
Summary
The facility failed to ensure that the consulting pharmacist completed written Monthly Medication Review (MMR) recommendations to the physician for five residents reviewed for MMRs, identified as Residents #2, #5, #6, #37, and #38. During interview, the Director of Nursing, Nursing Home Administrator, and Unit Manager/RN stated there were no written pharmacy recommendations resulting from MMRs for any resident in the facility during the last year. The consulting pharmacist also acknowledged that there were no written pharmacy recommendations for any resident in the facility during the last year, including the five residents reviewed. The pharmacist stated that when reviewing medications, he would sometimes note issues such as gradual dose reduction (GDR), medication frequency changes, lab draws, increased monitoring, or blood pressure monitoring, but he did not make written recommendations submitted to the physician. He explained that if the physician had already documented not wanting a GDR, he did not make the recommendation, and that his communications were made to the DON by email or correspondence rather than to the physician. The NHA stated the expectation was that the pharmacist would report recommendations to the medical doctor, preferably in writing with a copy to the DON for follow-up.
Failure to Conduct QAPI Performance Improvement Projects
Penalty
Summary
The facility failed to ensure that performance improvement projects and activities were conducted to identify problem areas, track performance, and achieve improvement. During an interview, the Nursing Home Administrator stated the QAPI committee had been "putting out fires" and was uncertain what performance improvement projects had been implemented in the last year. When asked if another staff member should be present, the Administrator requested the Director of Nursing join the interview. During the follow-up interview, the Nursing Home Administrator and Director of Nursing were unable to provide examples of any performance improvement projects conducted in the last year. The Director of Nursing stated the facility had not done any PIPs in the last year because the former Nursing Home Administrator said the facility got cited anyway, so they were not going to do them anymore. No PIPs were available for discussion or review. Review of the facility's QAPI Change Process policy showed the facility must conduct distinct performance improvement projects, conduct at least one annual improvement project focused on high-risk or problem-prone areas, track performance after actions are implemented, and complete at least an annual self-assessment of its performance improvement culture.
QAA Committee Meetings Not Held Quarterly With Required Members
Penalty
Summary
The facility failed to ensure that QAA committee meetings were held quarterly with participation from all required members. During interview and record review, only one QAA committee meeting was identified for the second quarter of 2025, held on 6/12/25. The sign-in sheet for that meeting did not include the Medical Director, Physician V, indicating he was not present. When asked for QAA committee sign-in sheets for April and May 2025, the NHA stated, "I don't believe there was a QA meeting in April or May of 2025," and no additional QAA committee meeting sign-in sheets for the second quarter were provided.
CNA Annual Training Hours Not Met
Penalty
Summary
The facility failed to ensure that one CNA, O, completed at least 12 hours of annual training. During an interview, the Human Resources Manager stated that the annual 12-hour CNA training is based on the CNA hire date. Review of the facility document titled Bayside Village Staff Disaster Notification showed that CNA O was hired on 4/16/24 and had only 9 hours of training in a year. Review of the Facility Assessment, last reviewed 8/21/25, stated that required in-service training for nurse aides must be sufficient to ensure continuing competence and must be no less than 12 hours per year. During an interview, the NHA acknowledged that CNAs must have 12 hours of training a year.
Homelike Environment Not Maintained
Penalty
Summary
The facility failed to provide a homelike environment by serving residents their meals on institutional trays and by allowing the nurses’ station common area to remain in deteriorating condition. On 9/3/25 at 11:40 AM, the nurses’ station entrances were observed with lifted and peeled paneling on the side and corners, and the front wall had one area of missing wallpaper and another area of wallpaper about the size of a small basketball peeled off and hanging. RN G stated the station looked rough and could use a revamp, and reported that residents get inside because the entrance areas do not lock and one resident had marked up one entrance with a wheelchair catching on the side while trying to get in. During breakfast at 8:45 AM and lunch at 12:25 PM on 9/3/2025, residents in the dining room were observed receiving meals on institutional trays. Meal trays were distributed by staff in no particular order, and residents were not served together with their tablemates. The Dietary Manager stated that the DON had asked why food was served on trays and said that if trays were not used it would be a better dining experience. The Dietary Manager also stated that there was no dietary policy presented by the close of the survey regarding this meal service practice.
Failure to Provide Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to provide written information on its bed hold policy for five residents, including Resident #27, Resident #15, Resident #2, Resident #3, and Resident #7. For Resident #27, who was transferred to the hospital Emergency Department on 7/26/25, there was no documentation in the EMR showing that the resident or responsible party received a bed hold notice. The Nursing Home Administrator stated during interview on 9/4/25 at 2:25 p.m. that the facility had not been giving bed hold information to the resident or responsible party when residents were discharged to the hospital. The facility also failed to provide written transfer notifications to the resident and resident representative for four residents reviewed for transfers out of the facility. Resident #3 and Resident #7 were hospitalized, and their EMRs did not specify that written notice of the reason for transfer or the bed hold policy was provided to either resident or their representative. Resident #15 was transferred to the ED on 8/5/25 and later admitted to the hospital, and the record did not show written notification of the reason for transfer or provision of the bed hold policy. Resident #2 was transferred to the ED on 7/22/25 and 8/27/25, and the EMR did not specify that written notice of the reason for transfer or the bed hold policy was provided. During interview on 9/4/2025 at 12:13 PM, the NHA and DON both agreed they did not send a written notification of transfer explaining the reason for hospitalization or an explanation of the current bed hold policy to the resident or responsible party.
Unattended Medication Cart and Unsecured Resident Medication
Penalty
Summary
The facility failed to ensure medications were stored in locked compartments and remained secured during administration. During observation and interview, an RN left a medication cart unlocked and unattended while she walked away to check on a resident for feeding assistance. Later, a 300-hall medication cart located in a resident common area was observed unlocked and unattended, and the RN acknowledged it was unlocked when asked. The DON stated that medication carts should be locked at all times if not attended by a nurse. Facility policy required all drugs and biologicals to be stored in locked compartments and, during a medication pass, to remain under direct observation or locked in the medication storage area or cart. The facility also failed to ensure resident medications were consumed or otherwise secured for one resident with intact cognition. Resident #27 had a BIMS score of 15 out of 15 and no physician order or completed assessment for self-administration of medication. During observation, the resident had a medicine cup with antacid medication on the bedside table, and the resident reported that nursing staff sometimes leave medication at bedside. Facility policy required medications to be administered by licensed staff and to observe resident consumption of medication.
Failure to Attempt GDR for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for one resident receiving psychotropic medications. Resident #37 had diagnoses including hypertension, diabetes mellitus, dementia, depression, and aphasia. The resident’s MDS assessment dated 9/9/25 showed no documented behaviors in section E, and behavior monitoring documentation also showed no behaviors checked as exhibited in the last 30 days. The resident was observed on 9/9/25 and 9/10/25 resting in a wheelchair in the day room with eyes closed and did not respond when asked how he was doing. The resident had physician orders for quetiapine 25 mg twice daily for dementia without behavioral disturbances and escitalopram 10 mg daily. Monthly pharmacy medication regimen reviews from 8/27/24 through 8/28/25 showed no recommendations and no GDR. A GDR request dated 6/9/25 documented no last GDR, no previous failed attempt, no behavioral care recommendations, and no behavior notes; on 6/17/25 the physician declined the GDR, stating the resident had a history of behaviors in the past and was currently stable with no side effects. However, the record reviewed by surveyors included behavior documentation only for two evening communication logs on 3/19/25 and 6/10/25, while multiple social services notes described the resident as pleasant, stable, happy, and without behavioral concerns. The physician’s progress notes from 2/25/25, 4/29/25, and 6/17/25 also stated the resident was doing well, had no complaints, and staff had no concerns. During interview, the physician stated the resident was stable and that a GDR was contraindicated, but also said there was no risk-versus-benefit review completed. The DON stated there should at least be one attempt to see how the resident would respond.
Failure to Obtain Current PASARR Annual Review
Penalty
Summary
The facility failed to ensure that a PASARR Level I annual resident review was obtained for one resident. The resident was admitted with diagnoses including depression, unspecified hallucinations, unspecified psychotic disorder with delusions due to a known physiological condition, anxiety disorder, and Alzheimer's disease. The resident's MDS quarterly assessment showed a BIMS score of 2 out of 15, indicating severe cognitive impairment, and behavioral symptoms directed toward others occurring every 1 to 3 days. The active physician's orders included quetiapine and sertraline, and the care plan documented potential physical and verbal behaviors, impaired cognitive function, trauma history, and use of antipsychotic medication. The resident's EMR contained a PASARR Level I form dated and filed as an annual resident review from the prior year, but a current annual PASARR Level I for the 2025 annual resident review could not be located. During interview, the DON stated she handled PASARRs and reviewed the record but could not find a current annual PASARR Level I for the resident, stating that PASARRs were "definitely a work in progress" and that there was not a Level I for the resident since the prior filing. The facility policy stated that it coordinates assessments with the PASARR program for individuals with mental disorder, intellectual disability, or related conditions.
Failure to Manage Supplemental Oxygen and Respiratory Equipment
Penalty
Summary
The facility failed to obtain physician orders for supplemental oxygen and failed to ensure respiratory equipment was changed, labeled, and appropriately stored for two residents receiving respiratory care. One resident with COPD, shortness of breath with exertion, and intact cognition was observed with a nebulizer on the bedside stand and tubing that was unbagged, labeled with an old date, and placed directly on the nebulizer without a barrier. The same resident also had an oxygen concentrator beside the bed with nasal cannula tubing that was unbagged, undated, and placed directly on top of the concentrator. The resident stated oxygen was used when respiratory difficulty occurred and nebulizer treatments were received when short of breath. The EMR did not contain a physician order for supplemental oxygen, a care plan for oxygen use, or physician documentation regarding oxygen use, and the DON confirmed a physician order was required even when standing orders were used. A second resident with COPD and intact cognition had oxygen equipment observed next to the bed and on the wheelchair, with tubing that was not marked and later found wrapped around the wheelchair wheel, under the wheelchair, and under the resident while sitting. The resident did not know when the tubing had last been changed. The physician orders required oxygen saturation checks twice daily or as needed, oxygen at 2-4 L if saturation was below 90, oxygen while sleeping or napping, and weekly tubing changes, but multiple ordered oxygen saturation checks were not completed. The care plan did not include interventions for oxygen saturation monitoring, tubing changes, or proper storage of oxygen tubing, and the DON acknowledged those interventions were absent. The facility policy stated oxygen is administered under physician orders, care plans should identify oxygen interventions, and tubing and masks/cannulas should be changed weekly and kept covered when not in use.
Missing Physician Visit Documentation
Penalty
Summary
The facility failed to ensure that physician assessments and visit progress notes, including review of the resident's program of care and condition, were available in the medical record for one resident reviewed for physician visits. Resident #25 was admitted with a primary diagnosis of acute embolism and thrombosis of the deep veins of the left lower extremity. During interview, RN I stated she contacted the resident's physician on 7/16/25 to report medication errors that had occurred for eight consecutive days from 7/8/25 through 7/15/25, but she did not know whether the physician assessed the resident after being notified. Review of the EMR on 9/10/25 showed the most recent physician documentation was dated 12/27/24. The DON stated the physician had been in the facility and assessed the resident, but could not recall the last visit, and said physician documents should be in progress notes or other EMR documents. The surveyor and DON reviewed the EMR and found no physician visit notes or documentation since December 2024. The NHA also confirmed there was no documentation in the EMR indicating the physician had assessed the resident since 12/27/24. The facility policy required the physician to see the resident at least every 30 days for the first 90 days after admission and at least every 60 days thereafter, and to review the total program of care and date, write, and sign a progress note for each visit.
Untimely Physician Visits for Two Residents
Penalty
Summary
The facility failed to ensure timely physician visits for two residents. Resident #7 was admitted with generalized anxiety disorder and was his or her own responsible party. The record showed an initial physician visit on 10/21/24, a second physician visit on 11/19/24, and a third physician visit on 1/28/25, which was documented as a late entry on 2/2/25 and occurred greater than 60 days after the previous physician visit. Resident #8 was admitted with diagnoses including pulmonary embolism, pneumonia, and unspecified dementia, and had a guardian for decision making. The record showed the first documented physician visit on 6/24/25, nearly two months after admission, followed by an NP visit on 8/26/25, more than two months after the previous physician visit, and another NP visit on 9/9/25. During an interview on 9/10/25, the NHA and DON reviewed the records and acknowledged that physician visit documentation for both residents showed visits were not completed at 30-day intervals for the first 90 days after admission, and they acknowledged difficulty with completion of timely physician visits by Physician L.
Wrong Medication Given to Resident
Penalty
Summary
The facility failed to prevent administration of an unnecessary medication for one resident when a nurse gave the resident another resident’s blood pressure medication. The medication discrepancy report stated that while preparing nighttime medications with two cups side by side, the nurse placed the other resident’s metoprolol into the resident’s cup and did not realize the error until the resident already had the pills in her mouth and swallowed them. The resident’s record identified diagnoses of Alzheimer’s disease, insomnia, essential tremor, muscle weakness, and cognitive communication deficit, and her BIMS score was 4 out of 10, indicating severe cognitive impairment. The resident’s chart showed progress notes documenting that the resident received the wrong medication and that vital signs were checked after the medication error. The report also noted that the resident’s blood pressure and heart rate were not recorded on the two days surrounding the error. The resident did not have diagnoses of hypertension, heart failure, or angina, which were the conditions associated with the medication that was mistakenly administered. Interviews showed that the on-call RN manager was not informed of the medication error until the next day. The DON stated the nurse was disciplined and mentioned a medication discrepancy report, but no incident and accident report was provided to the surveyor. The DON also did not think the resident’s husband or DPOA was contacted, and the resident’s electronic record lacked documentation that the husband was notified of the medication error.
Failure to Update Fall Care Plan After Repeated Head Injury
Penalty
Summary
The facility failed to update the comprehensive care plan for Resident #23 after multiple falls and related injuries. On 8/18/25, the resident had an unwitnessed fall in his room, was found sitting on the edge of the bed with blood dripping from his forehead, and stated he fell coming from the bathroom and hit his head on the floor. He was sent to the hospital for evaluation and treatment, and a progress note later documented a forehead laceration requiring 3 sutures. The resident’s care plan, last revised on 3/2/25, still focused on a prior fall with no injury and included only general fall-prevention interventions, with no added or updated interventions for the fall with injury. The record also showed ongoing problems after the initial injury. On 8/29/25, the resident returned to the ER for additional sutures because the forehead wound continued bleeding, and later notes documented that he picked out one or two stitches, causing excessive bleeding, while continuing on rivaroxaban 20 mg daily. The fall risk assessment dated 8/15/25 was blank and had not been completed, although an earlier assessment dated 6/1/25 identified the resident as at risk for falling. During interview, the DON stated that after a resident falls, the care plan should be updated to prevent further falls, but no added interventions were identified for this resident.
Repeated Eliquis and Xeljanz Medication Administration Error
Penalty
Summary
The facility failed to ensure that one resident received medications at the frequency ordered by the physician, resulting in repeated administration of Xeljanz XR instead of Eliquis for the resident. The resident had orders for Eliquis 5 mg twice daily for prevention related to acute embolism and thrombosis of the deep veins of the left lower extremity and atrial fibrillation, and an order for Xeljanz XR 11 mg once daily for rheumatoid arthritis. The resident’s diagnoses included acute embolism and thrombosis, rheumatoid arthritis, atrial fibrillation, and atherosclerotic heart disease. An LPN who worked the day shift identified that evening shift nurses were giving Xeljanz XR in place of Eliquis on more than one occasion. She stated she first noticed the issue when the resident’s Xeljanz supply was repeatedly depleted while Eliquis remained in excess in the medication cart. She then dated the blister packs and placed sticky notes on the Xeljanz packs reading not Eliquis to alert evening staff. She reported that the error recurred over a period of eight days, with the dates identified by the markings she had placed on the medications. The LPN said she verbally reported the first error to the DON and later texted the DON when the error continued. RN I confirmed awareness of the medication mix-up and stated the first time it was discussed in a morning meeting, and the second time she learned of it through the LPN and a text thread involving the DON and other nurses. RN I stated she contacted the physician after learning the error was ongoing. The consultant pharmacist said he was never informed of the medication errors. The EMR and MAR did not document the medication errors, and the DON acknowledged that the EMR should have included documentation. The DON also stated that all evening shift nurses were involved, but the record review showed only limited competency documentation and no completed competencies for the evening shift nurses involved in the error.
Failure to Provide Proper Catheter Care, Timely Documentation, and Physician Notification Resulting in Resident Harm
Penalty
Summary
The facility failed to provide proper care and treatment for a resident with an indwelling Foley catheter, resulting in significant harm. The resident, who had diagnoses including benign prostatic hyperplasia, urinary retention, and type 2 diabetes, was cognitively intact and admitted with a Foley catheter in place. Over several days, staff observed and documented blood in the resident's brief and at the tip of the penis, swelling in the thigh, decreased urine output, and a distended catheter bag. Despite these findings, there was a lack of timely and accurate documentation, and significant changes in the resident's condition were not communicated to the physician as required by facility policy. Multiple staff interviews revealed that the resident's catheter bag was repeatedly found to be overfilled, sometimes described as the size of a football, and not emptied during overnight shifts. Certified Nurse Aides reported these findings to nursing staff, but there was no evidence of appropriate follow-up or documentation. Additionally, there were instances where staff were instructed to document care tasks that had not been performed, and late entries were made in the medical record up to a month after the events occurred. The facility's Director of Nursing and other staff acknowledged issues with delayed documentation, lack of investigation, and failure to notify the physician of significant changes, including blood in the urine and decreased output. The resident ultimately experienced worsening symptoms, including abdominal pain, vomiting, confusion, and neurological changes, leading to emergency transfer to the hospital. Hospital records confirmed a diagnosis of ruptured bladder, urinary tract infection, and septic shock. The facility lacked effective catheter care policies at the time of the incident, and there was no documentation of required monitoring such as weights and leg measurements, despite physician orders. The cumulative failures in care, documentation, and communication directly contributed to the resident's decline and subsequent death.
Failure to Use Gait Belt During Transfer Results in Resident Fall and Major Injury
Penalty
Summary
A deficiency occurred when staff failed to provide adequate assistance and use required assistive devices during a transfer, resulting in a resident sustaining a fall with major injury. The resident, who had moderate cognitive impairment, a history of repeated falls, and required partial to moderate assistance with transfers, was being assisted by a CNA from bed to wheelchair. During the transfer, the CNA did not use a gait belt as required by the resident's care plan and facility policy, instead holding the resident by her pants and buttocks. The resident slipped and fell, hitting her head on the overbed table and sustaining a laceration and a pelvic fracture. The incident was not witnessed by a nurse, but the CNA involved provided a written statement confirming the lack of gait belt use. The resident's care plan specified the use of a gait belt and limited assistance for transfers, and the facility's policy mandated gait belt use for residents unable to transfer independently. Documentation and interviews confirmed that the plan of care was not followed at the time of the fall. Following the fall, the resident was assessed, treated for a head wound, and sent to the emergency department, where a pelvic fracture was diagnosed. The facility had not conducted monitoring audits of staff compliance with gait belt use after the incident, and the CNA involved was not available for further interview during the survey. The deficiency was directly related to the failure to follow established care plans and safety policies during resident transfers.
Significant Medication Error Due to Improper Medication Administration and Labeling
Penalty
Summary
A significant medication error occurred when a registered nurse (RN) administered medications intended for one resident to another. The error took place after the RN prepared two medication cups for two residents with similar first initials, labeling the cups with only initials. The RN placed one cup in the medication cart drawer while the resident was being assisted by CNAs, then later mistakenly administered the wrong cup to the resident. The nurse realized the error during administration but had already given the medications. The affected resident had a history of heart failure, hypertension, diabetes mellitus, and depression, and was cognitively intact. The resident received eight medications not prescribed to her, including drugs for blood pressure, diabetes, cholesterol, and an antipsychotic. Following the error, the resident was transferred to the emergency department for monitoring due to concerns about potential adverse effects, such as hypotension. The resident reported mild dizziness and dry mouth upon arrival at the hospital, where she was monitored and later discharged back to the facility. The facility's investigation revealed that the nurse did not notify the resident's family about the transfer or the medication error, and there was no documentation showing that the resident was asked about family notification. Additionally, the facility's policy prohibits saving medication cups in the medication cart, and the nurse's method of labeling contributed to the error. No audits or monitoring of medication administration were conducted following the incident, and only the involved nurse received education regarding the error.
Inadequate Staffing Leads to Unmet Resident Needs
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, as evidenced by interviews and record reviews. Four residents, along with three residents from a confidential resident council meeting, reported issues related to insufficient staffing. One resident fell and was left on the floor for an extended period due to a lack of available staff. Another resident experienced delays of up to three hours in receiving medications and having call lights answered. Additional residents and their representatives confirmed that the facility was short-staffed, leading to unmet care needs. Interviews with facility staff, including the Director of Nursing, Nursing Home Administrator, LPNs, and CNAs, corroborated the residents' concerns. The Nursing Home Administrator acknowledged that there were 11 open nursing positions. Staff members reported frequent understaffing, particularly during the night shift and weekends, which resulted in care being compromised. The facility's staffing schedule did not align with its Facility Assessment, which indicated a need for more CNAs than were actually scheduled during certain shifts.
Deficient Competency Training for CNAs
Penalty
Summary
The facility failed to ensure that three Certified Nurse Aides (CNAs) had the required yearly competency trainings, including demonstrations in skills and techniques necessary for resident care. CNA P, hired on February 25, 2022, did not have dated competency skills since the date of hire. CNA S, hired on April 13, 2021, also lacked dated competency skills after the date of hire. Similarly, CNA T, hired on May 27, 2023, did not have dated competency skills after the date of hire. During an interview, the Director of Nursing (DON) and Nursing Home Administrator (NHA) acknowledged the absence of dated competency skills for staff, with the DON admitting that the skills training should have been dated. The Facility Assessment, last revised on August 8, 2023, indicated that employees are evaluated annually on 23 areas regarding resident care and facility duties. However, the surveyor did not receive a checklist of these 23 areas, and the facility presented an incomplete and undated list of training on 13 areas, which the DON referenced as the staff's competency training.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for three Certified Nurse Aides (CNAs), identified as P, S, and T, which is a requirement according to their policy. CNA S was hired on April 13, 2021, CNA T on May 27, 2023, and CNA P on February 25, 2022, yet none had received a performance review since their hiring. Interviews with the Director of Nursing (DON) and Human Resource staff confirmed that no performance reviews had been conducted since 2022. This oversight was acknowledged by both the Nursing Home Administrator and the DON, indicating a lapse in adherence to the facility's policy that mandates annual reviews to ensure adequate care and meet resident needs.
Food Safety and Hygiene Deficiencies in Dietary Department
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Dietary Aide E was seen handling soiled dishes and then clean dishes without washing hands in between, violating the FDA Food Code 2017, which mandates handwashing after handling soiled equipment. Additionally, blue cooling collars used by staff were improperly cleaned, as they were only wiped down with a quaternary solution instead of being immersed, potentially leading to contamination. Further observations revealed that the concentration of sanitizer in wiping cloth buckets was not properly tested, as Kitchen Manager D did not follow the correct procedure for using test strips, resulting in an inaccurate reading. The walk-in freezer had significant ice buildup due to damaged door seals, and a fan near the dish machine was dusty, both of which are against FDA guidelines for maintaining clean and well-repaired equipment and facilities. In the dining room, the placement of a hand sink led to clean plates being exposed to splash contamination. Staff U was observed not performing hand hygiene after touching their scalp, facial hair, and clothing before handling food and utensils, contrary to the facility's hand hygiene policy. These actions and inactions collectively posed a risk of foodborne illness to the 57 residents in the facility.
QAPI Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that the Quality Assurance and Performance Improvement (QAPI) committee met at least once per quarter with the required committee members, as mandated by CMS regulations. The review of attendance documentation revealed that the Medical Director or their designee did not attend several meetings, including those held on 4/30/2024, 7/13/2024, 8/10/2023, 1/19/2024, 2/2/2024, 3/21/2024, 4/11/2024, and 5/9/2024. Additionally, no meetings were held in November and December of 2023, and no attendance records were found for these months. The Director of Nursing (DON) was also absent from the meeting on 1/19/2024 and 5/9/2024. The Nursing Home Administrator (NHA) acknowledged the absence of required QAPI committee members during each quarter, which is a violation of the regulation. During an interview, the NHA mentioned that the Medical Director, referred to as Physician K, only received payment for dictation provided for resident care and did not want payment for serving as the Medical Director. The facility's QAPI plan policy, which should detail the required committee member attendance per CMS regulation, was not provided by the survey exit. The absence of the Medical Director and other key members from the QAPI meetings resulted in the potential for quality-of-care concerns for all 57 residents in the facility.
Deficient CNA Training Hours
Penalty
Summary
The facility failed to ensure that three Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of annual in-service training. This deficiency was identified during interviews and record reviews. Human Resource Staff O confirmed that the annual training requirement is based on each CNA's hire date. However, CNA P, hired on February 25, 2022, had only completed 9.5 hours of training. CNA S, hired on April 13, 2021, had completed only 5 hours, and CNA T, hired on May 27, 2023, had completed 10.25 hours. The facility's policy and Facility Assessment both stipulate that CNAs must receive at least 12 hours of training annually to ensure their continuing competence. The Director of Nursing and Nursing Home Administrator acknowledged the failure to meet this requirement, which potentially affects the care needs of all 57 residents in the facility.
Lack of Behavioral Health Training for Staff
Penalty
Summary
The facility failed to ensure that behavioral health care training was provided to two of three staff members reviewed for this requirement. Specifically, Certified Nurse Aide (CNA) T, hired on May 27, 2023, and CNA S, hired on April 13, 2021, had no record of receiving behavioral health care training according to the [Vendor] computer training logs reviewed on July 10, 2024. The facility's policy on the Nurse Aide Training Program, implemented on April 11, 2024, mandates that in-service training should be provided by qualified personnel and should include behavioral health care training based on the special needs of the residents. However, the Facility Assessment did not include a requirement for behavioral health training for staff. During an interview on July 11, 2024, the Nursing Home Administrator and Director of Nursing acknowledged the absence of behavioral health training. This deficiency had the potential to result in unmet behavioral health care needs for all 57 residents in the facility.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
The facility failed to revise care plans after multiple falls for four residents, which resulted in the potential for further falls and injury. Resident #17, who had diagnoses including unsteadiness on feet and schizophrenia, experienced four falls between January and March, yet their care plan was not updated after any of these incidents. The Director of Nursing (DON) acknowledged that revisions should occur after each fall but admitted to sometimes lacking interventions to add. Similarly, Resident #47, with diagnoses including Parkinson's disease and hypertension, had a fall in July, but their care plan was not revised post-fall. The DON admitted to issues with person-centered care plans. Resident #26, diagnosed with Alzheimer's Disease and severely cognitively impaired, experienced multiple falls from May to July, but their care plan was not updated with new interventions to prevent recurrence. Resident #36, also with Alzheimer's Disease, had falls in February and April, yet their care plan did not include the use of a wheelchair tray table, which was used as a fall prevention measure. The facility's policy on accidents and supervision, as well as fall risk assessment, emphasized the need for implementing and modifying interventions to prevent accidents, which was not adhered to in these cases.
Deficient Physician Visits and Documentation
Penalty
Summary
The facility failed to ensure that physician visits accurately reviewed the total program of care for four residents, resulting in a potential lack of comprehensive and supervised medical care. The physician, identified as Physician K, did not conduct thorough reviews of the residents' medical conditions and medications during their visits. For Resident R24, the physician's notes over several months indicated the continuation of medications that had been discontinued, and the physician admitted to not verifying the accuracy of the medication information provided by the facility. Resident R26's records showed a lack of physician visit documentation after April, despite being due for a visit in June. The Health Information Coordinator (HIC) acknowledged the absence of documentation and intended to follow up with the hospital physician practice. Additionally, the physician's notes for Resident R26 included incorrect medication dosages and lacked a comprehensive review of the resident's condition. For Resident R36, the physician's notes included incorrect diagnoses and medication dosages, and there was no documentation of a comprehensive review of the resident's systems and medications. Similarly, Resident R38's records showed discrepancies in diagnoses and a lack of follow-up on a documented pressure ulcer. The Nursing Home Administrator was aware of the concerns with the physician's documentation but had not addressed them effectively. The facility's policy required physicians to actively supervise residents and document comprehensive progress notes, which was not adhered to in these cases.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to ensure that inhalers and eye drops were labeled with the dates when they were opened, as per the facility's policy. During an audit of the 100-hall medication cart, it was observed that five bottles of opened eye drops for four different residents were not labeled with the date they were opened. Additionally, three opened inhalers for two different residents were also not labeled with the date they were opened. One of these inhalers was found in a clear plastic bag with a pharmacy label indicating it was dispensed on 5/30/24, and a registered nurse confirmed that it was expired as inhalers are considered good for six weeks after opening. Similarly, an audit of the 300-hall medication cart revealed two opened eye drop bottles for one resident and four opened inhalers for two different residents, none of which were labeled with the date they were opened. Both the registered nurse and the licensed practical nurse involved acknowledged that the medications should have been labeled with the date when opened. The Director of Nursing confirmed that the facility's policy requires eye drops and inhalers to be labeled with the date they are opened, as their discard dates are based on this information rather than the expiration dates.
Failure to Ensure Proper Use and Documentation of Restraints
Penalty
Summary
The facility failed to ensure that appropriate assessments, physician orders, risk education, medical justification, and care plans for restraints were in place for a resident with Alzheimer's Disease. The resident was observed sitting in a wheelchair with a tray table attached, which secured her in the wheelchair, and a pommel cushion. There was no documentation in the care plan for the use of these restraints, and the Minimum Data Set (MDS) did not code the use of physical restraints. The facility did not have physician's orders for the tray table or pommel cushion, and the Director of Nursing (DON) confirmed that no restraint assessments or education on the risks of restraint usage had been provided to the resident's representative. The DON provided a sheet of paper with a note from the resident's daughter requesting the use of a tray table for safety and positioning, but there was no evidence of a formal consent process or discussion of potential risks. The DON admitted that no interventions had been attempted prior to applying the restraints and that the Occupational Therapist (OT) and Physical Therapist Assistant (PTA) had no information on the restraints. The facility's policy on a restraint-free environment was not followed, as there was no determination of a specific medical symptom requiring the use of restraints, nor was the care plan updated to address risks related to restraint use.
Failure in Hospice Care Coordination
Penalty
Summary
The facility failed to ensure proper collaboration and communication with the hospice provider for a resident receiving hospice services. The resident, initially admitted for skilled therapy, experienced a severe health decline and began receiving hospice care. However, the facility did not have a physician order for hospice in the resident's medical record, nor was there a care plan for hospice services. Additionally, hospice visit notes and documentation were missing from the resident's medical record. Interviews with the Director of Nursing (DON) and a Registered Nurse (RN) revealed that the hospice documentation was expected to be in a binder at the nurses' station or in the resident's room, but upon review, the binder lacked the necessary hospice documentation. The DON and RN were uncertain about the exact start date of hospice services for the resident, and there was no clear coordination of care plans between the facility and hospice. The RN mentioned that hospice would call on the day of their visits, but there was no documentation on staffing sheets regarding scheduled hospice visits. Hospice documentation received later indicated that the resident started hospice services on a specific date, but the hospice certification and plan of care lacked a physician's signature or date. The facility's policy on coordination of hospice services emphasized the need for communication and a coordinated care plan, which was not adhered to in this case.
Failure to Provide Adequate Social Services for Grieving Resident
Penalty
Summary
The facility failed to provide adequate medically related social services to a resident, identified as Resident #15, who was reviewed for social services care. The resident had been admitted to the facility with diagnoses including depression, heart failure, hypertension, and diabetes mellitus. Despite having intact cognition, as indicated by a perfect score on the Brief Interview for Mental Status, the resident expressed feelings of depression related to the recent loss of their son, who had cerebral palsy. The resident reported that the staff or social worker did not engage in discussions about this loss. The Social Services Designee (SSD) acknowledged that no supportive services or emotional support were provided to the resident regarding the loss of their son. The SSD admitted to not discussing grief counseling or offering outside agency support to the resident, nor was there any inclusion of this issue in the resident's care plan. The Nursing Home Administrator confirmed these oversights, noting that the SSD did not address the loss, implement a care plan, or offer support or outside services during the most recent assessment. The facility's policy on social services, which mandates the provision of medically related social services to maintain residents' well-being, was not adhered to in this case.
Failure to Provide Timely Wound Treatment Medication
Penalty
Summary
The facility failed to ensure the timely reorder and acquisition of Santyl, a wound treatment medication, for a resident with pressure ulcers. The resident, who had a history of partial traumatic amputation of the right great toe, required Santyl for multiple wound sites as per physician orders. However, from July 3rd to July 9th, the medication was unavailable, and there was no documentation of any attempt to contact the physician for a change in orders. During interviews, the RN and LPN involved in the resident's care confirmed the unavailability of Santyl and acknowledged that no action was taken to address the issue. The RN was unaware of the reason for the medication's absence, and the LPN did not inquire about the missing medication or document any communication with the physician. The Director of Nursing confirmed the lack of Santyl and the absence of any documented attempts to resolve the issue. The facility's policies on medication cross-matching and reordering were not followed, as evidenced by the failure to reorder Santyl when it was running low. The Medication Cross Match policy required a weekly check to ensure sufficient medication supply, and the Medication Reordering policy mandated reordering when doses were low. These policies were not adhered to, resulting in the resident going without the prescribed wound treatment medication for seven days.
Failure to Attempt GDR and Ensure Accurate Medication Dosage
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for a resident prescribed psychotropic medications, specifically Seroquel, despite a recommendation for GDR in the psychological assessment. The resident, who was admitted with diagnoses including Alzheimer's disease, psychotic disorder with delusions, and depression, had no documented evidence of acceptance or declination of the GDR recommendation for Seroquel. Interviews with facility staff confirmed that no GDR was completed in the last year, and no clinical rationale for the lack of an attempted dose reduction was provided. Additionally, the facility failed to ensure accurate antipsychotic medication dosage for another resident, who was observed with abnormal involuntary facial movements suggestive of antipsychotic medication use. The resident's medication orders included an antipsychotic dosed at 3 mg twice daily, which was not signed by a physician. Discrepancies were found between the physician's documentation, psychiatric service provider's notes, and the current medication order, with no recommendations from the consultant pharmacist regarding the antipsychotic medication. Interviews with facility staff, including the social services designee and nurse manager, revealed a lack of documentation for physician visits and medication orders. The facility's administrator and director of nursing were unable to explain the discrepancy in the antipsychotic medication dosage, and no information was found to justify the administration of 3 mg twice daily instead of the documented 2 mg twice daily.
Failure to Implement Comprehensive Water Management Plan for Legionella Control
Penalty
Summary
The facility failed to develop and implement a comprehensive Water Management Plan (WMP) for controlling Legionella in its potable water supply system. During an inspection, it was observed that a humidifier in the boiler room was used to aerosolize potable water into the resident area, but this device had not been assessed for Legionella control. The Maintenance Supervisor (MS) admitted that the facility only collected one water sample per year for Legionella testing, which is insufficient according to the facility's own WMP guidelines. The WMP outlined specific control measures, including temperature management and disinfectant level control, but these were not being documented or monitored effectively. Further interviews revealed that the Maintenance Supervisor was unaware of any discussions regarding Legionella during the facility's Quality Assurance (QA) or Quality Assurance and Performance Improvement (QAPI) meetings. The facility's WMP required regular monitoring and reporting of water management activities, but there was no documentation of disinfectant levels, temperature control, or risk assessments related to the humidifier. This lack of documentation and oversight indicates a significant gap in the facility's infection prevention and control program, potentially exposing all 57 residents to the risk of Legionella-related respiratory infections.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate supervision to prevent an elopement for a cognitively impaired resident. The incident occurred when a visitor entered the building and allowed the resident to exit. The resident, who had severe cognitive impairment and a history of wandering, was found at a nearby gas station and returned to the facility by a former employee who recognized her. Staff were unaware of the resident's exit until alerted by another visitor who had taken a photograph of the resident at the gas station. The resident's Minimum Data Set (MDS) assessment indicated severe cognitive impairment and a history of wandering behavior. Despite being identified as an elopement risk, the resident did not have a wander/elopement alarm due to a history of cutting off the alarms. The facility's Elopement Risk binder included the resident's information, but there was no consistent process or policy for determining the placement of wander guards on residents at risk of elopement. Interviews with staff and family members revealed that the facility lacked adequate supervision, especially during weekends when staffing levels were lower. The facility's policy on elopements and wandering residents emphasized the need for adequate supervision and person-centered care plans, but these measures were not effectively implemented. Surveillance video confirmed that no staff were present near the entrance doors when the resident exited the building.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near L' Anse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Canal View - Houghton County | 26 mi | ★★★★★ | 12 | 0 |
| Portagepointe | 26.8 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 26.8 mi | ★★★★★ | 0 | 0 |
| Greentree Of Hubbell Rehabilitation And Health | 28.2 mi | ★★★★★ | 42 | 0 |
| Mission Point Nsg & Phy Rehab Ctr Of Ishpeming | 39.8 mi | — | 0 | 0 |
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