Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Clearstream Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident repeatedly reported that meals were served cold, both in her room and in the dining room, and said she had raised the concern with multiple staff members. Survey observations found hot items on the steam table and on meal carts at temperatures below expected serving levels, while staff continued plating and delivering trays despite not taking preservice temperatures.
Food Storage and Handling Deficiencies: Staff were observed storing a spray bottle of yellow solution without a common name label, placing ready-to-eat foods such as cooked ham, cooked brats, and cooked roasts with or on raw ground beef and raw shaved steak in the cooler, leaving an opened lemon juice container at room temperature despite refrigeration being required after opening, storing wet sheet pans stacked together, keeping an ice scoop in stagnant water in a holder without proper drainage, and handling serving utensils during lunch so the handles were placed into rice and chicken while meals were being plated.
Advance directive and code status records were not kept accurate for two residents. One resident with dementia had a DNR advance directive signed by a patient advocate, but the EMR banner and active MD order still showed Full Code, and the facility had not obtained an updated form after guardianship changed. Another resident’s EMR banner showed Full Code even though the chart contained an advance directive marked unsure for CPR and an incomplete DNR order signed by the guardian. Care conference notes did not show review of code status or advance directives.
Failure to protect a resident from inappropriate sexual contact by another resident. A cognitively intact resident reported that another resident with a history of inappropriate touching grabbed her buttocks in a common area near the nurse’s station. The other resident had bipolar disorder, a sexual behavior disorder, and a care plan calling for close supervision around female residents, but he was able to exit the dining area without staff assistance and make contact with the resident. Staff interviews and the facility investigation confirmed the contact and the other resident’s prior history of similar behavior.
Failure to provide a written bed hold notice before a resident’s hospital transfer. A resident with metastatic cancer, weakness, HTN, and mild cognitive impairment was sent to the ED by ambulance after being evaluated and ordered for transfer. The record contained no bed hold form or proof the notice was given, and staff reported transfer packets were sometimes forgotten and that bed hold notices were not being provided or followed up on.
Failure to update care plan after resident-to-resident sexual contact. A resident with bipolar disorder and a sexual behavior history made inappropriate contact with a female resident in a common area. Although the incident was investigated and the resident’s behavior history was known, the IDT did not revise the care plan with new interventions after the event, and the NHA confirmed the update was missed.
A resident with dementia, malnutrition, severe cognitive impairment, and dependence for transfers was identified as at risk for pressure ulcers. The care plan and MD order required bilateral elbow pads while up in a specialty wheelchair, but staff observed the resident multiple times with elbows resting directly on the armrests and no pads in place, and an RN stated she could not find the elbow pads and confirmed they were supposed to be used when the resident was out of bed.
Fall Prevention Care Plan Not Followed: A resident with Alzheimer’s disease, severe cognitive impairment, lack of coordination, and muscle wasting had a care plan for fall risk that included keeping the call light within reach and placing a sign on the walker. During repeated observations, the call light was found out of reach, the walker sign was missing, and the resident was seen walking without the walker until an LPN and an activity assistant redirected her.
Failure to Provide Person-Centered Dementia Care: Two residents with severe cognitive impairment did not receive individualized dementia interventions based on lifelong habits and preferences. One resident with vascular dementia and a history of nicotine dependence became agitated by nearby residents, loud activity, and crowding around his usual recliner, while staff noted he was calmer in quiet settings and liked to smoke and watch TV in his room. Another resident with Alzheimer’s disease wandered into other residents’ rooms, including the other resident’s room, but her care plan did not address the conflict between the two residents or her entering his personal space.
A resident admitted with depression and visual hallucinations had expired conservatorship paperwork in the record, and the SW knew it was expired but did not follow up after an initial request for updated documents went unanswered. The care conference note did not document discussion of the conservatorship paperwork, and the facility’s records showed ongoing issues with updated guardianship paperwork and code status signatures.
Two residents with dementia and mental health conditions became involved in a physical altercation after one resident, who frequently wandered and picked up items, took a pair of gloves belonging to another resident. The second resident, who had a history of depression, suicidal ideation, and irritability, followed and forcefully grabbed the first resident’s arm, prompting the first resident to slap her in the face. Care plans did not address the first resident’s behavior of picking up others’ belongings or the second resident’s frustration with peers, despite known patterns of wandering, item-handling, and conflict with other residents. A family member witnessed the incident, and staff interviews confirmed the behavioral patterns that led to the conflict, which met the facility’s own policy definitions of physical abuse (hitting, slapping, grabbing).
A nurse administered a discontinued dose of Meloxicam to a resident after failing to reconcile the medication with the current physician order and not removing the outdated medication card from the cart. Multiple medication cards for both discontinued and current dosages were present, and audits of medication administration and storage did not consistently check for discontinued medications, leading to a medication error.
Surveyors found that medication carts were not properly managed, including missing narcotic count documentation, discontinued medications left accessible and administered to a resident, and an insulin pen in use without an open date. LPNs and other staff acknowledged lapses in following procedures for medication removal and labeling, and audits did not consistently check for discontinued medications.
The facility failed to maintain a sanitary environment in Resident #61's room and the spa room, with issues such as debris and stains. Additionally, the locked memory care unit's dining room did not provide a home-like atmosphere, as meals were served on trays, unlike the main dining room. Staff interviews revealed a lack of understanding regarding the differing meal service practices.
The facility failed to notify the provider of missed medication doses for two residents, one with atrial fibrillation and another with hypertension and a PEG tube. Medications were not reordered in time, leading to missed doses, and feeding tube orders were not in place, resulting in missed flushes. Staff interviews revealed systemic issues with medication reordering and communication.
The facility failed to provide adequate grooming for four residents with severe cognitive impairments, resulting in unkempt appearances and potential embarrassment. Observations showed these residents had noticeable facial hair that was not addressed, despite the facility's policy to improve appearance according to preferences. Staff interviews revealed a lack of awareness of residents' grooming preferences, and no documentation was provided to justify the lack of care.
The facility failed to provide residents with their food and beverage preferences, leading to incorrect items being served. Observations showed residents receiving beverages and nutritional supplements that did not match their meal tickets, such as being served Ensure Plus instead of Boost. Additionally, meals did not align with dietary needs or preferences, like serving regular jam to a diabetic resident. Staff interviews revealed these discrepancies were due to the dietary department providing available items rather than preferred ones.
A resident reported overhearing CNAs making derogatory comments about another resident's hygiene, which was not thoroughly investigated by the facility. Despite being cognitively intact, the resident's concerns were not adequately addressed by the Unit Manager or other staff, leading to a lack of communication and follow-up. The Director of Nursing was unaware of the incident, and grievance forms were not provided, indicating a failure in documentation and response to resident complaints.
A facility failed to update a resident's advanced directive and code status, despite requests from the designated patient advocate. The resident, unable to make medical decisions, was listed as Full Code, contrary to their signed directive and the advocate's request for DNR status. The advocate, living out of state, struggled with decision-making responsibilities and requested guardianship, which the facility did not initiate.
A facility failed to notify a resident's emergency contact of a change in condition, involving bruising and a laceration discovered during catheterization. The resident, who was moderately cognitively impaired with dementia and Alzheimer's, had their condition noted by a nurse, but the family was not informed, as confirmed by the DON.
A facility failed to prevent the misappropriation of a resident's narcotic medications, resulting in the loss of pain medication. An RN signed for a new Norco prescription but did not add it to the narcotic count sheet, leading to a discrepancy. The RN tested positive for opioids and oxycodone, and the facility concluded that the RN diverted the Percocet, as she could not provide a valid prescription for oxycodone and failed to follow proper procedures.
A facility failed to follow its abuse policy when staff did not report observations of potential sexual abuse of a resident with dementia and Alzheimer's disease. Despite noticing bruising and swelling in the resident's genital area, staff did not immediately inform the Nursing Home Administrator as required. The Administrator only learned of the injury weeks later, highlighting a lapse in the facility's reporting procedures.
A resident with dementia and muscle weakness experienced multiple falls due to the facility's failure to update the care plan with appropriate fall prevention interventions. Despite being at high risk for falls, the resident's care plan did not include the use of a fall mat, which was not consistently placed by the bed. Staff interviews confirmed the lack of documentation and communication regarding this intervention.
A resident with multiple pressure ulcers did not receive necessary care to prevent and treat her condition. Despite having a care plan that included the use of bilateral boots for offloading, these were not consistently applied. Observations showed the resident often without the prescribed boots, and staff interviews revealed a lack of adherence to the care plan. The MAR/TAR inaccurately indicated the boots were applied, contributing to the deficiency in pressure ulcer care.
A resident with multiple health conditions and a high fall risk experienced two falls due to staff failing to use prescribed assistive devices during transfers. Despite training, a CNA did not use a slide board or gait belt, leading to the resident being found on the floor on separate occasions.
A facility failed to provide timely emergency physician services for a resident with multiple health conditions who had not voided for 13 hours after returning from the hospital. Despite multiple attempts to contact the resident's physician and the facility's on-call provider, no immediate medical intervention was provided, leading to significant urinary retention. The facility lacked a contingency plan for emergency care when the resident's independent physician did not respond.
Two residents experienced medication administration errors, leading to a 12% error rate. A resident received an incorrect dose of Depakote due to an incomplete order, and another resident missed a dose of Symbicort inhaler because it was not available. The LPN failed to follow the facility's medication administration policy, which requires verifying orders before administration.
The facility failed to properly label, date, and store medications in the medication cart. An opened insulin lispro pen was found without an open date, and in the stock meds area, an opened bottle of Mucus ER and Cetirizine 10 mg were also missing open dates. RN FF confirmed that nurses were supposed to label medications with open dates, but this was missed. The DON reported that night shift staff were expected to review medication carts to ensure proper labeling.
The facility failed to implement Enhanced Barrier Precautions for two residents, one with a urinary catheter and another with a feeding tube. Observations showed a lack of signage and PPE, and staff did not consistently use gloves and gowns during care activities, despite the requirements. This resulted in potential cross-contamination risks.
The facility failed to prevent elopement for two residents and ensure safe mechanical lift transfers for another, resulting in Immediate Jeopardy. One resident expressed a desire to leave and was not reassessed for elopement risk, while another with a known history of elopement was found outside. Additionally, a resident was injured during a lift transfer due to improper equipment maintenance and staff training.
The facility failed to protect residents from abuse, resulting in incidents where a resident physically assaulted another, and another resident engaged in inappropriate sexual behavior. Despite care plans, interventions were insufficient, leading to emotional distress and physical harm. The facility's policy on abuse was not adequately enforced, contributing to these deficiencies.
A resident with dementia and other health issues fell from a mechanical lift and sustained a head injury. A CNA moved the resident back to bed without waiting for a nurse's assessment, contrary to facility policy and guidelines. The resident was later hospitalized and returned with stitches and a hematoma. Staff interviews confirmed the breach in protocol.
A resident with severe cognitive impairment and limited mobility was injured during a transfer when a CNA failed to use the prescribed sit-to-stand lift, resulting in a laceration requiring sutures. The CNA did not check the care plan and manually transferred the resident, leading to the injury.
A resident with dementia experienced two unwitnessed falls resulting in head trauma, but the facility failed to notify the physician. The resident was on hospice care, and facility staff assumed the hospice nurse would inform the hospice physician. However, the hospice nurse expected the facility to notify the resident's physician directly. A follow-up visit note lacked any mention of the falls, highlighting a communication breakdown.
A facility failed to prevent physical abuse between two residents with dementia, resulting in repeated incidents of aggression. Despite known triggers and a history of aggression, the facility lacked consistent supervision and effective interventions, leading to physical altercations. Staff interviews highlighted insufficient dementia training and inadequate supervision, particularly during weekends and evenings.
A resident with dementia experienced a right hip fracture that was not reported as an injury of unknown origin by the facility. The fracture was discovered after the resident complained of pain, but the facility attributed it to a previous fall without proper documentation or timely reporting. Interviews and records indicated a lack of immediate pain or injury signs post-fall, leading to a delay in investigation.
A resident with dementia experienced two falls in one night, but the facility failed to document a complete post-fall assessment. Although the resident initially showed no abnormalities, a hip fracture was discovered two days later when the resident complained of leg pain. The lack of documentation delayed necessary interventions.
Cold Meals Served During Tray Delivery
Penalty
Summary
The facility failed to provide food at a palatable temperature for Resident #33, who repeatedly reported that meals were served cold. During interviews on 5/3/2026, 5/4/2026, and 5/5/2026, Resident #33 stated that food served in her room was always cold, that she had spoken with multiple staff members about the issue on numerous occasions, and that even meals served in the dining room were frequently cold. She specifically reported that her lunch on 5/5/2026, including pork chop and potatoes, was not warm to her mouth. Observations and record review showed that meal temperatures were not maintained during service. On 5/5/26, a sample tray intercepted from the B hall cart showed the pork chop at 126.5 degrees and the roasted potatoes at 117 degrees. On 5/4/26, the Dietary Director stated hot food on the steam table should stay hot through service, but preservice temperatures were not taken because staff got in a hurry, and the surveyor found asparagus around 165F and chicken breast ranging from 110F to 138F while staff continued plating meals. Later that day, a test tray placed first on the D hall cart returned with chicken breast at 96F, another item at 102F, and asparagus at 101F after all meals were delivered.
Food Storage and Handling Deficiencies
Penalty
Summary
The facility failed to maintain best practices in the food service area during observation, interview, and record review. In the kitchen, a spray bottle with a yellow solution was observed on the shelf above the hand sink without a common name label. In the three-door cooler labeled #1, a cooked ham and a bag of cooked brats were stored on top of raw ground beef, and later a box of raw shaved steak was observed sitting on top of a box of cooked roasts. The Dietary Director stated that ready-to-eat food should not be stored with raw product and that the items should not be stored this way, but the cooler was later found rearranged so the cooked ham and cooked brats were again laying on raw ground beef. Additional food service observations showed an open container of lemon juice at room temperature even though the container required refrigeration after opening. Five large metal sheet pans were stacked and stored wet with moisture between the pans. In the dining room, the ice machine holder did not have a proper drain and the ice scoop was sitting in stagnant water in the bottom of the holder. During lunch service, staff plated food from the steam table while placing the handles of tongs or a mechanical scoop into the food product, including the scoop laying in rice three times and tong handles laying in chicken breast while staff used gloved hands to grab the chicken.
Advance Directive and Code Status Records Were Inaccurate
Penalty
Summary
The facility failed to ensure updated and accurate advance directive information was in place for two residents reviewed for advance directives. For one resident, the record showed vascular dementia and major depressive disorder, with a BIMS score of 9/15 indicating moderate cognitive impairment. The resident’s EMR banner listed Full Code, while an advance directive signed by the patient advocate indicated CPR should not be performed. A physician order also listed Full Code as active. During interview, the SW stated the facility did not honor the advance directive because the patient advocate did not have guardianship at the time, and although temporary guardianship was later granted, the facility had not obtained an updated advance directive form. For the second resident, the record showed depression and visual hallucinations. The EMR banner listed Full Code, but the advance directive form signed by the guardian marked CPR as unsure. A separate DNR order signed by the guardian stated that no person shall attempt to resuscitate the ward, but the form was not signed by two witnesses or a physician. During interview, the SW stated she believed the resident was listed as Full Code because the guardian had marked CPR as unsure on the advance directive form, and she was unaware of the incomplete DNR form scanned into the EMR. The SW also reported that advance directives were reviewed quarterly at care conferences, but the resident’s most recent care conference notes did not include review of code status or advance directives. The facility policy stated that staff would review and explain advance directive options, obtain signed acknowledgment, complete an advance directive form with the resident or legal representative to verify treatment options and code status, and review the resident’s choices during reassessment and quarterly care planning.
Failure to Protect Resident from Inappropriate Sexual Contact
Penalty
Summary
The facility failed to protect a cognitively intact resident from sexual abuse by another resident. Resident #67, who had diagnoses including major depressive disorder and anxiety disorder and a BIMS score of 13/15, reported that Resident #43 grabbed her buttocks in a common area near the nurse’s station after she had stopped to speak with a CNA. Resident #67 was upset by the incident and later stated she was willing to move rooms to feel safer and stay away from Resident #43. Resident #43 had diagnoses including bipolar disorder and other sexual disorder and a BIMS score of 10/15. His care plan documented a behavior concern related to sexual disorder and a history of inappropriate touching of other residents and staff, typically female residents, with interventions to have staff assist him last into meals and activities and seat him in an area with males only. Despite this history and plan, the incident occurred as Resident #43 was exiting the dining room without staff assistance and was able to approach Resident #67 in a common area. Facility documentation and staff interviews confirmed that Resident #43 had a history of touching females inappropriately and that staff needed to monitor him around female residents at all times. The facility’s investigation recorded that Resident #43 made contact with Resident #67’s buttocks and that staff separated the residents immediately. The administrator stated he was not aware of the care plan intervention to escort Resident #43 out of the dining area and believed the incident did not rise to the level of abuse because Resident #67 said she was not afraid of him and understood his cognitive complexities.
Failure to Provide Written Bed Hold Notice Before Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written bed hold notice was provided to Resident #95 before transfer to the emergency department. Resident #95 was a female resident originally admitted to the facility with diagnoses including metastatic cancer, weakness, and hypertension. Her MDS assessment dated 2/9/26 showed a BIMS score of 10/15, indicating mild cognitive impairment. On 2/11/26, a progress note documented that she was recommended for transfer to the ED for evaluation, the resident was notified, the provider was notified, and an order was given to transfer her. Later that day, Resident #95 was transferred to the ED by ambulance on a stretcher. Review of her medical record found no documented bed hold policy form or evidence that a bed hold notice was provided before the transfer. The NHA reported he was unable to provide a written bed hold policy that had been given to the resident before transfer. Staff interviews indicated that transfer paperwork was supposed to accompany residents, but it was sometimes forgotten, and the interim DON reported that bed holds were not being provided because nurses were not sending the packets with residents. The NHA also reported there was no staff follow-up for bed hold notices with residents who transferred out of the facility.
Failure to Update Care Plan After Resident-to-Resident Sexual Contact
Penalty
Summary
The facility failed to review and revise a comprehensive, individualized care plan after a resident-to-resident incident involving Resident #43. Resident #43 was admitted with diagnoses including bipolar disorder and other sexual disorder, and the care plan already identified a behavior concern related to sexual disorder with a history of inappropriate touching of other residents and staff, typically female residents. The incident occurred when Resident #43, while propelling in a wheelchair behind Resident #67 in a common area, reached out and made contact with Resident #67’s buttocks. Staff immediately separated the residents, and the facility completed an investigation. The investigation summary documented that Resident #43 could not consistently recall the event, later acknowledged being inappropriate with a female resident, and expressed remorse. Resident #67 stated she was upset but calm, understood Resident #43 had cognitive complexities, was not afraid of him, and requested to be moved to a different unit. Despite the incident and the resident’s known history of sexually inappropriate behavior, the care plan was not updated with new interventions after the event. The existing plan continued to list general interventions such as redirection away from female residents, seating with males only, behavioral health consults as needed, and review of behaviors and interventions, but no new interventions were added after the incident. During interviews, Social Services and the NHA were unable to identify what new interventions had been initiated to address the behavior, and the NHA confirmed the care plan had been missed after the resident-to-resident incident.
Failure to Use Ordered Elbow Pads for Pressure Ulcer Prevention
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not implemented for Resident #42, who had unspecified dementia, moderate protein-calorie malnutrition, a BIMS score of 0/15, and was dependent for rolling in bed and transferring. The resident’s MDS identified him as at risk for pressure ulcers, and the care plan included elbow pads when up in his specialty wheelchair and removal when in bed. A physician’s order also directed bilateral elbow pads while up and removal when in bed. During observations, Resident #42 was seen in his specialty wheelchair with both elbows resting directly on the armrests and no elbow pads in place. On one observation, a mint green elbow pad was found on the resident’s nightstand. On another observation, the resident wore an elbow pad on the right elbow only, while the left elbow rested directly on the armrest with skin gathered in folds. Later, the resident was again observed sitting in the wheelchair with both elbows on the armrests and no elbow pads on either arm. RN K stated she had looked all over the building and could not find any elbow pads for the resident that morning, and confirmed the resident was supposed to use bilateral elbow pads when out of bed to prevent skin breakdown on his elbows.
Fall Prevention Care Plan Not Followed
Penalty
Summary
The facility failed to implement care plan interventions for fall prevention for Resident #58, who was admitted with diagnoses including Alzheimer’s disease, lack of coordination, and muscle wasting. The resident’s MDS assessment showed a BIMS score of 1/15, indicating severe cognitive impairment, and the assessment also documented a fall with injury since the prior assessment. The care plan identified the resident as at risk for falls related to medical condition, muscle wasting, and a history of sacrum fracture, with interventions including a sign on the walker that says “please take me with you” and ensuring the call light was within reach. During multiple observations, the resident’s call light was repeatedly found out of reach, placed under the foot of the bed or on the floor behind the resident’s feet. The resident’s walker was observed nearby with the brakes locked, but the required sign was not present on the walker. The resident was also observed walking into the hallway without the walker, and an LPN and an activity assistant then reminded the resident to use the walker and encouraged her to sit back down. A CNA later reported that the resident sometimes used the call light to alert staff that she needed something.
Failure to Provide Person-Centered Dementia Care
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions based on lifelong habits and personality for two residents with severe cognitive impairment. One resident had diagnoses including vascular dementia, anxiety disorder, major depressive disorder, and a history of nicotine dependence, with a BIMS score of 3/15. The other resident had Alzheimer’s disease and generalized anxiety disorder, with a BIMS score of 2/15 and daily wandering that had worsened since the prior assessment. For the resident with vascular dementia, the care plan addressed agitation and smoking, but the record and observations showed repeated distress in the common area when other residents were nearby or when there was increased stimulation. He was observed sitting in his usual recliner while other residents, staff, and family members were present, appearing tense with a furrowed brow, rapid knee bouncing, and gripping the armrests, and no intervention was offered. He was also observed making a jabbing motion toward another resident and later was reported by staff to yell at nearby residents, including telling one resident to get out of here and another to shut the f### up. Staff described him as easily agitated by residents walking near him, by loud vocalizations, and by activity around his chair, while also noting he appeared calm in quieter settings and liked to watch television in his room. The resident’s history and preferences were not incorporated into a consistent individualized approach. Staff and family reported he had smoked for many years, preferred to keep to himself, and did not enjoy crowds, yet smoking breaks were not scheduled on a consistent basis and staff did not routinely use his known preference for quiet or his lifelong habits to reduce stress. The social worker stated staff did not want him to self-isolate, and staff reported no documented episodes of agitation despite multiple observations and interviews describing agitation toward other residents. For the resident with Alzheimer’s disease, the care plan addressed wandering and entering peers’ rooms, but there were no interventions specific to entering the other resident’s personal space or to the conflict between the two residents. She was observed wandering into another resident’s room, where she was yelled at, and later wandered into the other resident’s room when the stop sign door sign was not in place. Psychiatry notes also documented that staff reported she wandered in and out of other residents’ rooms.
Incomplete Conservatorship Documentation
Penalty
Summary
The facility failed to maintain accurate and complete medical records for 1 of 18 residents reviewed, involving a resident admitted with depression and visual hallucinations. The resident had letters of conservatorship showing an expiration date, and the conservatorship was noted to be expired. During interview, the SW stated she was aware the conservatorship had expired and reported that she had reached out to the conservator for updated paperwork but had not received a response and had not followed up since. The SW also stated that guardianship/conservatorship paperwork should be reviewed quarterly at resident care conferences, but the resident’s care conference note did not include discussion of the conservatorship paperwork. Review of the facility’s Advance Directive Action Plan showed the facility had identified that updated guardianship paperwork was not being obtained and that code statuses were still being signed by the guardian on file. The record also included an email from the SW requesting updated guardianship paperwork and a later email from the NHA making the same request, while the SW later reported she had called the conservator and learned the conservator did not realize the paperwork had expired.
Failure to Prevent Resident-to-Resident Physical Altercation Over Personal Belongings
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse when two residents engaged in a physical altercation. One resident with Alzheimer’s disease and generalized anxiety disorder, who was severely cognitively impaired with a BIMS score of 0/15, frequently walked around the unit and picked up items in her environment. Her care plan identified that she spent time walking around the unit picking up sensory items and directed staff to offer cues and prompts as needed, but there was no care plan addressing her behavior of picking up other residents’ belongings. On the day of the incident, this resident walked by another resident in the dining area and picked up a pair of gloves that were next to the second resident, then walked away carrying the gloves. The second resident involved had unspecified dementia, major depressive disorder, and a history of suicidal ideation, with a BIMS score of 12/15 indicating moderate cognitive impairment. Her care plan identified risk for psychosocial well-being concerns related to suicidal ideation and included an intervention to remove residents to a calm, safe environment when conflict arises, but there was no care plan addressing her frustration with peers. A family member witness reported that after the first resident picked up the gloves and began walking down the hall, the second resident followed, forcefully grabbed the first resident’s arm, and pulled back in a way that caused the first resident to turn around. In response, the first resident slapped the second resident on the side of the face, after which the second resident appeared angered and verbally stated that she had been slapped. Staff interviews and documentation further described the residents’ behaviors and the circumstances leading to the altercation. An LPN stated that the first resident frequently explored her environment by picking up items and did not have the capacity to consider ownership of the items she handled. A CNA reported that the second resident felt frustrated by the actions of other residents and would respond by yelling at them. A progress note documented that the second resident had been upset about a disagreement with another resident over her gloves, and a later psychiatric evaluation noted that she argued with another resident and had current symptoms including anxiety, depression, and irritability. The facility’s Resident Rights, Abuse and Neglect policy defined physical abuse to include hitting, slapping, and grabbing, and the reasonable person concept was applied to determine that neither resident would want to be grabbed forcefully by the arm or slapped in the face, establishing that the resident-to-resident physical contact constituted abuse that the facility failed to prevent.
Medication Administration Error Due to Failure to Remove Discontinued Medication
Penalty
Summary
A deficiency occurred when a nurse failed to follow professional standards of nursing practice during medication preparation and administration for a resident. The nurse retrieved and administered Meloxicam 7.5 mg from a medication card that had been discontinued, instead of the current order for Meloxicam 15 mg once daily. The discontinued medication card was not removed from the medication cart after the physician changed the order, leading to the administration of the incorrect dose. The nurse did not reconcile the medication dosage against the physician order prior to administration. Interviews with facility staff revealed that there were multiple medication cards for both the discontinued and current dosages in the cart, and that audits of medication administration and cart storage were performed without consistently checking for discontinued medications. Documentation of medication pass audits was incomplete, lacking details such as dates, resident names, or specific medications observed. Professional standards, including the six rights of medication administration, were not consistently followed, resulting in a medication error for the resident.
Medication Labeling, Storage, and Administration Deficiencies
Penalty
Summary
Surveyors observed multiple failures in the facility's medication management practices. On one medication cart, the narcotic count sheets were not verified for the current day, with the last entry recorded the previous night. The Assistant Director of Nursing (ADON) confirmed that narcotic counts should be performed and documented at each shift change, but the responsible LPN had not completed the count and cited the absence of a log sheet as a possible reason. Additionally, another LPN admitted to not having counted narcotics that day. Further observations revealed that a resident was administered Meloxicam 7.5 mg, which had been discontinued per physician orders and replaced with a 15 mg dose. The discontinued medication remained in the cart alongside the new medication, and the LPN acknowledged the error after reviewing the orders. Another issue was found with an insulin pen in a medication cart that was in use but lacked an open date, which the LPN attributed to forgetting to date it. Audits performed by the ADON and Unit Manager (UM) focused on medication administration and storage, but the UM reported not regularly checking for discontinued medication cards, and insulin pens were not always dated upon opening.
Deficiencies in Sanitation and Dining Environment
Penalty
Summary
The facility failed to maintain a sanitary and orderly environment in two specific areas: Resident #61's room and the spa room between C and D hall. Observations revealed that Resident #61's room had a windowsill track littered with dead bugs, dust, and debris, a cracked and chipped tile sill, and a headboard with veneer pulled away, leaving a large gap. Additionally, a window curtain had a noticeable stain. Resident #61, who was cognitively intact, expressed dissatisfaction with the room's condition, comparing it unfavorably to her home environment. In the spa room, a padded shower chair was found with stuck-on and smeared brown debris, and the supply cabinet had black-spotted debris on the inside walls, indicating a lack of cleanliness and maintenance. The facility also failed to provide a home-like dining environment in the locked memory care unit's dining room. Observations showed that residents in this unit were served meals on trays placed on dining tables, which contrasted with the main dining room where meals were served directly on the table without trays. Interviews with staff, including the Dietary Director, DON, and a CNA, revealed a lack of awareness and understanding of why meals were served differently in the locked memory care unit. The facility's policy emphasized creating a pleasant dining atmosphere, which was not adhered to in the memory care unit, potentially leading to an institutionalized dining experience for residents.
Failure to Notify Provider of Missed Medication Doses
Penalty
Summary
The facility failed to maintain professional standards of nursing practice by not notifying the provider of missed medication doses for two residents. Resident #6, who was admitted with atrial fibrillation, missed a morning dose of Symbicort inhaler because the medication was not reordered in time. The LPN responsible did not notify the facility's medical doctor, believing it was unnecessary. This oversight was attributed to a common issue where staff were not diligent in reordering medications, leading to missed doses. Resident #338, admitted with hypertension and a PEG tube, also experienced missed medication doses. Upon readmission, the facility did not have the resident's medications available, including Coreg, due to a failure in ordering them. Additionally, there were no feeding tube orders in place, resulting in missed flushes for the PEG tube. The LPN involved did not verify the orders with a second nurse, as required, and the Unit Manager was not informed of the missing orders. Interviews with facility staff, including the DON and pharmacists, revealed systemic issues with medication reordering and communication. The facility's policy required nurses to reorder medications when there were 7 doses remaining and to notify providers of missed doses, but these procedures were not consistently followed. The pharmacy confirmed that urgent medications could be delivered the same day if requested, but this option was not utilized, leading to the deficiencies observed.
Failure to Provide Adequate Grooming for Residents with Cognitive Impairments
Penalty
Summary
The facility failed to provide adequate grooming care for four residents who were dependent on staff for activities of daily living, resulting in unkempt appearances and potential feelings of embarrassment. Observations revealed that these residents, all with severe cognitive impairments, had noticeable facial hair that was not addressed by the staff. Despite the facility's policy to improve residents' appearance in accordance with their preferences, there was no documentation to explain why the grooming was not performed. Resident #12 was observed multiple times with long white facial hairs on her chin, and no documentation was provided to justify the lack of shaving. Similarly, Resident #14 had facial hair resembling a mustache and chin hairs, with a family member confirming that the resident would not have wanted facial hair. Resident #17 had a visible mustache and debris in her hair, while Resident #53 had long chin hairs. All these residents were observed over several days with the same grooming issues. Interviews with staff, including the Director of Nursing and a Registered Nurse, revealed a lack of awareness regarding the residents' preferences for facial hair grooming. The staff prioritized completing baths over addressing facial hair, and there was no documentation of refusals or preferences for grooming. The facility's shaving policy, adopted in 2018, emphasized improving residents' appearance according to their preferences, but this was not adhered to in these cases.
Failure to Provide Resident Food and Beverage Preferences
Penalty
Summary
The facility failed to consistently provide residents with their food and beverage preferences, leading to incorrect items being served to 12 residents out of a census of 88. Observations revealed that residents were often given beverages and nutritional supplements that did not match their meal ticket preferences. For instance, Resident #17 was repeatedly served a red beverage instead of apple juice and a Vanilla Ensure Plus instead of Chocolate Boost, which was specified on her meal ticket. Similarly, Resident #53 and others were served Ensure Plus instead of Boost, despite the nutritional differences between these products. In several instances, residents were served meals that did not align with their documented preferences or dietary needs. Resident #2, who preferred sweet breakfasts, was served only one portion of French toast instead of the double portion noted on her meal ticket. Resident #64, who disliked broccoli, was served it despite her meal ticket specifying alternative vegetables. Additionally, Resident #24, a diabetic, was served regular jam instead of the sugar-free condiments she preferred, and was given oatmeal instead of Fruit Loops on a day when Fruit Loops were requested. Interviews with staff, including the Dietary Director, revealed that the discrepancies were due to the dietary department providing what was available rather than what was preferred or ordered. The Dietary Director acknowledged that the facility's policy was to provide substitutes from the same food group and nutritionally equivalent, but this was not consistently followed. The report highlights that the residents in the locked memory care unit were unable to express their dissatisfaction, which could impact their nutritional intake.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by the interactions between staff and residents. Resident #54, who was cognitively intact with a BIMS score of 15/15, reported overhearing CNAs making derogatory comments about a resident's hygiene, which she found upsetting. Despite reporting this to the Unit Manager (UM) CC, no thorough investigation was conducted to address the issue or identify the resident involved. Interviews with staff revealed a lack of communication and follow-up on the reported concerns. Social Services Director (SSD) GG admitted to not investigating Resident #54's previous complaints, assuming they were being handled by the nursing team. UM CC acknowledged speaking to the CNAs about keeping their voices down but did not report the incident to higher management or investigate further. The Assistant Director of Nursing (ADON) was aware of the complaint but did not pursue it, believing UM CC had resolved the issue. The Director of Nursing (DON) was unaware of the incident until the survey, indicating a breakdown in communication and reporting within the facility. The facility also failed to provide grievance forms for Resident #54, suggesting a lack of documentation and follow-up on resident complaints. Previous issues with CNA P's behavior were noted, but no corrective actions were mentioned in the report.
Failure to Update Advanced Directive and Code Status
Penalty
Summary
The facility failed to ensure that Resident #338's advanced directive information was updated and accurate, which could potentially lead to the resident's preferences for medical care not being followed. Resident #338 was admitted with a diagnosis of hypertension and had designated a family member, FM RR, as their patient advocate. The resident had signed a form indicating they did not want life-sustaining treatment under certain conditions. However, despite being listed as a Full Code at the facility, FM RR had requested a change to Do Not Resuscitate (DNR) status, which was not processed by the facility. FM RR, who was responsible for making medical decisions due to the resident's inability to participate in complex decision-making, expressed difficulty in fulfilling this role due to living in another state. FM RR had informed the facility of the desire to change the code status to DNR and later requested the facility to obtain a guardian for the resident. Despite these requests, the facility did not send the necessary paperwork to FM RR to change the code status, nor did they initiate the process for guardianship. The Social Services Director confirmed awareness of these issues but could not explain why the paperwork was not sent or why the guardianship process was not started.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the responsible party of a change in condition for a resident who was moderately cognitively impaired with diagnoses of dementia and Alzheimer's disease. On March 15, 2025, a progress note indicated that the resident had bruising and swelling on the labia and a laceration above the urethra, discovered during a catheterization procedure. Despite these findings, the nurse on duty did not inform the family or emergency contact. The Assistant Director of Nursing was informed, but the family was still not contacted. The Director of Nursing confirmed that the resident's emergency contact was not notified of the bruising and tear when they were found.
Misappropriation of Resident's Narcotic Medications
Penalty
Summary
The facility failed to prevent the misappropriation of narcotic medications for a resident, resulting in the loss of the resident's pain medication. The issue was identified when the Director of Nursing (DON) received a call from the facility pharmacy about a discrepancy involving 20 unaccounted Percocet pills prescribed to a resident. An audit of medication carts and narcotic drawers was conducted, but the missing medication could not be located. The investigation revealed that a Registered Nurse (RN) had signed for a new Norco prescription for the resident but failed to add it to the narcotic count sheet, which should have reflected 35 scripts instead of 34. The RN was the last to document the administration of Percocet to the resident and tested positive for opioids and oxycodone during a drug test. Despite providing an undated script for Norco, the RN could not explain the missing narcotic card and narcotic sheet or why the Norco script was not logged onto the shift-to-shift count sheet. The facility concluded that the RN had diverted the Percocet from the resident, as she was unable to provide a valid prescription for oxycodone and did not follow procedure with the addition of the Norco script to the narcotic count log. The investigation included interviews with the RN and a Licensed Practical Nurse (LPN), as well as a review of the narcotic count logs and medication administration records. The Consulting Pharmacist confirmed the discrepancies in the documentation and noted that the RN had signed for the delivery of the Norco prescription and was the last to document the administration of Percocet. The facility's disciplinary action report for the RN indicated a previous violation of department policies and procedures related to medication documentation.
Failure to Report Observations of Potential Abuse
Penalty
Summary
The facility failed to operationalize its abuse policy and procedure for a resident who was moderately cognitively impaired with diagnoses including dementia and Alzheimer's disease. The deficiency occurred when staff did not report observations of potential sexual abuse to the Nursing Home Administrator immediately. On a specific date, a progress note indicated that the resident had bruising and swelling in the genital area, which was not reported to the Administrator as required by the facility's policy. The Nursing Home Administrator only became aware of the injury weeks later when informed by the Assistant Director of Nursing. Interviews with staff revealed that the Licensed Practical Nurse who observed the injury did not report it to the Abuse Coordinator but instead informed the oncoming nurse. The Registered Nurse who also observed the injury did not notify the Administrator or the Abuse Coordinator, only discussing it with the Assistant Director of Nursing. The facility's policy mandates that all allegations and suspicions of abuse must be reported immediately to the Administrator or their designee, which was not followed in this case. The facility's abuse training records showed that the involved staff had received training on reporting requirements, yet failed to adhere to them.
Failure to Update Care Plan for Fall Prevention
Penalty
Summary
The facility failed to update and revise the person-centered care plan in a timely manner with appropriate interventions for the prevention of falls for a resident. The resident, a male with diagnoses including lack of coordination, muscle weakness, dementia, and Alzheimer's disease, was identified as being at high risk for falls. Despite this, the care plan did not include necessary interventions such as the use of a fall mat, which was not consistently placed by the resident's bed as required. The resident experienced multiple falls, including one incident where he was found on the floor after attempting to self-transfer from bed to wheelchair. Observations revealed that the fall mat, which was supposed to be a part of the resident's fall prevention strategy, was not in place during these incidents. Interviews with staff, including a CNA and an LPN, confirmed that the fall mat was not listed as an intervention in the resident's care plan or kardex, indicating a lack of communication and documentation. The Director of Nursing (DON) acknowledged the oversight and noted that the interdisciplinary team met weekly to review falls and care plans, but the necessary updates had not been made for this resident. The failure to include and implement the fall mat intervention in the care plan contributed to the resident's repeated falls, highlighting a deficiency in the facility's care planning and communication processes.
Failure to Implement Pressure Ulcer Care Plan
Penalty
Summary
The facility failed to provide necessary care and services to prevent, treat, and promote healing of pressure ulcers for a resident with multiple pressure ulcers and chronic venous hypertension. The resident had several pressure ulcers, including a stage 3 ulcer on the right buttock, an unstageable ulcer on the left ankle, and a stage 3 ulcer on the left heel. Despite having a care plan that included interventions such as the use of bilateral boots for offloading pressure, these interventions were not consistently implemented. Observations revealed that the resident was often left in a supine position without the prescribed bilateral boots for offloading, which were intended to prevent further skin breakdown. The resident reported that staff had not assisted her in getting out of bed since her admission and that she was not taken to the bathroom despite being continent. The resident's legs and feet were frequently observed without the necessary offloading devices, and her wounds were not properly managed, as evidenced by purulent drainage and multiple open sores on her lower legs. Interviews with staff indicated a lack of adherence to the care plan, as the intervention for bilateral boots was not documented in the resident's kardex, and staff failed to apply the boots consistently. The Medication Administration Record/Treatment Administration Record (MAR/TAR) inaccurately indicated that the boots were applied, despite observations to the contrary. The facility's failure to implement the care plan and document refusals or changes in the resident's condition contributed to the deficiency in pressure ulcer care.
Failure to Use Assistive Devices Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of Resident #33, who has a high risk for falls due to multiple health conditions, including the absence of a right leg above the knee, multiple sclerosis, blindness in the left eye, and muscle wasting. The resident's care plan indicated the use of a slide board for transfers, but this was not consistently followed by the staff. On two separate occasions, the resident was found on the floor after attempted transfers by a CNA, indicating a lack of adherence to the prescribed safety measures. On the first incident, the CNA attempted to pivot transfer the resident from the bed to a wheelchair without the resident's assistance, resulting in the resident sliding to the floor. The CNA reported using a gait belt, but the resident was described as dead weight and did not assist during the transfer. The bed was positioned higher than the wheelchair to facilitate a safe transfer, but the lack of proper technique and assistive device use led to the fall. In the second incident, the resident explicitly stated that the CNA did not use the slide board and attempted to lift him independently, which resulted in the resident being lowered to the floor. The resident reported that the slide board was usually placed against the footboard of his bed, but it was not utilized during the transfer. Despite the CNA having completed training for fall prevention and the use of assistive devices, the failure to follow the care plan and use the slide board contributed to the resident's fall risk and subsequent incidents.
Failure to Provide Timely Emergency Physician Services
Penalty
Summary
The facility failed to ensure that emergency physician services were utilized for a resident who was moderately cognitively impaired and had multiple diagnoses, including morbid obesity, anxiety disorder, metabolic encephalopathy, COPD, and chronic respiratory failure. After returning from a hospital stay, the resident had not voided for approximately 13 hours, and facility staff made several attempts to contact the resident's physician and the facility's on-call medical provider without success. The facility's nurse practitioner was unable to provide an order for catheterization because the resident was not under their care. The Director of Nursing acknowledged that there was no plan in place for residents under the care of the independent physician if he did not respond to calls. The resident eventually received a straight catheterization, which relieved 600cc of urine, indicating significant urinary retention. The lack of timely physician response and the absence of a contingency plan for emergency care contributed to the deficiency, as the resident did not receive prompt medical intervention for a potentially serious condition.
Medication Administration Errors Result in 12% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a 12% error rate. This deficiency was observed in two residents. Resident #338, who was readmitted to the facility, did not receive the correct dosage of Depakote due to an incomplete medication order that lacked a specified dose. The LPN administered a 125 mg dose instead of the prescribed 500 mg. Additionally, the morning dose of Coreg was omitted because it was not available. The LPN documented the administration of Depakote under an order that did not specify the dose, which was confirmed by the DON during a review of the MAR. The DON acknowledged the error and confirmed that the LPN did not follow the rights of medication administration. Resident #6 did not receive the morning dose of Symbicort inhaler because it was not available, as it had not been reordered. The LPN noted the absence of the inhaler and omitted the dose. The facility's policy requires that medications be administered as prescribed by the attending physician, and any discrepancies in dosage or schedule should be verified against the physician's orders. The failure to adhere to this policy contributed to the medication errors observed.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to properly label, date, and store medications in the medication cart, as observed during a survey. An opened insulin lispro (Humalog) pen was found in the top shelf of the cart without the date it was opened, although it was labeled with the resident's name. Additionally, in the stock medications area of the cart, an opened bottle of Mucus ER and an opened bottle of Cetirizine 10 mg were found without open dates. Registered Nurse (RN) FF confirmed that the nurses were supposed to label the insulin pens and other medications with the date they were opened, but this was missed. The Director of Nursing (DON) reported that the night shift nursing staff were expected to review the medication carts to ensure all medications were labeled with open dates, and that nurses should label medications when they are opened. This oversight in labeling and dating medications could potentially lead to decreased efficacy of medications and exacerbate medical conditions.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to effectively implement Enhanced Barrier Precautions (EBP) for two residents, R7 and R338, which resulted in potential cross-contamination risks. For R7, the medical records indicated the presence of a urinary catheter, but there was no documentation of EBP being implemented until several days after the catheter was inserted. Observations revealed that there was no signage or personal protective equipment (PPE) available at R7's room, and staff, including the Unit Manager, handled the catheter tubing without wearing gloves or gowns. The Director of Nursing later confirmed that R7 should have been placed on EBP due to the urinary catheter. For Resident #338, who had an enteral feeding tube, there was a sign indicating the need for EBP, but staff did not consistently adhere to these precautions. A Certified Nursing Assistant was observed assisting the resident without wearing a gown, despite the requirement for both gloves and gowns for direct care activities. An LPN confirmed that the resident was on EBP due to the feeding tube, highlighting a lapse in adherence to infection control protocols.
Failure to Prevent Elopement and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure the safety and prevent elopement for three residents, resulting in Immediate Jeopardy. Resident #100 and Resident #101 left the premises without staff knowledge and were later found in the community. Resident #100, who had a history of expressing a desire to leave the facility, was not reassessed for elopement risk despite showing signs of exit-seeking behavior. The facility's elopement policy was not followed, as door alarms were not functioning properly, and staff were not immediately responsive to alarms. Resident #101, who had a known history of elopement risk, was found outside the facility without staff knowledge, indicating a failure in monitoring and supervision. Additionally, the facility failed to minimize the risk of injury during mechanical lift transfers for Resident #106. The resident fell during a transfer when the sling clips became detached from the lift, resulting in a head injury. The facility did not conduct routine inspections of the mechanical lift slings, and the sling used did not have a manufacturer's tag, making it impossible to determine its age or condition. The CNA involved in the transfer was not aware of the requirement for two staff members to assist with transfers, further contributing to the incident. The facility's inaction in maintaining proper safety protocols and equipment checks led to these deficiencies. The lack of reassessment for elopement risk, failure to ensure door alarms were functioning, and inadequate training and equipment maintenance for mechanical lift transfers were significant factors in the incidents involving Residents #100, #101, and #106.
Removal Plan
- All licensed nurses present in the facility were re-educated on warning signs of elopement, reassessing residents to determine their risk of elopement and development of an elopement care plan and communicating new resident needs related to elopement to the interdisciplinary team. Non licensed staff were educated on resident warning signs for elopement and need to report signs to the nurse immediately.
- Plan put in place to educate every staff member prior to their next working shift.
- Facility confirmed all at risk residents had a care plan to address their needs related to their risk of elopement as well as a functioning personal alarm.
- Facility confirmed all door alarms and personal safety alarms were in working order and were monitored for functionality daily.
- Resident #101 was placed on 15-minute checks until a personal safety alarm was placed on him.
- Facility ensured the door codes were changed.
- Facility ensured elopement drills will be conducted on a weekly basis.
- Facility ensured signs were posted to educate visitors on the need to avoid assisting any resident through a door and to have staff escort visitors out of the building.
- Facility ensured the elopement book was reviewed and up to date.
- Facility reviewed the elopement policy and deemed it was appropriate.
- Facility ensured all windows were functioning properly.
- Facility ensured behavior tracking orders for elopement tendencies were added to all residents at risk.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in incidents involving four residents. Resident #102, who was severely cognitively impaired, physically assaulted Resident #103. Despite having a care plan in place to manage potential aggression, Resident #102 exhibited wandering, abusive language, and threatening behavior prior to the assault. The incident occurred when Resident #102 struck Resident #103 multiple times, causing emotional distress and physical pain. Staff intervention was delayed, and Resident #103 was left emotionally upset and physically bruised. In another incident, Resident #107, also severely cognitively impaired, engaged in inappropriate sexual behavior by grabbing Resident #108 in the dining room. Resident #107 had a history of socially inappropriate behavior, yet the care plan interventions were insufficient to prevent the incident. Resident #108, who was moderately cognitively impaired, experienced significant emotional distress and fear following the incident, leading her to request a change in her living arrangements to avoid further encounters with Resident #107. The facility's failure to implement effective interventions and monitor residents' behaviors contributed to these incidents of abuse. The facility's policy on abuse and neglect was not adequately enforced, as evidenced by the lack of preventive measures and timely staff response to the residents' aggressive and inappropriate behaviors. These deficiencies highlight the facility's inability to maintain a safe environment free from abuse for its residents.
Failure to Follow Post-Fall Protocols
Penalty
Summary
The facility failed to ensure proper post-fall care and assessment for a resident, resulting in the potential for serious injury. The facility's policy required that a resident not be moved until a nurse evaluated their condition after a fall. However, after a resident fell from a mechanical lift and sustained a head injury, a Certified Nursing Assistant (CNA) panicked and moved the resident back to bed without waiting for a nurse's assessment. This action was contrary to the facility's policy and the guidelines published by the American Association of Post-Acute Care Nursing, which emphasize the importance of assessing for spinal column injuries and other significant injuries before moving a resident. The resident involved had a history of cerebral infarction, major depressive disorder, unspecified dementia, and anxiety disorder, and required maximal assistance for transfers. After the fall, the resident was sent to the hospital and returned with stitches and a hematoma. Interviews with staff confirmed that the resident was moved before a proper assessment was conducted, which could have worsened the injuries. The Director of Nursing reiterated the importance of leaving a resident in the position they were found until assessed by a nurse to prevent complications.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to adhere to the care plan for a resident, resulting in an injury. The resident, who was severely cognitively impaired and had limited physical mobility, was supposed to be transferred using a sit-to-stand lift as per her care plan. However, a CNA attempted to transfer the resident from her bed to a wheelchair without using the recommended equipment or a gait belt. During this manual transfer, the resident sustained a laceration on her right lower leg, which required sutures. The incident occurred when the CNA responded to the resident's call to go to the bathroom. Without checking the care plan, the CNA stood the resident up and twisted her into the wheelchair, leading to the injury. The CNA admitted to not using the sit-to-stand lift or a gait belt during the transfer. The Director of Nursing confirmed that the transfer was conducted incorrectly, as the sit-to-stand lift should have been used according to the care plan.
Failure to Notify Physician After Resident Falls
Penalty
Summary
The facility failed to immediately notify the resident's physician of a change in condition for a resident who experienced two unwitnessed falls with known head trauma. The resident, who had been admitted to the facility with dementia, fell twice on the same night. The first fall was documented by a registered nurse, who noted the resident was found kneeling with their forehead on the floor, but vital signs were stable and the resident denied pain. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the facility did not notify the resident's physician. Interviews revealed that the facility staff believed it was the responsibility of the hospice nurse to communicate with the hospice physician, as the resident was a hospice patient. However, the hospice nurse reported that the facility declined an offer for a nurse visit to examine the resident after the falls. The hospice nurse also indicated that the facility nurse was expected to contact the resident's physician directly. A follow-up visit note from the resident's provider did not mention the falls, indicating a lack of communication and assessment regarding the resident's condition after the incidents.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically involving two residents, Resident #104 and Resident #105. Resident #105, who has a history of dementia and psychosis, was involved in two incidents of physical aggression towards Resident #104 within an eight-day period. The first incident occurred when Resident #105 placed her hands on Resident #104's shoulders and squeezed them, reportedly because Resident #104 was making comments about her. The second incident involved Resident #105 bending back Resident #104's fingers, resulting in redness and pain, although an X-ray showed no fractures. Resident #105's care plan indicated a potential for physical aggression due to cognitive impairments and poor impulse control. Despite interventions such as providing a private room and activities to keep her engaged, there was a lack of consistent supervision and interaction, particularly from the activities department. Observations noted that Resident #105 was often left alone in her room without engagement, and staff were not always present to intervene during incidents. Resident #104, also diagnosed with dementia, was known to make inappropriate comments, which often triggered Resident #105's aggressive behavior. Staff interviews revealed that there was insufficient dementia-specific training and a lack of adequate supervision, especially during weekends and evenings. The facility's failure to ensure consistent supervision and effective interventions contributed to the repeated incidents of resident-to-resident abuse.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to recognize and report an injury of unknown origin for a resident, resulting in a lack of timely reporting and potential delay in investigation. The resident, who had dementia, was admitted to the facility and later complained of right hip pain. An X-ray revealed an impacted intertrochanteric fracture with varus deformity. Despite the fracture being identified, the facility did not report it as an injury of unknown origin because they attributed it to a fall that occurred earlier. The Director of Nursing (DON) and Nursing Home Administrator (NHA) both indicated that the fracture was linked to a fall on the resident's right side. However, there was no documentation of a post-fall assessment or evidence showing when the interdisciplinary team determined the fracture was due to the fall. The incident report from the fall noted no immediate pain or discomfort, and subsequent notes indicated no changes in the resident's condition until the pain was reported two days later. Interviews with staff revealed that the resident initially showed no signs of injury or pain following the fall. The resident's records showed stable vital signs and no pain complaints immediately after the incident. The fracture was only identified after the resident experienced pain and difficulty walking, leading to an X-ray. The facility's delay in correlating the fracture to the fall and lack of immediate reporting to the state contributed to the deficiency.
Incomplete Post-Fall Assessment Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation of post-fall assessments for a resident, leading to potential insufficient follow-up and lack of necessary interventions. The resident, who had been admitted with a diagnosis of dementia, experienced two falls on the same night. The first fall was documented in the nurse's notes, indicating that the resident was found kneeling with their forehead touching the floor, with stable vital signs and no pain reported. The resident was then placed in a wheelchair and moved to a common area for observation. Shortly after, the resident fell again, resulting in a raised bump on the right temple. Despite these incidents, the post-fall neurological check record indicated no abnormalities or changes in the resident's range of motion. However, the Director of Nursing (DON) later reported that a post-fall nursing assessment had not been documented in the resident's health record. This lack of documentation led to a delay in identifying a hip fracture, which was discovered when the resident complained of right leg pain and was unable to bear weight two days after the falls. The deficiency highlights the importance of accurate and complete medical documentation to ensure proper follow-up and intervention.
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Illustrative
What surveyors actually found near you
We read the 221 citations issued within 25 miles in the last 12 months — including the 4 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
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Illustrative
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Nursing homes near Hastings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thornapple Manor | 4.1 mi | ★★★★★ | 11 | 0 |
| The Laurels Of Sandy Creek | 18 mi | ★★★★★ | 6 | 1 |
| The Laurels Of Kent | 18.9 mi | ★★★★★ | 12 | 0 |
| The Laurels Of Bedford | 21.9 mi | ★★★★★ | 14 | 0 |
| Holland Home Breton Rehabilitation & Living Centre | 22.1 mi | ★★★★★ | 0 | 0 |
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