Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Greentree Of Hubbell Rehabilitation And Health during CMS and state inspections, most recent first.
Failure to Administer Consented COVID-19 Vaccinations: The facility did not administer COVID-19 vaccines to multiple residents despite signed consent forms and MCIR records showing they were overdue. Records showed no refusal or contraindication for the affected residents, and interviews with the DON and ADON/IP confirmed immunizations were not being tracked or completed after consent was obtained. One resident with CAD, CHF, and moderate cognitive impairment later became COVID positive, was found unresponsive, and died; the death certificate listed COVID as the cause of death.
The facility failed to ensure adequate weekend CNA staffing to meet resident needs, as shown by CMS PBJ data indicating excessively low weekend staffing and by internal schedules and payroll records reviewed with the COO. On multiple weekend day and afternoon shifts, only 3 to 3.5 CNAs were scheduled, which did not meet the facility’s own Facility Assessment requirement of at least 4–5 CNAs on day shift and 4 CNAs on afternoon shift. This deficiency, occurring under CMS rules that require staffing to be determined by the facility assessment, had the potential to affect all residents’ physical, mental, and psychosocial well-being.
The facility did not complete required annual performance reviews for five CNAs, as confirmed by personnel record review and interviews with the BOM and DON. Staff files for CNAs hired over multiple years lacked any documented evaluations, despite the expectation that reviews be conducted annually. The facility was unable to provide a performance review policy, and this failure created the potential for inadequate care and unmet needs for all residents.
A resident with colon cancer and severe cognitive impairment had an order for scheduled hydrocodone-acetaminophen, but 120 tablets of this Schedule II narcotic were found to be missing when staff attempted to administer a dose. Internal review showed the medication had not been administered, destroyed, or documented as wasted, and chain-of-custody records did not account for its disposition. At the time, pharmacy medications, including controlled drugs, were delivered in unsecured cardboard boxes via common carriers, often left unattended in the front office among other packages, and opened by nursing staff without tamper-evident safeguards. Facility policies on pharmacy services and medication storage did not describe the actual delivery process, did not specify who was responsible for receiving and inspecting shipments for tampering, and did not address the handling of courier-delivered medications, contributing to the misappropriation of the resident’s narcotic pain medication.
Surveyors found that the facility failed to maintain a clean, homelike, and odor-free environment, with strong urine odors noted at the entrance, in hallways, on both A and B units, and in multiple resident rooms and nursing station areas. Several resident rooms had heavily soiled privacy curtains and bathrooms with dried urine buildup and smeared feces on and around toilets, along with strong urine odors. A bathroom door was also observed with a large area of chipped paint. A housekeeper reported that resident room and bathroom floors are not mopped daily and that soiled linens and briefs are sometimes not promptly removed, especially on weekends when staffing is limited.
Surveyors found that multiple CNAs had not received the required 12 hours of annual in‑service training, despite facility policy stating that each nurse aide must complete at least 12 hours of training per year based on their hire date. Review of training records showed several CNAs with no documented training for extended periods after hire, and the DON acknowledged that these staff did not meet the annual training requirement.
Food safety and sanitation deficiencies were observed in dietary services. A dietary staff member was seen in the kitchen without a beard net, multiple refrigerated foods were missing required date markings or were expired, a bin of dry goods contained debris and unrelated items, the standing mixer had dried buildup, and a staff member handled soiled dishes and then clean dishes without washing hands between the dirty and clean sides of the dish room.
Improper garbage storage was observed in the dumpster area when one dumpster was overfilled with black trash bags stacked above the rim so the lid could not be used, while two nearby dumpsters contained filled garbage bags and were covered. The deficiency involved the facility’s failure to keep the outside refuse area sanitary and properly contained, affecting all residents.
The facility failed to implement and maintain a comprehensive QAPI program covering the full range of services provided. The DON stated she oversaw QAPI but was unaware of any PIPs, said the facility was not working on PIPs for sentinel events, was not tracking or monitoring anything, and was not documenting action plans. The QAPI plan stated the program was intended to be a facility-wide, data-driven process to monitor, analyze, and improve performance.
QAPI Program Not Implemented or Monitored: The facility failed to establish priorities for improvement activities, develop and implement action plans, or review and analyze QAPI data. The DON stated she was unaware of any PIPs, reported no tracking or monitoring was being done, and said no action plans were being documented. The facility's QAPI plan stated the committee was responsible for analyzing information, setting PIP priorities, and tracking adverse events with action plans to prevent recurrences.
Failure to Provide Bed-Hold and Transfer Notifications: The facility did not document or provide written bed-hold notices when several residents were transferred to the hospital, and it also lacked evidence of LTC Ombudsman notification for one resident. Records showed transfers for residents with conditions including acute respiratory failure, COPD, and diabetes, with staff documenting only basic transfer packets such as face sheets, orders, and vital signs, while interviews confirmed staff were unaware of bed-hold policy details and the DON could not find written transfer notification in the EMR.
Therapeutic diets were not followed as ordered for multiple residents. Residents with NAS and renal diet orders were served foods that did not match the physician orders or the facility’s renal menu, and tray cards showed 2 gm sodium for residents ordered NAS. The CFM stated the facility was out of low sodium gravy, was unaware that certain foods had been served on a renal diet, and reported the consultant RD had not yet been onsite.
A cognitively severely impaired resident with colon cancer had an order for scheduled Hydrocodone-Acetaminophen, but during a routine med pass staff discovered the narcotic supply was missing. Pharmacy records indicated 120 tablets should have been on hand, yet review of proof-of-use sheets and shift counts showed no documentation of administration, destruction, or waste. Staff interviews revealed that pharmacy medications were delivered in unsecured cardboard boxes left among other packages in the front office, without consistent signing or verification, and that the entire inventory sheet, narcotic count sheets, and four 30-tablet packages of the drug were missing. The facility’s abuse, neglect, and exploitation policy referenced preventing misappropriation of resident property but did not include specific protocol for misappropriation under F602.
Surveyors found that two CNAs did not have any documented initial or annual competency evaluations or skills demonstrations in their personnel files, despite facility policy requiring competency assessment during orientation and annually thereafter. A manager confirmed that staff are expected to have yearly competency training, but these two CNAs’ records lacked any such documentation.
A resident admitted with anxiety disorder, depression, and PTSD had active orders for chlorpromazine, duloxetine, and mirtazapine, but the EMR did not contain a signed consent for the psychotropic medications from the resident or responsible party. The DON stated consents are completed on admission by the SSD, but neither the DON nor the SSD could locate a signed consent in the EMR or the SSD’s office.
Opened Resident Package Not Delivered Unopened: A resident reported that a package ordered for them was not received when expected and was later found opened in a conference room. A CNA confirmed finding the opened package and delivering it to the resident, while the Business Office Manager stated she opened the package in error and left it on a conference room table instead of giving it directly to the resident.
The facility failed to provide advance directive information for two residents. Review of the EMR for one resident admitted to the facility and another resident admitted on 5/16/25 did not show that the resident or responsible party received advance directive information or completed an advance directive. The SSD stated the advance directives had not been completed and were supposed to be done on admission and reviewed quarterly.
A resident was not given timely notice that Medicare coverage for PT/OT/ST services was ending, and the notice was signed after the billing change had already taken effect. The BOM stated the form should have been provided 48 hours before coverage ended, and the facility policy referenced notification of Medicare non-coverage and beneficiary notice.
The facility failed to attempt a GDR for a resident receiving psychotropic medications for depression and anxiety. The resident had active orders for Cymbalta and busPIRone, and the care plan addressed antidepressant and antianxiety use. The DON stated the facility relied on the pharmacist to identify when GDRs were due, but later confirmed there was no GDR information, no GDR attempts, and no documentation showing why GDRs were not done.
A resident with PTSD, anxiety disorder, depression, and non-Alzheimer's dementia was admitted without a PASARR completed before admission. An RN stated the only PASARR on file was completed later and that a new or updated PASARR was needed. Facility policy states PASARR Level 1 pre-screening is completed prior to admission.
Improper Storage of Oxygen Equipment: Two residents receiving O2 had tubing and cannulas observed draped over equipment and lying on the floor, rather than kept in a proper bag when not in use. One resident with COPD had tubing without a change date and said it had been a while since it was changed; another resident with pulmonary fibrosis, COPD, and chronic respiratory failure had coiled tubing on the floor despite weekly tubing-change orders. The DON stated the tubing should not be on the floor and should be dated and changed weekly.
Failure to identify PTSD triggers and develop a person-centered care plan for a resident with PTSD, anxiety, depression, and dementia. The psych consult called for a trauma-informed approach, including minimizing environmental triggers, calm redirection/distraction, and comfort measures, but the SSD stated she had not contacted any mental health agency, had not developed a care plan for PTSD, and did not know the resident’s triggers. The DON acknowledged there was no PTSD care plan or interventions.
Failure to track and administer pneumococcal vaccinations after consent was obtained. Two residents had signed consent for the vaccine, including one resident with COPD and cognitive impairment and another resident with CAD, HTN, and severe cognitive impairment, but the records showed no administration for one resident and an overdue status for the other. The DON and ADON/IP stated they had not recognized that immunizations were not being completed and were not keeping track of signed consents or vaccination status.
A resident with dementia, dysphagia, chronic kidney disease, and recent treatment for walking pneumonia experienced a drop in SpO2 to 82% during a breathing treatment. An RN applied supplemental O2 under standing orders but did not document repeat vitals, follow-up SpO2, or the use of an oxygen mask, and began O2 without a specific physician order beyond standing orders. Later, an LPN documented that the resident’s O2 saturation dropped with O2 titration, along with decreased appetite, weakness, and increased sleep, and the resident requested hospital transfer, which was ordered by the MD. The EMR showed an order for O2 at 8 L/min via nasal cannula but no repeat vitals after the change in condition. The DON reported that standing orders allowed only up to 2 L O2 without an MD order and that titration required physician direction, while facility policies required physician notification for SpO2 below 89% and for significant changes in condition.
A resident with dementia, dysphagia, and chronic kidney disease developed a congested cough, bilateral rhonchi, and weakness, but was not tested for COVID-19 despite existing PRN orders for SARS-CoV-2 testing and facility policy requiring testing of anyone with even mild COVID-19 symptoms. The ADON/IP stated that symptomatic residents should be tested and acknowledged that testing "slipped" their mind because the resident was being treated for pneumonia. This inaction conflicted with the facility’s Infection Prevention and Control Program and CDC guidance to test residents and HCP with new respiratory illness signs or symptoms.
Two residents with cognitive impairments and special dietary needs were inadequately supervised, resulting in one resident repeatedly accessing and eating discarded food not suitable for her diet, and another sustaining serious burns from hot coffee served without a lid. Staff interviews and documentation revealed persistent staffing shortages, leading to lapses in supervision and failure to follow dietary orders.
The facility did not provide enough nursing staff to meet resident needs, resulting in missed hygiene and grooming, lack of supervision for residents at risk of choking, extended call light wait times, and a severe burn injury to a resident. Staff reported frequent mandatory overtime, burnout, and an inability to complete care tasks, which directly contributed to these deficiencies.
Multiple residents were observed with poor personal hygiene, including soiled clothing, dirty fingernails, and matted hair, while staff interviews revealed that chronic understaffing and frequent mandatory overtime led to rushed care and missed hygiene tasks. Residents reported long wait times for assistance and sometimes refused care due to staff being rushed or perceived as rude. Facility policies required maintaining resident dignity, but these standards were not met due to insufficient staffing.
The facility failed to adhere to food safety standards, risking foodborne illness for 53 residents. An uncovered ice container was left unattended, hamburger patties were improperly reheated, and sanitizing solutions were inaccurately tested. Staff lacked knowledge of proper procedures, violating FDA Food Code 2017.
The facility failed to maintain a safe and sanitary environment, affecting all 53 residents. An exit door had a gap allowing cold air and vermin entry, and a shower room wall had missing tiles with sharp edges. In the kitchen, a vacuum breaker was defective, risking contamination of the water supply.
The facility failed to ensure accurate and timely completion of advance directives for four residents. One resident's Code Status form was improperly witnessed before the legal guardian's signature, another resident's previous form was missing, and a third resident did not have a directive completed upon admission. Additionally, a fourth resident's documentation lacked the required witness signatures. These deficiencies were identified through interviews and record reviews, contrary to the facility's policy of quarterly review.
The facility failed to maintain a sanitary and homelike environment, as evidenced by persistent odors of urine and feces and inadequate room aesthetics. Strong odors were noted near the Hall B nurses' station and other areas, with staff unable to identify the source. Additionally, window draperies were improperly fastened, and cork bulletin boards were insecurely attached in residents' rooms. Maintenance issues were not documented, leading to delays in addressing these deficiencies.
The facility failed to ensure staff in food and nutrition services had the necessary skills, leading to potential unsafe practices. The Kitchen Manager (KM) A and another staff member were unable to demonstrate proper sanitizing procedures, and KM A had not completed the required Certified Dietary Manager program, holding only a Certified Food Manager credential.
The facility failed to provide meals at a palatable temperature and in a consumable form for several residents. Observations showed that food was served cold from un-insulated carts, and residents expressed dissatisfaction with the quality and temperature of their meals. One resident, unable to peel a hard-boiled egg due to arthritis, received no assistance, highlighting a lack of consideration for residents' needs.
A facility failed to obtain consent for psychotropic medications for a resident with severe cognitive impairment. The resident was prescribed quetiapine fumarate and sertraline without prior consent from the guardian, who reported a lack of communication from the facility. Interviews revealed that obtaining consents for mood-altering medications was a known issue, and verbal consent was obtained long after the medications were initiated.
A facility failed to conduct quarterly care conferences and notify the responsible party for a resident with severe cognitive impairment. The resident's guardian was only involved in two care conferences since admission, with significant gaps between meetings. Staff confirmed the absence of a regular care conference process under previous administration, contrary to facility policy requiring quarterly reviews.
A facility failed to conduct the required quarterly assessments for a resident self-administering medication, despite the resident having intact cognition and a diagnosis of peripheral vascular disease. The last assessment was documented months prior, and interviews with staff confirmed the oversight. Facility policy required quarterly reassessments, which were not completed, leading to the resident self-administering medication without appropriate evaluations.
Two residents experienced discomfort and dissatisfaction due to inappropriate incontinence briefs provided by the facility. One resident was given briefs that were too small, while another preferred a different style that was not available. The ADON acknowledged the need for accurate sizing and respecting resident preferences, and the NHA was informed of the deficiency.
A facility failed to obtain written authorization before withdrawing $500 from a resident's trust fund, intended for personal use, and applied it to the facility bill. The resident, with severe cognitive impairment, had a guardian who reported the unauthorized transaction. The Business Office Manager admitted to receiving verbal consent but did not provide a receipt or written documentation, contrary to facility policy.
A facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, despite requests from their guardian. The facility had recently switched to using their own EMR system for managing resident fund accounts, and the BOM noted that the previous management service did not allow access to verify if statements were sent. The NHA planned to contact the management service to confirm the status of the statements, but none were provided by the survey exit.
The facility failed to provide timely 48-hour notices of Medicare benefit termination for three residents, preventing them from appealing non-coverage decisions. A resident with severe cognitive impairment did not receive any notification, while two others received notices only one day before coverage ended, contrary to the facility's policy requiring a two-day notice.
A facility failed to provide a resident and their representative with written notification of transfer reasons before hospitalizations. The resident, with intact cognition, was hospitalized three times due to medical emergencies, but no transfer notices were documented. The Social Services Designee was unfamiliar with the notification process, indicating a deficiency in policy adherence.
A resident with dementia, diabetes, hypertension, and anemia experienced multiple falls over several months. Despite these incidents, the facility failed to revise the resident's care plan after each fall, contrary to their policy on incidents and accidents, which requires immediate interventions and corrective actions to prevent recurrences.
The facility failed to maintain infection control and implement effective pressure ulcer prevention for three residents. An LPN contaminated wound supplies by using a personal cell phone without changing gloves. A resident's heels were not properly elevated, and another developed a Stage 2 pressure ulcer due to lack of timely pressure redistribution measures. The facility did not follow its own policies, leading to these deficiencies.
A resident with intact cognition and multiple diagnoses sustained a burn injury while smoking, which was not investigated by the facility. The resident reported burning himself when smoking cigarettes down to the filter, and staff failed to notice. The facility did not document or investigate the incident, contrary to their policy requiring such actions for resident injuries.
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents with cognitive impairments and mental health conditions. Medications were administered without proper consent or documentation, and required assessments were not conducted as per facility policy.
A facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during insulin administration for a resident. Errors included not disinfecting the insulin pen hub and failing to prime the pen properly, leading to potential inaccurate dosing. The RN acknowledged the mistakes, and the ADON confirmed the errors, which were against the instructions for proper insulin pen use.
The facility failed to perform pre-employment and pre-admission TB screenings for several newly hired staff and recently admitted residents, as required by CDC guidelines. The Nursing Home Administrator confirmed the lapse in infection control practices, resulting in the potential for TB exposure and transmission.
A visually impaired resident was repeatedly unable to locate her call light, which was found out of reach on multiple occasions. The resident expressed frustration and helplessness, and staff confirmed the call light was not properly secured near her. The DON acknowledged that call lights should always be accessible, especially for residents with severe visual impairments.
The facility failed to ensure privacy and dignified treatment for two residents. One resident was left exposed during incontinence care, while another was fully visible from the hallway while sitting on the toilet. The Director of Nursing confirmed that residents should be cared for in a manner that preserves their dignity.
Failure to Administer Consented COVID-19 Vaccinations
Penalty
Summary
The facility failed to administer COVID-19 vaccinations for six of nine residents reviewed for COVID-19 vaccination status, despite documented consent and no documented refusal or medical contraindication for those residents. The report states that residents #49, #7, #14, #28, #43, and #45 had vaccination consents on file, and their MCIR records showed they were overdue for COVID-19 vaccination. The facility’s policy required education, documentation of each dose administered, or documentation of refusal or contraindication, and stated that administration should not be delayed. Resident #49 had diagnoses including CAD and CHF and a BIMS score of 10/15 indicating moderate cognitive impairment. The resident’s POA agreed to all vaccinations, and the universal consent form documented consent for COVID-19 vaccination. The progress notes did not show that the resident declined the vaccine, refused it, or had a contraindication. The MCIR showed the resident was overdue for COVID-19 vaccination and that vaccination had been recommended. The death certificate listed COVID as the chain of events directly causing death. Progress notes also documented that the resident became lethargic, later tested COVID positive, was placed in isolation, and was found unresponsive and without a pulse before EMS declared the resident deceased. Resident #14 had respiratory failure, asthma, COPD, or chronic lung disease and a BIMS score of 15/15. Resident #28 had CAD and hypertension and was moderately impaired for decision-making. Resident #43 had CAD and hypertension and a BIMS score of 15/15. Resident #45 had diabetes and hypertension and was rarely or never understood and rarely or never made decisions. Each of these residents had a signed universal vaccination consent form, and each MCIR record showed the resident was overdue for COVID-19 vaccination with vaccination recommended, yet the record review did not show the vaccine was administered. For Resident #7, the admission record showed COPD and a BIMS score of 6/15 indicating cognitive impairment; the immunization record showed verbal consent by the responsible party for COVID-19 vaccination, but the EMR contained no documentation that the vaccine was given, and the MICR showed the resident was overdue. Interviews with the DON and ADON/IP confirmed that immunizations were not being completed after consents were signed and that tracking of immunizations and consents had not been maintained.
Inadequate Weekend CNA Staffing Below Facility Assessment Requirements
Penalty
Summary
The facility failed to provide adequate nursing staff on weekends to meet resident needs and to comply with its own Facility Assessment (FA) and CMS requirements, potentially affecting all 44 residents. CMS Payroll Based Journal (PBJ) staffing data for fiscal year quarter 4 of 2025 showed the facility triggered for excessively low weekend staffing. During an interview and record review, the Chief Operating Officer (COO) confirmed that weekend schedules and payroll records revealed low Certified Nurse Aide (CNA) staffing on specific weekend dates and shifts, including day and afternoon shifts staffed with only 3 to 3.5 CNAs. These staffing levels were below the FA, last updated 2/1/25, which specified a minimum of 4–5 CNAs on day shift and a minimum of 4 CNAs on afternoon shift. The deficiency occurred in the context of a CMS final rule, effective 8/8/24, requiring that facility assessments directly inform and determine staffing requirements. The report does not identify specific residents by condition or medical history but states that the inadequate staffing had the potential to affect all 44 residents residing in the facility, in terms of their physical, mental, and psychosocial well-being.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete required annual performance reviews for all five reviewed CNAs, creating a deficiency in monitoring and evaluating staff performance. Personnel record review showed that one CNA hired in November 2021, one CNA hired in February 2023, one CNA hired in July 2023, one CNA hired in November 2023, and one CNA hired in January 2024 each had no documented performance review completed at least every 12 months. The Business Office Manager stated there were no evaluations for any of these five staff members and acknowledged that evaluations were supposed to be done annually. The DON also acknowledged that annual performance reviews had not been completed. The facility did not provide a policy regarding performance reviews prior to exit. This deficient practice resulted in the potential for inadequate care and unmet care needs for all 44 residents residing in the facility. All 44 residents in the facility were identified as being potentially affected by the lack of annual performance reviews for the CNAs, but no specific resident medical histories or conditions at the time of the deficiency were described in the report.
Misappropriation of Controlled Pain Medication Due to Inadequate Delivery and Storage Controls
Penalty
Summary
The deficiency involves the facility’s failure to fully implement its own policies for the delivery, receipt, and secure storage of controlled medications, resulting in the misappropriation of 120 hydrocodone-acetaminophen tablets prescribed for Resident #51. Resident #51 was originally admitted on 8/6/2024 with diagnoses including colon cancer and had a physician’s order for hydrocodone-acetaminophen 10-325 mg, one tablet three times daily. A Minimum Data Set dated 10/24/2025 documented a BIMS score of 9/15, indicating severe cognitive impairment. On 9/19/2025, during a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic pain medication was missing when they attempted to obtain it from the StatSafe and were informed by the pharmacy that the facility should already have 120 tablets on hand. The facility’s internal investigation determined that the hydrocodone tablets for Resident #51 had not been administered, destroyed, or documented as wasted and were unaccounted for. Review of proof-of-use sheets, shift counts, and chain of custody records showed no documentation explaining the disposition of the medication. A nurse was identified as potentially involved in the missing medication based on the chain of custody review, and that nurse was no longer employed at the facility as of 9/14/2025. The incident was reported as misappropriation of 120 narcotic pain medications for Resident #51. Interviews and observations revealed that, at the time of the incident, pharmacy medications, including controlled substances, were delivered to the facility in regular cardboard boxes sealed with standard packaging tape, without locks or tamper-evident features. Nurses reported that these boxes were often left unattended in the front office among other facility and resident packages, and a nurse would have to search through multiple boxes to locate the pharmacy shipment. A single nurse would open the box, check inventory, and fill the medication cart with routine medications, and later call another nurse to sign off on the narcotic inventory sheet, even though the box itself could be easily opened and re-taped, including from the bottom. Staff interviews indicated that there was no clear, written procedure in the facility’s Pharmacy Services or Medication Storage policies describing who was responsible for receiving delivered medications, checking the box for tampering, or ensuring secure handling upon delivery. Policy review confirmed that, although the policies addressed storage and reconciliation of controlled substances, they did not address the actual delivery process or current courier methods, contributing to the conditions under which the controlled medications for Resident #51 were misappropriated. Additional staff interviews further supported that the delivery process lacked defined safeguards. RN B and RN C both described that pharmacy boxes arrived via UPS or FedEx, were not locked, and could be opened and re-taped without detection. They acknowledged that, even after the missing narcotic incident, pharmacy boxes sometimes continued to be retrieved from the front office among other packages, and there was uncertainty about who was responsible for inspecting boxes for signs of tampering. Observation of a pharmacy-labeled box delivered by UPS showed it to be a standard cardboard box with packaging tape and no locking or tamper-proof features. The Assistant DON confirmed that the facility’s policies did not specify the current procedures for receiving medications, did not address how medications were delivered, and did not identify who was responsible for checking in delivered medications or inspecting for tampering, which were key process gaps associated with the misappropriation of Resident #51’s controlled medication supply.
Failure to Maintain Clean, Odor-Free, and Homelike Environment
Penalty
Summary
The facility failed to maintain a homelike, clean, and odor-free environment for all residents, staff, and visitors. On multiple observations over several days, surveyors noted a strong odor of urine upon entering the facility, in the hallways leading to the A and B units, and throughout the nursing station areas. Strong urine odors were repeatedly documented on both units, including the back unit rooms 1–20 and the unit with rooms 21–31, as well as during environmental inspections and resident pool observations. Individual resident rooms were also affected, with some rooms having a strong urine odor when toured by the surveyor. In addition to pervasive odors, surveyors observed visibly soiled environmental surfaces. Privacy curtains in at least two rooms were heavily soiled with brown smudge marks in multiple areas. Bathrooms in at least two rooms had dried urine buildup around the toilet seat, seat fasteners, and base, and dried feces smeared on the toilet tank, rim of the toilet seat, and underneath the toilet seat on the tank bowl, with strong urine odors present. A bathroom door in another room had a large area of chipped paint greater than 12 inches in diameter. A housekeeper reported that resident room and bathroom floors are not mopped daily and attributed the strong urine smell to infrequent mopping, soiled linens, and soiled briefs not being promptly removed to the off-site laundry and garbage building, particularly on weekends when the facility is short staffed.
Failure to Provide Required Annual In‑Service Training for CNAs
Penalty
Summary
The facility failed to ensure that CNAs received at least 12 hours of annual in‑service training as required by its Nurse Aide Training Program policy. During an interview, the Business Office Manager (BOM) stated that the annual 12-hour CNA training requirement is based on each CNA’s hire date. Facility documents reviewed showed that CNA E, hired on 11/10/21, had 0 hours of training since 5/28/24; CNA K, hired on 11/10/23, had 0 hours of training since 11/10/23; CNA L, hired on 1/15/24, had 0 hours of training since hire; CNA M, hired on 7/13/23, had 0 hours of training since hire; and CNA N, hired on 2/24/23, had 0 hours of training since 11/15/23. In a subsequent interview, the DON acknowledged that these five CNAs did not have the required 12 hours of annual training, despite the written policy stating that each nurse aide shall be provided at least 12 hours of in‑service training annually based on their employment date. No specific residents, medical histories, or resident conditions were described in relation to this deficiency, and the report focused solely on staff training records and staff interviews.
Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for all 44 residents living in the facility. During observation of the dietary department after lunch service, a dietary staff member was seen moving throughout the kitchen without wearing a beard net. The Certified Foodservice Manager stated that staff with beards should have a beard restraint in place, and the staff member then donned one. The reach-in refrigerators contained multiple improperly labeled or expired items, including silk milk without an opened-by or use-by date, an opened 2-quart container of tomato juice without dates, an unlabeled plastic baggie containing a breaded chicken patty that a dietary staff member said she was taking home, Boost with a use-by date of 2/24, and wrapped sandwiches stored in a pan marked egg salad with a use-by date of 2/28/26 even though staff identified them as tuna salad and noted the date had passed. Additional observations showed a bin holding partially used dry mix products, cords, instructions, and candy with debris inside, a standing mixer with dried buildup on the undercarriage above the mixer arm and bowl, and a dishwashing process in which a dietary staff member moved from handling soiled dishes to the clean side of the dishwasher and handled clean dishes without washing her hands. The Certified Foodservice Manager acknowledged the dirty bin and observed that handwashing should occur between the dirty and clean sides of the dish room.
Improper Garbage Storage in Dumpster Area
Penalty
Summary
The facility failed to maintain the outside grounds garbage storage area in a sanitary condition to prevent the harborage and feeding of pests, affecting all 44 residents of the facility. During a tour of the grounds, the surveyor, a Certified Foodservice Manager, and a dietary staff member walked to the garbage dumpster area and observed three mid-sized dumpsters located about one foot apart from each other. The first dumpster was filled with full black trash bags stacked above the rim, which prevented the lid from being used. The second dumpster was half full of filled black garbage bags and was covered. The third dumpster contained one filled black garbage bag and was also covered. The report cited FDA Food Code section 5-501.116 regarding proper storage and disposal of garbage and refuse, including the need for outside receptacles with tight-fitting lids or covers.
QAPI Program Not Implemented or Monitored
Penalty
Summary
The facility failed to implement and maintain a comprehensive Quality Assurance Performance Improvement (QAPI) program that addressed the full range of services provided. During an interview, the DON stated she oversees QAPI but was unaware of any Performance Improvement Projects (PIPs) being worked on, reported that the facility was not working on any PIPs for sentinel events, and said the facility was not tracking or monitoring anything. The DON also stated that no action plans were being documented and described QAPI as "a broken system." Review of the facility's 2026 Quality Assurance and Performance Improvement (QAPI) Plan stated that the program was designed to establish and maintain an organized facility-wide, data-driven program using a proactive approach to improving quality of care and services, and that the facility had performance improvement programs that systematically monitor, analyze, and improve performance.
QAPI Program Not Implemented or Monitored
Penalty
Summary
The facility failed to establish priorities for its improvement activities, develop and implement action plans, and review or analyze data collected under the QAPI program. During an interview, the DON stated she oversees QAPI but was unaware of any Performance Improvement Projects the facility was working on, reported that the facility was not working on any PIPs for sentinel events, and stated that nothing was being tracked or monitored. She also stated that no action plans were being documented and described QAPI as "a broken system." Review of the facility's 2026 Quality Assurance and Performance Improvement Plan dated 12/7/25 stated that the facility uses a systematic approach to determine when in-depth analysis is needed, uses a structured approach to determine root cause, and that the committee is responsible for developing and modifying the plan, analyzing information, setting priorities for PIP, and tracking, investigating, and monitoring adverse events, including developing action plans to prevent recurrences.
Failure to Provide Bed-Hold and Transfer Notifications
Penalty
Summary
The facility failed to provide written notification of the bed-hold policy and failed to notify the local ombudsman when residents were transferred to the hospital. Review of records and interviews showed that for Resident #2, who had acute respiratory failure and a BIMS score of 10/15, the EMR documented a hospital transfer on 2/27/26, but there was no bed-hold policy documentation or evidence that the resident or representative received the policy. Staff interviews indicated that transfer packets typically included a face sheet, physician orders, and current vital signs, but they were not aware of a bed-hold policy being provided. For Resident #21, who had type 2 diabetes and a BIMS score of 13/15, the EMR documented an emergency transfer to the hospital after the resident became unable to sit or stand without physical assistance, leaned to the left, had blurred vision, unequal pupil reaction, and could not state the day, month, or year. The record showed report to the ER prior to transport, but there was no bed-hold policy documentation for the transfer. For Resident #7, who had COPD and a BIMS score of 6/15, the EMR documented that the physician was called about an oxygen saturation of 88% on 2L oxygen and agreed to send the resident to the ER, but again there was no bed-hold policy documentation in the record. For Resident #5, the EMR showed discharge from the facility and admission to the hospital on two occasions, but the miscellaneous section contained no evidence of written transfer notification, no bed-hold policy provided to the resident or representative, and no evidence that the LTC Ombudsman was notified. The DON reviewed the record and confirmed there was no written notification of transfer in the EMR. The NHA designee also reported being unable to find the ombudsman list for September or October and could not find information regarding bed holds for residents discharged from the facility and admitted to the hospital.
Therapeutic diets not followed as ordered
Penalty
Summary
Therapeutic diets were not provided as ordered for four residents reviewed for diet compliance. During breakfast meal rounds, one resident with a physician order for No Added Salt (NAS), low fat, and Beneprotein twice daily was served scrambled eggs and sausage with gravy, while the meal tray card listed a 2 gm sodium diet; the Certified Food Service Manager stated the facility was out of low sodium gravy. Another resident with a physician order for NAS diet, regular texture, and thin consistency was observed eating a cheese and egg croissant and oatmeal, and the tray card also listed a 2 gm sodium diet. A third resident with a physician-ordered renal diet, regular/IDDSI 7 texture, and thin consistency was served a cheese and egg croissant, oatmeal, and mandarin oranges, while the tray card listed a renal diet. A fourth resident also had a physician order for a renal diet, regular/IDDSI 7 texture, and thin consistency, and was identified as potentially affected by the same staff knowledge gap. During interview, the Certified Food Service Manager stated there were differences between a 2 gm sodium diet and an NAS diet, that no residents were on a 2 gm sodium diet, and that she was surprised the tray cards printed as 2 gm sodium for two residents. She also stated several foods, including mandarin oranges, should not be served on a renal diet, but was unaware they had been served to the resident. The planned renal menu did not match the breakfast served, and the manager stated the consultant RD had not yet been in the building and the telehealth system was not yet in place.
Misappropriation of Resident Narcotic Medication Due to Inadequate Control of Pharmacy Deliveries
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s property, specifically a controlled pain medication, from misappropriation. A cognitively severely impaired resident with colon cancer was admitted with an order for Hydrocodone-Acetaminophen 10-325 mg, one tablet three times daily. During a routine medication pass, nursing staff discovered that the resident’s scheduled narcotic medication was missing and contacted the pharmacy to obtain a refill. The pharmacy reported that the facility should already have 120 tablets of the medication on hand, prompting a review of medication records and counts. Review of proof-of-use sheets and shift narcotic counts showed that the 120 tablets of Hydrocodone-Acetaminophen had not been administered, destroyed, or documented as wasted and were unaccounted for. Chain-of-custody review identified a nurse as potentially involved in the missing medication, and this nurse was no longer employed at the facility as of several days prior to the discovery. Interviews with nursing staff indicated that the medication was likely taken by a staff member when the pharmacy shipment was delivered, and that the nurse in question had not been signing for the pharmacy medication box upon delivery. Further interviews revealed that the pharmacy medication boxes arrived as regular cardboard packages taped with packaging tape, without locks or tamper-proof features, and were sometimes left in the front office among other delivered packages. Staff reported that it would have been easy for anyone, including staff or delivery personnel, to open and retape the boxes, and that in this case the entire inventory list, four narcotic count sheets totaling 120 pills, and four packages of 30 pills each were missing from the box. The facility’s Abuse, Neglect and Exploitation policy stated that the facility would prohibit and prevent misappropriation of resident property, but the policy did not address or reference the State Operations Manual or protocol specific to misappropriation (F602).
Missing Initial and Annual Competency Evaluations for CNAs
Penalty
Summary
The facility failed to ensure that two CNAs had the required initial and annual competency evaluations and documented skills demonstrations as required by facility policy. Review of personnel records showed that one CNA hired on 1/15/24 had no dated competency skills documented in the file from the date of hire onward, and another CNA hired on 2/24/23 likewise had no dated competency skills documented since hire. During an interview, the Business Office Manager confirmed that two CNAs did not have competency trainings in their personnel files, despite the expectation that staff receive annual competency training. The facility’s written Competency Evaluation policy, last reviewed/revised on 1/1/25, states that each employee is to be evaluated to assure appropriate competencies and skills for their job, with initial competency evaluated during orientation and subsequent or annual competency evaluated thereafter, but these evaluations were not documented for the two CNAs. No resident-specific information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications for one resident who was admitted with diagnoses including anxiety disorder, depression, and PTSD. Review of the resident’s EMR showed active physician orders for chlorpromazine, duloxetine, and mirtazapine, all psychotropic medications, but the record did not contain any consent signed by the resident or the responsible party. During interview, the DON stated that psychotropic medication consents are completed on admission by the SSD, but she could not locate a signed consent in the EMR. The SSD also acknowledged that signed consents were not in the EMR and that she could not find any signed consent in her office.
Opened Resident Package Not Delivered Unopened
Penalty
Summary
The facility failed to deliver a resident’s mail/package unopened and instead opened it before it was given to the resident. Resident #20 reported that a package ordered by the resident and acknowledged as delivered was not received on the expected day. The resident stated that after asking a CNA to look for it, the package was later found opened in the conference room and left there. The resident said the package had been opened and that a complaint was filed and reported to the administrator. During follow-up interviews, the CNA confirmed finding the package opened in the conference room and delivering it to the resident. The ADON stated she was investigating the opened package and said several packages had been delivered on Friday and placed in the Business Office for safe keeping. The Business Office Manager stated she opened the package for Resident #20 in error and then placed it on the conference room table instead of delivering it to the resident. The grievance log later documented the concern that the package was opened by a staff member for Resident #20.
Failure to Provide Advance Directive Information
Penalty
Summary
The facility failed to provide information for residents to formulate advance directives for two residents reviewed for advance directives. Resident #3 was admitted to the facility, and review of the electronic medical record did not reveal that the resident or responsible party had received advance directive information or formulated an advance directive. Resident #49 was admitted on 5/16/25, and review of the electronic medical record also did not reveal that the resident or responsible party had received advance directive information or formulated an advance directive. During interview, the Social Services Designee reported that advance directives had not been completed for these residents and were supposed to be done on admission and reviewed quarterly.
Late Notice of Medicare Non-coverage
Penalty
Summary
The facility failed to provide timely notice of a change in Medicare coverage and the resulting change in billing for one resident reviewed for Notice of Medicare Non-coverage. Resident #35 was identified on a facility list of residents whose Medicare Part A services had ended and who were eligible to receive a Notice of Medicare Non-coverage. Record review showed the resident was notified that Medicare coverage for current PT/OT/ST services would end on 10/8/2025, and the notice stated the resident could appeal the decision through the QIO. The signature line on the notice indicated verbal consent from the DPOA and was dated 10/9/2025, which was the day after the change in charges had already occurred. During interview, the Business Office Manager stated the form should have been given 48 hours before Medicare coverage ended. The facility also presented a Social Services policy that referenced notification to the resident or responsible party of Notice of Medicare Non-coverage and Beneficiary Notice.
Failure to Attempt GDR for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) for psychotropic medications for one resident reviewed for unnecessary medications. The resident had an admission date of 5/1/2024 and diagnoses including depression and anxiety disorder, with active physician orders for Cymbalta 60 mg and busPIRone 10 mg. The care plan included focus plans for antidepressant and antianxiety medications. During interviews, the DON stated the facility relied on the pharmacist to let them know when GDRs were due, and later stated there was no GDR information for the resident, no GDR attempts, and no documentation reflecting the lack of GDRs. Review of the EMR found no evidence of a GDR attempt for the prescribed psychotropic medications.
Failure to Complete PASARR Before Admission
Penalty
Summary
The facility failed to obtain a PASARR (Preadmission Screening/Annual Resident Review) prior to admission for Resident #3, who had diagnoses including PTSD, anxiety disorder, depression, and non-Alzheimer's dementia. Review of the MDS showed the resident was admitted to the facility on the documented admission date, and an RN stated that PASARRs are completed just prior to admission and annually. The RN also reported that the only PASARR for Resident #3 was completed on 10/2/24 and that there was not one completed prior to the resident's admission. The facility policy stated that all applicants are to be screened and that the PASARR Level 1 initial pre-screening is completed prior to admission.
Improper Storage of Oxygen Equipment
Penalty
Summary
The facility failed to store oxygen equipment in a sanitary manner for two residents who were receiving oxygen therapy. For Resident #18, who had diagnoses including COPD and anxiety disorder, an observation on 3/2/26 showed the oxygen tubing draped over the oxygen concentrator with the nasal cannula lying on the floor. During interview, an RN stated the resident was not on continuous oxygen, but the cannula and tubing were supposed to be kept in a bag when not in use and not left on the floor. For Resident #37, who had pulmonary fibrosis, COPD, and chronic respiratory failure, the medical record showed active orders for oxygen at 1 L via nasal cannula and for oxygen tubing to be changed weekly. Observations on 3/1/26 and 3/3/26 showed the resident wearing oxygen with tubing extending from the face to the floor in coils, including long loops lying on the floor, and one observation noted no labeling to show when the tubing had been changed. The resident stated he was not sure when the tubing had last been changed. The DON stated the tubing should not be on the floor, should be in a proper bag, should be changed each week and dated, and that O2 sats should be documented each shift for residents on oxygen.
Failure to Identify PTSD Triggers and Develop a Person-Centered Care Plan
Penalty
Summary
The facility failed to identify triggers and failed to implement a comprehensive person-centered care plan for Resident #3, who was admitted with diagnoses including post traumatic stress disorder (PTSD), anxiety disorder, depression, and non-Alzheimer's dementia. Review of the psychiatric consult documented a trauma-informed approach, including minimizing environmental triggers when possible, using calm redirection/distraction, and comfort measures, with close observation for agitation or distress. During interview, the Social Services Designee stated she had not communicated with any mental health agency to inquire about the resident’s triggers or past trauma, and that she had not developed a care plan to address the resident’s PTSD and did not know what the resident’s triggers might be. The Director of Nursing acknowledged there was no care plan or interventions regarding PTSD for the resident. The facility assessment stated the facility accepts and cares for residents with mental health and behavior conditions, including PTSD, and the social services policy stated the facility will provide medically related social services, identify and promote individualized non-pharmacological approaches, and ensure the care plan reflects ongoing social service needs.
Failure to Track and Administer Pneumococcal Vaccinations After Consent
Penalty
Summary
The facility failed to ensure eligible residents received pneumococcal vaccinations after consent was obtained and failed to maintain a process for tracking and securely documenting pneumococcal vaccination status. For one resident with COPD and cognitive impairment, the record showed pneumococcal vaccination consent was signed by the responsible party on 10/28/2025, but there was no documentation that the vaccine was administered. The resident’s MICR record showed prior pneumococcal immunizations, including PPSV23 on 05/29/12 and PCV13 on 09/23/15, with a note to consider vaccination on 09/23/2020. For another resident admitted with CAD and hypertension, the MDS showed the resident was rarely or never understood and required supervision and cues to make decisions. The facility’s universal vaccination consent form showed the DPOA consented to pneumococcal vaccination on 10/15/25, but the MICR record dated 3/3/26 showed the resident was overdue for the pneumococcal vaccination. During interviews, the DON stated consents were offered on admission, annually, and when vaccine recommendations changed, and that if consent was signed the DON reviewed the MICR and ordered vaccines from the pharmacy. The DON and ADON/Infection Preventionist also stated they had not recognized that immunizations were not being completed after consents were signed and had not been keeping track of immunizations or signed consents at the end of February 2026.
Failure to Monitor and Notify Physician After Resident’s Respiratory Decline
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and notify a physician of a change in condition for one resident and to document follow-up assessments after initiating supplemental oxygen. The resident was an elderly female with dementia, dysphagia, and chronic kidney disease who had recently been treated with antibiotics and prednisone for walking pneumonia. On 1/7/26 at 2:10 PM, an RN documented that the resident’s SpO2 was 82% during a breathing treatment, that the resident attempted to eat breakfast and did not want to continue the treatment, and that oxygen was applied and tolerated. However, there was no documentation of repeat vital signs or oxygen saturation after the administration of supplemental oxygen, and the RN acknowledged in interview that she believed she had entered follow-up information but it was not present in the EMR. She also confirmed she began oxygen without a physician’s order, relying on standing orders, and recalled use of an oxygen mask that was not documented. On 1/8/26 at 11:35 AM, an LPN documented that the resident’s oxygen saturation dropped with oxygen titration after finishing the course of antibiotics and prednisone for walking pneumonia, and that the resident had decreased appetite, weakness, and was sleeping during the shift, and stated she wanted to go to the hospital. The LPN contacted the medical director, who ordered transfer to the ER, but could not recall who ordered the titration of supplemental oxygen and suggested it may have been something they “just tried” or possibly directed by the ADON. Review of the EMR showed an order for oxygen at 8 L/min via nasal cannula starting 1/7/26, but no repeat vital signs were documented after the change in condition. The DON stated she expected to see follow-up documentation, including repeat vitals and physician notification if the condition did not improve, and clarified that standing orders allowed only up to 2 L of oxygen without a physician’s order and that titration should occur only under physician direction. Facility policies required initiation of 2 L O2 and physician notification if SpO2 was below 89%, and prompt physician notification for significant changes in condition requiring alteration of medical treatment.
Failure to Test Symptomatic Resident for COVID-19 per Facility Protocol and CDC Guidance
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program and CDC guidance for testing residents with new respiratory symptoms. A female resident with dementia, dysphagia, and chronic kidney disease was admitted on an unspecified date and later developed respiratory symptoms. On 12/29/25, a physician communication note documented that the resident presented with a congested cough, rhonchi throughout both lungs, and some weakness. The resident had existing physician orders dated 12/20/25 and 12/26/25 for SARS-CoV-2 (COVID-19) testing as needed per facility protocol, but there was no evidence that a COVID-19 test was ordered or performed after the onset of these symptoms. A complaint submitted to the State Agency on 1/28/26 stated that the resident was transferred to an emergency room on 1/8/26 with severe respiratory issues and was confirmed COVID-positive, and that the nursing home did not test her when she first showed symptoms, treating her only for pneumonia. During interviews, the ADON/Infection Preventionist explained that symptomatic residents should be tested for COVID-19 per facility protocol and identified symptoms warranting testing as sore throat, congestion, cough, fever, and fatigue. The ADON/IP confirmed that the resident was not tested for COVID-19 after respiratory symptoms began on 12/29/25 and stated that because the resident was being treated for pneumonia, it had “slipped my mind” to test for COVID-19, acknowledging that the resident should have been tested at symptom onset. This failure was inconsistent with the facility’s written Infection Prevention and Control Program, which required viral testing for anyone with even mild COVID-19 symptoms, and with CDC guidance directing testing of residents and HCP with new respiratory illness signs or symptoms.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and maintain an environment free from accident hazards for two residents with cognitive impairments and special dietary needs. One resident with Alzheimer's disease and a mechanical soft diet was observed repeatedly accessing and consuming discarded food from an unattended meal cart in the dining room without staff intervention. The resident was also given a sandwich that did not meet her dietary restrictions, resulting in her struggling to eat and dropping food on the floor. Multiple staff interviews confirmed that there were not enough staff present to monitor residents adequately, and that dietary orders were not consistently followed, increasing the risk of choking for the resident. Another resident with dementia and severe cognitive impairment, who required substantial assistance with eating, was left unsupervised in the dining room. This resident sustained second- to third-degree burns after spilling hot coffee on herself. The coffee was provided without a lid, despite care plan instructions, and staff acknowledged that the coffee was too hot and that a lid was needed. The staff member responsible was distracted due to short staffing and did not return with the lid before the resident was given the coffee. The burn resulted in significant injury, including blistering and pain, as documented in the resident's medical record and skin evaluation photos. Staff interviews consistently reported ongoing staffing shortages, which contributed to lapses in supervision, failure to follow dietary orders, and inability to provide adequate care. Staff expressed concerns about being unable to monitor all residents, leading to missed care and increased risk of harm. Grievance forms and care plan reviews further documented these deficiencies, with staff acknowledging that the current staffing levels made it difficult to ensure resident safety and compliance with care requirements.
Failure to Provide Sufficient Nursing Staff Resulting in Resident Harm and Missed Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple observations and interviews. Several residents were found with poor hygiene, such as long, dirty fingernails, soiled clothing, and unclean bedding. Staff reported being frequently mandated to work extended shifts, leading to burnout and an inability to complete all required care tasks. Certified Nurse Aides (CNAs) and an LPN described having to cut corners on resident care, including missing nail care, hygiene, and timely response to call lights, due to chronic understaffing and high rates of staff call-ins and turnover. One resident with a seizure disorder and severe cognitive impairment was observed in a disheveled state, with soiled clothing and untrimmed, dirty fingernails. Another resident, who was cognitively intact but fully dependent for toileting and bathing, reported waiting over an hour for call light responses and experiencing soiled bedding and skin. This resident also described refusing care at times because staff were rushed and unable to provide care in a respectful manner. Staff confirmed that these issues were due to insufficient staffing levels, which made it difficult to provide adequate supervision and assistance to all residents. A resident with Alzheimer's disease and swallowing difficulties was observed eating food from discarded trays and being given food inconsistent with her prescribed mechanical soft diet, without adequate staff supervision in the dining area. Another resident suffered a third-degree burn from hot coffee when a CNA, distracted by other resident needs and short staffing, failed to ensure the coffee was safe before serving it. Staff interviews consistently attributed these incidents to inadequate staffing, which resulted in missed care, lack of supervision, and direct harm to residents.
Failure to Maintain Resident Dignity and Personal Hygiene Due to Inadequate Staffing
Penalty
Summary
The facility failed to maintain resident dignity and provide adequate personal hygiene for three residents, as evidenced by multiple observations and interviews. Residents were noted to be disheveled, with soiled clothing, untrimmed and dirty fingernails, and, in one case, matted hair. One resident with severe cognitive impairment was observed with dried food on his shirt, food crumbs in his lap, and significant dirt under his fingernails. Another resident, who was cognitively intact but physically dependent, was found with very dry, peeling skin, untrimmed and dirty fingernails, and soiled bedding with food crumbs and stains. This resident reported waiting extended periods for staff to respond to call lights and sometimes refused care due to staff rushing and perceived rudeness, attributing these issues to short staffing. Staff interviews confirmed that chronic understaffing and frequent mandatory overtime led to rushed care and the need to cut corners, particularly in areas such as nail care, hygiene, and timely response to call lights. Certified Nurse Aides reported being mandated to work double shifts, frequent call-ins, and burnout, which resulted in residents not receiving the care they deserved. Staff also indicated that other personnel with CNA licenses rarely assisted with time-consuming tasks like bathing, nail care, and feeding, further exacerbating the problem. Facility policies and job descriptions reviewed during the survey emphasized the importance of maintaining resident dignity and providing assistance with activities of daily living according to care plans. Despite these policies, the observed deficiencies in personal hygiene and resident appearance, as well as resident and staff reports of inadequate care, demonstrated a failure to uphold these standards. The lack of sufficient staffing and support directly contributed to the inability to provide dignified and respectful care to residents.
Food Safety Violations in LTC Facility
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, which could potentially result in foodborne illness among the 53 residents. During an observation, a snack cart was left unattended in the hallway with an uncovered container of ice cubes used for filling resident drinking water cups. The Activity Aide confirmed he was not instructed to cover the ice cubes, which is a violation of the FDA Food Code 2017 that requires food to be protected from contamination. In another instance, during the noon meal service, hamburger patties were found at an unsafe temperature of 120 F in the steam table. The staff member responsible admitted to not reheating the patties to the required 165 F for 15 seconds before placing them in the steam table, which is only meant for maintaining food temperature. The staff member was unaware of the proper reheating requirements, indicating a lack of knowledge about food safety standards. Additionally, the facility's procedure for testing sanitizing solutions was inadequate. Staff members were observed using test strips incorrectly, not measuring the water temperature, and failing to achieve the proper concentration of sanitizer. The water temperature was too high, and the concentration of sanitizer was below the required level. Staff admitted they were not aware of the correct procedures for testing sanitizing solutions, which is a violation of the FDA Food Code 2017 that requires accurate measurement of sanitizing solutions.
Facility Environment Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain a safe, sanitary, and functional environment for its residents, staff, and the public, potentially affecting all 53 residents. During an inspection, an exit door identified as Exit #4 was found to have a gap between the threshold and the bottom of the door, allowing cold air and potentially insects and vermin to enter the building. The Maintenance Director confirmed the door was in disrepair and needed replacement. Additionally, a community shower room was observed with a vertical wall missing eight ceramic tiles, exposing sharp edges that could cause injury. The Maintenance Director acknowledged the missing tiles and stated that replacements were unavailable, leading to the removal of the remaining tiles, which left the underlying drywall board exposed. Further inspection revealed issues in the kitchen's dishwashing area, where an atmospheric vacuum breaker connected to the garbage disposal was not intact, with the top bell housing missing. This defect could lead to a failure in the device during a negative pressure event in the potable water supply system, potentially causing contaminated liquids to backflow into the drinking water supply for the entire building. These deficiencies highlight significant lapses in maintaining a safe and functional environment within the facility.
Failure to Accurately Document Advance Directives
Penalty
Summary
The facility failed to ensure that advance directives related to code status were accurately and timely completed for four residents. Resident #6 had a Code Status form that was improperly documented, with the facility staff witnessing the form before the resident's legal guardian signed it. Resident #26's previous Code Status form was missing, and a new form was completed on the day of the survey, indicating a lack of documentation from admission until that day. Resident #46 did not have an advance directive completed upon admission, and the Social Services Designee admitted to not filling out a new directive as required. Resident #50's documentation was incomplete, with only one witness signature instead of the required two. The facility's policy mandates that residents' code status be reviewed at least quarterly, but this was not adhered to in these cases. The deficiencies were identified through interviews and record reviews, highlighting the facility's failure to properly document and manage advance directives for these residents, which included those with conditions such as dementia, heart failure, and diabetes.
Facility Fails to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary, clean, and homelike environment for its residents, as evidenced by multiple observations of strong odors and inadequate room aesthetics. On several occasions, surveyors noted a pervasive odor of urine and feces in various areas of the facility, including near the Hall B nurses' station, the resident room hall, and the hall outside the kitchen and dining room. Certified Nurse Aide (CNA) Q and other staff members were unable to identify the source of the odors, although it was suggested that they might be emanating from the air vents or the soiled utility room. The odors were persistent over several days, indicating a systemic issue with odor management in the facility. In addition to the odor issues, the facility also failed to maintain the aesthetic quality of resident rooms. Observations revealed that window draperies in some rooms were improperly fastened with paper clips and could not be fully closed, which was acknowledged by residents as unsatisfactory. Maintenance Director (Staff) D confirmed that the condition of the draperies was not conducive to a homelike environment and should have been addressed by the staff. Furthermore, cork bulletin boards in residents' rooms were found to be insecurely attached or leaning against walls, posing potential safety hazards. Staff D admitted that these issues were not recorded in the maintenance binder, which is used to track and address maintenance concerns. The facility's failure to address these environmental deficiencies was further highlighted by the lack of communication and documentation regarding maintenance needs. Staff D and the Nursing Home Administrator (NHA) acknowledged that the state of the bulletin boards and draperies did not meet the facility's aesthetic expectations. The NHA noted that these issues should have been documented in the maintenance binder to ensure timely repairs. The facility's policy on resident rights emphasizes the importance of providing a safe, clean, comfortable, and homelike environment, which was not upheld in this instance.
Inadequate Competency in Food and Nutrition Services
Penalty
Summary
The facility failed to ensure that staff in the food and nutrition services had the appropriate competencies and skills, which could potentially lead to unsafe practices in the kitchen and dietary services affecting all 53 residents. During an observation, the three-compartment sink was used for washing, rinsing, and sanitizing food contact surfaces. However, the Kitchen Manager (KM) A was unable to demonstrate the proper testing procedure to ensure the correct concentration of sanitizing chemicals. Additionally, another staff member, [NAME] C, was also unable to demonstrate the procedure and confirmed that no training had been provided by KM A. Further investigation revealed that KM A had not completed the Certified Dietary Manager (CDM) program, having only finished one out of ten required modules over two years. Despite being in the position of manager of dietary services for almost three years, KM A only held a Certified Food Manager (CFM) credential. The FDA Food Code requires the person in charge of a food service operation to demonstrate knowledge of foodborne disease prevention and other critical principles, which was not adequately demonstrated by KM A.
Deficient Food Service Practices
Penalty
Summary
The facility failed to provide food in a manner that was palatable and at a safe and appetizing temperature for 10 residents. During a group interview, several residents expressed dissatisfaction with the cold temperature of their meals, including pizza and noodles, which were described as undercooked and bland. One resident mentioned receiving a hard-boiled egg with the shell on, which they could not peel due to arthritis, and no assistance was provided. Another resident complained about the quality of their meal, which included plain pasta, mushy zucchini, and hard cauliflower. A resident also reported significant weight loss due to the poor quality of food. Observations revealed that meal trays were delivered from un-insulated metal carts, resulting in food temperatures ranging from 102°F to 109°F, which is below the recommended serving temperature. The kitchen manager admitted that the staff was supposed to peel eggs for residents who couldn't do it themselves but had not considered the difficulty of removing all the shells. The menu did not specify that the eggs would be served unpeeled. These findings indicate a failure to ensure that meals were served at appropriate temperatures and in a form that residents could consume comfortably.
Failure to Obtain Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain consent for psychotropic medications before initiating them for a resident with severe cognitive impairment. The resident, who was admitted with diagnoses including Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, was prescribed quetiapine fumarate and sertraline without prior consent from the guardian. The guardian, who had legal authority over the resident's treatment decisions, reported a lack of communication from the facility regarding these treatment decisions. Interviews with the Director of Nursing and the Social Services Designee revealed that obtaining consents for mood-altering medications had been a recognized issue within the facility. The facility's policy required that residents and/or their representatives be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments. However, verbal consent for the medications was only obtained from the guardian approximately 1 year and 8 months after the medications were initiated, indicating a significant lapse in following the facility's policy and ensuring informed consent.
Failure to Conduct Quarterly Care Conferences and Notify Responsible Party
Penalty
Summary
The facility failed to ensure that care conferences were scheduled on a quarterly basis and that the responsible party was notified, resulting in a deficiency in resident rights. This issue was identified for one resident, who had severe cognitive impairment due to Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression. The resident's guardian reported not being given the opportunity to participate in regular care conferences, having only been involved in two since the resident's admission. The facility's records showed that care conferences for the resident were held on three occasions, with significant gaps of 9 and 5 months between them, despite the requirement for quarterly meetings. Interviews with facility staff, including the Social Service Designee and the Nursing Home Administrator, confirmed the lack of a regular care conference process under previous administration. The facility's policy mandates that comprehensive care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, which was not adhered to in this case.
Failure to Conduct Quarterly Assessments for Self-Administering Resident
Penalty
Summary
The facility failed to perform a resident assessment for a resident who was self-administering medication, resulting in a deficiency. The resident, who had been admitted with diagnoses including peripheral vascular disease, scored a perfect 15 on the Brief Interview for Mental Status, indicating intact cognition. Despite this, the facility did not conduct the required quarterly assessments to ensure the resident's continued ability to safely self-administer medication. The last documented assessment was on 7/23/24, and no subsequent assessments were found in the resident's electronic medical record. Interviews with the Assistant Director of Nursing and a Registered Nurse revealed that the facility's policy required quarterly assessments for residents self-administering medication. However, it was acknowledged that the quarterly assessment for the resident in question was missed. The facility's policy also stipulated that a licensed nurse should complete a Medical Self-Administration screening tool in the electronic medical record, and reassessments should be considered quarterly by the interdisciplinary team. The failure to adhere to these procedures led to the resident self-administering medication without the appropriate assessments being conducted.
Inappropriate Incontinence Briefs Provided to Residents
Penalty
Summary
The facility failed to provide appropriately sized and styled incontinence briefs to meet the needs and preferences of two residents, resulting in discomfort and dissatisfaction. Resident #23 expressed dissatisfaction with wearing incontinence briefs that did not fit properly, as the size had been changed from XXL to Large, which did not cover the waist adequately. The resident had been complaining to a CNA for at least a week. Observation confirmed that only size Large briefs were available in the resident's closet, which did not fit properly. Resident #26 was observed wearing an incontinence brief that appeared too small, causing discomfort. The resident expressed a preference for pull-up style briefs, which were not provided, as they were told the current style held more urine. The Assistant Director of Nursing acknowledged the need for accurate waist measurements to determine the appropriate size and style of briefs, and confirmed that the residents' preferences should be considered. The Nursing Home Administrator was informed of the deficiency concern.
Unauthorized Withdrawal of Resident Funds
Penalty
Summary
The facility failed to obtain authorization prior to withdrawing personal funds for a resident with severe cognitive impairment. The resident, diagnosed with Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, had a BIMS score of 3, indicating severe cognitive impairment. The resident's guardian reported that the facility withdrew $500 from the resident's trust fund without authorization and applied it to the facility bill. The guardian stated that the funds were intended for personal use, such as haircuts, shopping, and snacks. The Business Office Manager (BOM) confirmed the withdrawal and stated that verbal consent was received from the guardian, but no receipt or written documentation was provided. The facility's policy requires a receipt for any transaction involving resident funds, and the Nursing Home Administrator confirmed the need for written authorization before withdrawing money from resident accounts. The BOM acknowledged the oversight and recognized the need for proper documentation in future transactions.
Failure to Provide Quarterly Resident Trust Fund Statements
Penalty
Summary
The facility failed to provide quarterly resident trust fund financial statements for a resident with severe cognitive impairment, as required by their policy. The resident, who has Alzheimer's disease, vascular dementia, delusional disorders, anxiety disorder, and depression, did not receive the necessary financial statements despite requests from their guardian. The facility had recently transitioned to using their own EMR system to manage resident fund accounts, and the Business Office Manager (BOM) indicated that the previous management service did not provide access to verify if statements were sent. The Nursing Home Administrator (NHA) acknowledged the issue and intended to contact the management service to confirm the status of the statements, but no statements were provided by the time of the survey exit.
Failure to Provide Timely Medicare Termination Notices
Penalty
Summary
The facility failed to provide a 48-hour notice of termination of Medicare benefits for three residents, which resulted in the residents' inability to appeal their non-coverage decision in a timely manner. Resident #8, who had severe cognitive impairment due to Alzheimer's disease and other mental health conditions, did not receive any beneficiary notification since admission, as confirmed by both the complainant/guardian and the responsible registered nurse. The Director of Rehabilitation confirmed that Resident #8 received skilled therapy services under Medicare Part B, but there was no record of a notification being issued. For Resident #204, the Notice of Medicare Non-Coverage (NOMNC) form was signed one day before the effective date of coverage termination, and similarly, for Resident #205, the NOMNC form was signed one day before the end of coverage. The facility's policy requires that such notices be provided at least two days before the end of Medicare-covered services, but this was not adhered to in these cases. The failure to provide timely notifications is a violation of the facility's policy and federal regulations, impacting the residents' rights to make informed decisions about their care and financial responsibilities.
Failure to Provide Transfer Notification
Penalty
Summary
The facility failed to provide timely written notification to a resident and their representative regarding the reasons for transfers to an acute care hospital. The resident, who had intact cognition as indicated by a BIMS score of 15, was hospitalized three times since their initial admission. Despite these hospitalizations, the resident did not recall receiving or signing any transfer notification documents prior to being transferred. The facility's records confirmed the resident's transfers occurred on three separate occasions due to medical emergencies, including a dehisced surgical incision, uncontrollable shaking with cyanosis, and a need for evaluation and treatment in the emergency room. However, a review of the electronic medical record revealed no written transfer notices were provided before any of these hospitalizations. Additionally, an interview with the Social Services Designee revealed a lack of familiarity with the transfer notification process, further indicating a deficiency in the facility's adherence to its own policy on transfer and discharge.
Failure to Revise Care Plan After Multiple Falls
Penalty
Summary
The facility failed to update or revise the care plan for a resident after multiple falls, which was identified as a deficiency. The resident, who has active diagnoses including dementia, diabetes, hypertension, and anemia, was admitted to the facility and was noted to rarely or never be understood or make decisions. The resident experienced one fall in August, two falls in October, and two falls in November. Despite these incidents, the care plan was not revised after any of the falls. The facility's policy on incidents and accidents emphasizes the importance of implementing appropriate and immediate interventions and corrective actions to prevent recurrences, which was not adhered to in this case.
Inadequate Pressure Ulcer Prevention and Infection Control
Penalty
Summary
The facility failed to maintain proper infection control and implement effective interventions for the prevention and treatment of pressure injuries for three residents. For Resident #11, during a wound care observation, an LPN used her personal cell phone without changing gloves, contaminating the wound supplies and the wound itself. The LPN also placed a foam dressing on the resident's bed linens instead of a sterile barrier, further compromising infection control standards. Resident #26 reported a sore area on the tailbone, and during a wound care observation, it was noted that the resident's heels were in contact with the bed mattress, with one heel showing signs of redness and sponginess. The facility's standing orders and policies were not followed, as the resident did not have an air mattress or proper heel elevation to prevent pressure injuries, despite being at risk. Resident #54 developed a Stage 2 pressure ulcer on the coccyx after admission, despite not having any pressure ulcers upon entry to the facility. The DON acknowledged that an air mattress should have been provided earlier, and the resident was not educated on the risks of pressure ulcers. The facility's failure to implement timely and appropriate pressure redistribution measures contributed to the development of the pressure ulcer.
Failure to Investigate Resident's Burn Injury
Penalty
Summary
The facility failed to investigate an accident involving a resident who sustained a burn injury while smoking. The resident, who has intact cognition and a history of diabetes mellitus, anxiety disorder, depression, and hypertension, was observed with a scab on his right middle finger. The resident reported that he burned himself while smoking cigarettes down to the filter, and staff did not notice his actions. The resident was informed that his smoking privileges would be revoked if the incident occurred again. The facility's policy requires staff to report, investigate, and review any accidents or incidents involving residents. However, there was no incident or accident report for the resident's burn injury. The Assistant Director of Nursing was aware of the blister but not the cause. The facility's failure to document and investigate the incident is a deficiency in adhering to their policy, which mandates documentation of the date, time, nature of the incident, location, initial findings, immediate interventions, notification, and follow-up interventions for unobserved injuries.
Failure to Obtain Consent and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to obtain consent, document non-pharmacological interventions, and monitor the effects of psychotropic medications for three residents. Resident #8, diagnosed with Alzheimer's disease, vascular dementia, and other mental health conditions, was prescribed quetiapine fumarate and sertraline without documented consent or specific non-pharmacological interventions in the care plan. The Director of Nursing acknowledged missing AIM assessments and consent issues, while the Social Services Designee confirmed the lack of timely consent. Resident #33, with multiple diagnoses including anxiety disorder and dementia, was prescribed several psychoactive medications without justification for continued use or proper consent documentation. The facility failed to provide signed consents for the use of haloperidol and other medications until recently, despite the medications being administered for an extended period. The Social Services Designee admitted to the absence of previous consents before the newly signed documents. Resident #38, with Alzheimer's disease and schizophrenia, was prescribed olanzapine without a signed consent from the legal guardian. Additionally, the resident had not received an AIM assessment since March 2022. The facility's policy requires education on psychotropic drug use and non-pharmacological interventions, as well as regular AIM assessments, which were not adhered to in these cases.
Medication Administration Errors Observed in Insulin Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in a 7.69 percent error rate during the observation of medication administration for a resident. The errors were observed during the administration of insulin by a Registered Nurse (RN) to a resident. The RN did not disinfect the hub of the humalog insulin pen before attaching the needle and failed to prime the pen properly, which is necessary to ensure accurate dosing. The RN acknowledged the oversight and attempted to correct the process but still did not prime the pen before administering the insulin. Additionally, the RN made errors while preparing the lantus insulin pen by priming it incorrectly and not following the proper procedure to ensure accurate dosing. The Assistant Director of Nursing (ADON) was consulted and confirmed the errors in the insulin administration process. The instructions for both the humalog and lantus insulin pens clearly state the need for priming to avoid air bubbles and ensure accurate dosing, which was not adhered to during the administration process.
Failure to Perform TB Screenings for Staff and Residents
Penalty
Summary
The facility failed to perform pre-employment and pre-admission screenings for tuberculosis (TB) based on current professional guidelines. During a review of staff records from January 2024 through April 2024, it was found that no TB screening information was available for several newly hired employees, including dietary aides, certified nurse aides (CNAs), and housekeeping aides. The Office Manager confirmed that the head of each department was responsible for ensuring TB screenings, but no documentation was provided for the sampled employees. The Nursing Home Administrator (NHA), who was also the interim Infection Preventionist, acknowledged the issue but had not made any changes to the process as of the survey date. The NHA confirmed that no TB screening information was found for the newly hired staff members listed in the report. Additionally, a review of electronic medical records (EMRs) for residents admitted within the past 30 days revealed that several residents did not have TB screening information prior to or since their admission. The NHA confirmed that the staff responsible for TB screening of newly admitted residents did not understand the process. The facility's policy on TB screening, which aligns with CDC guidelines, was not followed, resulting in the potential for exposure and transmission of TB to susceptible residents. The NHA confirmed that residents admitted within the specified period were not screened for TB, highlighting a significant lapse in infection control practices.
Call Light Accessibility for Visually Impaired Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a visually impaired resident (R16). R16, who was admitted with diagnoses including legal blindness, dementia, anxiety, and depression, was observed on multiple occasions unable to locate her call light. On one occasion, R16 was found sitting in her wheelchair, facing the wall with an over bed table in front of her, and the call light wrapped around the left upper grab bar of the bed, out of her reach. R16 reported she often could not find the call light and was observed patting her hands around her lap and the table in an attempt to locate it. The call light was confirmed to be out of reach by both the resident and the surveyor's observations. On another occasion, R16 was heard calling for help repeatedly and was found in a similar position with the call light lying on the floor, two feet away from her and on the opposite side of the over bed table. R16 expressed frustration at not being able to find the call light and needing assistance to go back to bed. An LPN confirmed the call light was out of reach and activated it for assistance. The LPN also found a small metal clip on the call light cord that was not being used to secure the light near the resident. The Director of Nursing confirmed that call lights should always be accessible to residents, especially those with severe visual impairments like R16.
Failure to Ensure Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure privacy and dignified treatment during the provision of care for two residents. One resident, who had severe cognitive impairment and was dependent on staff for various activities, was observed lying naked from the waist down while the CNA and the Nursing Home Administrator were out of sight. This occurred during incontinence care when the CNA left to wash her hands and the NHA went to retrieve a clean brief, leaving the resident exposed and unattended on the bed. Another resident, also with severe cognitive impairment, was observed sitting on the toilet with her pants and brief pulled down below her knees, fully visible from the hallway. The privacy curtain was not drawn, and the door to the shower room was fully open. A staff member walking down the hallway noticed the exposed resident and subsequently drew the privacy curtain. The Director of Nursing confirmed that all residents should be cared for in a manner that preserves their dignity, including ensuring privacy during toileting and covering exposed body parts during care.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — 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 Hubbell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Portagepointe | 7.9 mi | ★★★★★ | 0 | 0 |
| Mission Point Nursing & Physical Rehabilitation Ce | 8.3 mi | ★★★★★ | 0 | 0 |
| Canal View - Houghton County | 8.7 mi | ★★★★★ | 12 | 0 |
| Bayside Village | 28.2 mi | ★★★★★ | 22 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.