Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Farmington during CMS and state inspections, most recent first.
Failure to Monitor and Assess Significant Weight Loss: Two residents had significant weight changes without adequate monitoring, assessment, or documented interventions. One resident on PEG tube feeding had severe weight loss with no progress note documentation and an incomplete nutrition assessment, while another resident with aphasia and dysphagia had severe weight gain followed by severe weight loss, missed weight documentation, and no RD or provider reassessment despite diet orders and meal supervision needs.
Surveyors found widespread environmental deficiencies, including residents lying on worn, ripped, stained linens and using beds, tube feeding equipment, and privacy curtains that were visibly soiled with dried substances and debris. Multiple shower rooms and bathrooms had grimy floors, pooled water, hair, caked-on substances, and toilets with bowel movement left for extended periods, while clutter such as Hoyer lifts, wheelchairs, and oxygen cylinders was inappropriately stored in shower areas. Several resident rooms had heavily soiled bedside tables used for meal service, floors littered with trash and medical items, damaged blinds, incorrect wall clocks, broken wall coverings and lights with sharp edges, and trash cans without liners. Linen rooms on several units repeatedly lacked basic supplies such as towels, sheets, gowns, and draw sheets, and available linens were often thin, frayed, dingy, or full of holes; residents reported rarely changed sheets, being left in wet linens due to lack of clean replacements, and staff cutting towels in half and discarding them. Backup storage areas for linens and emergency supplies were dirty, water-damaged, and poorly maintained, and staff interviews revealed confusion over cleaning responsibilities and a lack of work orders documenting the numerous environmental and safety issues observed.
The facility failed to provide sufficient nursing staff to meet residents’ needs, particularly on weekend and night shifts, leading to prolonged delays in incontinence care and responses to call lights. A ventilator-dependent resident reported waiting three hours for a brief change after activating the call light, while other residents described only one CNA covering an entire floor during overnight hours, resulting in delayed assistance with getting out of bed and unmanaged disruptive behaviors. Several residents reported that weekends were chronically understaffed and that call lights were often ignored or passed by, causing waits of over an hour. CNAs reported being assigned up to 17 residents, working alone on a ventilator unit multiple times, and being unable to respond to all call lights promptly. A nurse confirmed minimal CNA coverage during an overnight shift, and the DON, who based staffing on PPD and census, was initially unaware that staffing had dropped to one CNA on the ventilator unit and one CNA on the first floor after two CNAs left mid-shift without notifying management.
The facility failed to use its QAA process to identify and correct deficiencies in handling an abuse allegation involving a resident and a CNA. Although the facility’s abuse policy required immediate, thorough investigation, protection of residents, timely reporting to state agencies and law enforcement, and QAPI coordination, surveyors found that the incident lacked timely state notification, no police report was filed, the alleged perpetrator was not suspended during the investigation, and the investigation was incomplete. The Administrator reported that abuse allegations, including this case, were reviewed by the QAA Committee, but no concerns were identified.
Surveyors found that the facility lacked a functional infection prevention and control program, with monthly surveillance reports missing infection summaries, infection rates, and documentation of signs and symptoms needed to justify antibiotic use. Infection origins were inconsistently labeled with unclear terms, mapping for trends and clusters was incomplete, and test results and infection types were often left blank. The DON reported frequent turnover of infection preventionists and acknowledged gaps in data accuracy and trend mapping, while the Administrator was unaware of the program’s status and noted that the infection preventionist had not reported to QAPI. Environmental observations showed uncovered backup linens and resident care equipment on carts, visibly soiled linens, and a heavily soiled basement storage room with water-damaged ceilings and contaminated boxes of blankets, contrary to linen-handling policies. In addition, respiratory staff provided care to residents on Enhanced Barrier Precautions wearing only gloves and failed to perform hand hygiene after care, despite facility policies requiring appropriate PPE and hand hygiene.
Food storage and sanitation practices were not maintained during a kitchen observation. Food debris and trash were found behind the ovens, several refrigerated and frozen items were past their used-by dates or not labeled, and uncooked bacon was left open to air in the walk-in refrigerator. The low-temp dishwasher was also observed not sanitizing at required PPM levels, and the dishwasher log had no entry for the morning observation.
QAPI failed to identify deficiencies in the facility's clean, comfortable, homelike environment and infection control program. The administrator stated no environmental concerns or infection control issues were identified through QAPI, and noted the facility had four different infection control preventionists over the prior year, with the most recent prior ICP not providing monthly reports to QAPI members.
Surveyors found that the facility failed to thoroughly and accurately investigate multiple allegations of abuse and poisoning involving two residents, including an allegation that a CNA held a cognitively impaired resident’s wrists down during prolonged care and a separate allegation that a nurse aide raped a resident. Key witness details were omitted from investigation summaries and the report to the State Agency, dates of discovery and occurrence were inconsistent, and required assessments were not documented as completed when claimed. Allegations that another resident and an LPN poisoned a resident’s coffee or otherwise poisoned her were not fully investigated, with no documented interviews of the resident for those events, reuse of prior interviews for a different allegation, and no timely submission of a five-day investigation. Staff implicated in the allegations were not consistently suspended pending investigation, and law enforcement was not notified despite the serious nature of the reports.
Surveyors found multiple unsecured and improperly managed medication and treatment carts on the second floor, including unlocked respiratory and treatment carts left unattended, and a medication cart drawer containing an energy drink, an expired box of Dulcolax suppositories, and unlabeled eye drops. An LPN was observed storing an unidentified cloudy gel-like substance in medicine cups inside the narcotic box, having transferred it from a treatment cart without clear labeling or immediate knowledge of the medication name. The DON acknowledged that carts must be locked and that unlabeled and unsanitary medication storage practices were inconsistent with the facility’s medication storage policy.
The facility failed to timely and accurately report multiple allegations of abuse and poisoning to the State Agency and law enforcement, and did not submit required five‑day investigations. One resident with severe cognitive impairment was allegedly held down by a CNA, but the FRI omitted the specific allegation, misreported discovery and incident dates, listed no witnesses, and conflicted with internal witness statements that were misfiled and not reflected in the investigation summary. Another cognitively intact resident with schizoaffective disorder alleged rape by a CNA and poisoning by another resident and an LPN; the rape allegation was documented by an LPN but not described as such in the investigation summary, was not reported to law enforcement, and the poisoning allegations were reported to the State Agency 12 and 22 hours after discovery, with one lacking a required five‑day investigation. The Administrator was unable to explain the inaccurate, incomplete, and delayed reporting identified by surveyors.
A resident developed a new skin tear in the gluteal fold, but nursing staff did not document the wound in weekly assessments for several weeks and treatment orders repeatedly listed the wrong gluteal side. A nurse reported using triple antibiotic ointment and foam dressing, while a wound care nurse later entered an order for the rear right thigh despite identifying the wound as being on the left side and stating they had only recently been informed of it. The facility’s pressure ulcer/skin breakdown protocol requires measurement, documentation, and continued assessment of all skin issues, but this wound was not consistently assessed or accurately described in the medical record.
A resident who was ventilator-dependent and received all nutrition via a PEG tube did not receive ordered enteral feeding when the tube feeding pump remained inactive or in alarm status for an extended period, with the formula volume unchanged. The pump repeatedly displayed error messages indicating inactivity and a tube slip, but staff did not intervene, and the resident’s husband reported the alarm had been sounding all day without nursing response. A RT who had been in the room stated she did not notice or report the alarm, and a RN and the DON later confirmed that staff are expected to notify nursing of such alarms so tube feedings can be reset and administered according to physician orders and facility policy.
Surveyors identified that the facility did not maintain a medication error rate below 5%, observing three errors out of 32 opportunities. An LPN crushed a Metoprolol ER tablet labeled "do not crush" and administered it via PEG tube instead of by mouth as ordered. Another LPN underdosed Miralax 17 g by filling the cap only to the inner threading rather than to the marked 17 g line, based on informal instruction from another nurse and prior experience with a different resident. The unit manager later confirmed this was not the full ordered dose, and leadership acknowledged these as medication errors.
The facility failed to complete PASARR/OBRA Level II evaluation consideration for two residents. One resident had schizophrenia, severe cognitive impairment, and care plans for psychiatric symptoms, but the record showed no clear follow-through after a change in condition PASARR was completed. Another resident had COPD with ventilator dependence, toxic encephalopathy, and legal incapacity, but the PASARR Level II remained outstanding because updated guardianship documentation was not available.
The facility failed to ensure medical provider notification and assessment for two residents with major weight changes. One resident on PEG feeding and a ventilator had significant and severe weight loss documented, but no provider evaluation or complete nutrition reassessment was found. Another resident with aphasia and dysphagia had severe weight gain followed by severe weight loss, with missed weight documentation, no RD reassessment after the initial evaluation, and no provider assessment despite the weight swings and an order for 1:1 meal supervision.
Failure to complete ordered lab tests in a timely manner. Three residents had physician-ordered diagnostics that were not resulted in the record: one resident with severe respiratory failure and leukocytosis had a UA C&S delayed by specimen labeling and stability problems, and no result was found; another resident with a stage IV sacral pressure ulcer and concern for osteomyelitis had ordered CBC, BMP, CRP, and ESR with no results available; and a third resident with nausea and emesis had ordered CBC and BMP with no results available. The DON and UM reported ongoing problems with the lab company completing ordered tests.
A resident with severe respiratory conditions and dependent on a mechanical ventilator experienced respiratory distress that was not promptly assessed or escalated by nursing staff. Despite family concerns and abnormal vital signs, the RN delayed contacting a provider and did not document or administer ordered respiratory treatments. The resident's condition worsened, requiring emergency intervention and transfer to the hospital, with documentation and communication failures noted throughout the event.
Two residents with significant wounds did not receive proper physician oversight, as evidenced by missing or incomplete documentation of wound assessments, treatment plans, and physician notes. Staff interviews confirmed that wound care was managed without physician involvement for an extended period, and no documentation of physician guidance was available for these cases.
Two residents did not receive timely or appropriate wound care, including missed dressing changes, delayed care planning, and lack of physician orders for identified pressure ulcers and skin tears. Inconsistent skin assessments and documentation failures contributed to the worsening of wounds and lack of treatment.
A resident with a gastrostomy and dysphagia was overfed due to inaccurate transcription and administration of enteral feeding orders. The resident received a significantly higher volume of Glucerna than ordered, resulting in abdominal distension and a large gastric residual. Nursing staff identified the error, stopped the feeding, and notified the medical provider. Facility policy required adherence to physician orders for enteral nutrition, but this was not followed in this instance.
A resident in a vegetative state with a tracheostomy did not consistently receive or have documented tracheostomy care and stoma site assessments as ordered by the physician. Multiple care dates were missed, and the DON indicated that a transfer of care responsibility from respiratory therapy to nursing staff may have led to confusion and lapses in care, contrary to facility policy requiring twice-daily tracheostomy care documentation.
A resident with severe cognitive impairment and limited ability to communicate was subjected to repeated non-consensual sexual contact by another resident with moderate cognitive impairment. Despite prior incidents and staff interventions, inappropriate contact occurred multiple times, with the victim observed visibly shaken and trembling. The facility failed to prevent these incidents and did not adequately protect the resident from sexual abuse.
A resident with intact cognition and multiple medical diagnoses alleged being poisoned by a roommate, leading to a hospital transfer after contacting police. The allegation was not reported to the Abuse Coordinator or State Agency within the required timeframe, as the nurse on duty failed to notify the Administrator promptly, resulting in a delay that did not comply with facility policy.
A resident was admitted without discharge paperwork, physician orders, or medication lists, resulting in no medications or treatments being administered and no care plan initiated. Nursing staff attempted to obtain the necessary documentation and notified the DON and physician, but no temporary orders were received. The resident, with multiple chronic conditions, did not receive prescribed medications and left the facility AMA after approximately 16 hours, with the required hospital discharge summary arriving only after their departure.
A resident dependent on TPN following recent surgery was admitted without the necessary nutrition supplies available. Staff attempted to provide IV dextrose as a temporary measure, but when TPN was delivered, incompatible equipment prevented administration. Despite repeated notifications to the provider and management, the resident did not receive TPN, developed weakness and electrolyte imbalances, and required hospitalization for dehydration and replacement therapy.
A resident with a history of cancer and recent surgery was admitted with an order for TPN, but the pharmacy provided incompatible pumps and tubing, preventing administration. Despite multiple calls to the pharmacy and involvement of nursing staff, the correct equipment was not supplied in time. The resident developed dehydration and electrolyte imbalances, requiring hospitalization.
A facility failed to timely assess and intervene for a resident with a tracheostomy in distress, resulting in death from aspiration. The resident, with a history of respiratory issues, used non-verbal cues to alert staff, but the CNA did not communicate effectively. Additionally, two residents experienced inadequate wound care; one developed an open lesion with exposed tendon due to improper offloading, and another had untreated vascular wounds on the toes, with an LPN falsifying treatment records due to workload.
The facility failed to maintain an adequate supply of linens, affecting multiple residents and potentially all on the second floor. Complaints highlighted shortages of washcloths, towels, and blankets, with some linens stained with feces. Observations confirmed the lack of clean linens, and staff reported insufficient supplies due to a switch from wipes to washcloths. The linen closets and laundry room were inadequately stocked, with a washer machine down due to a leak.
A resident admitted with osteomyelitis required IV antibiotics for 28 days, but the facility incorrectly entered the order for only 7 days, leading to missed doses. The resident's medication administration record showed lapses in administration, and issues with the PICC line further delayed treatment. Interviews revealed that a nurse was reprimanded and reeducated for the error.
A resident's right to dignity was compromised when a new administrator ordered the removal of their personal refrigerator, which had been approved by a previous administrator. The administrator did not review the facility's policy, which allowed for such refrigerators, and based the decision on practices from a previous facility. The resident, a former chef, maintained the refrigerator properly, but the administrator cited concerns about its size and the resident's ability to keep it clean, despite staff being responsible for maintenance.
A resident alleged rough handling by a CNA during peri-care, which was reported to the facility's Administrator but not to the State Agency within the required two-hour timeframe. The resident, who required assistance for bed mobility and toilet hygiene, reported the incident to an LPN. The facility's policy mandates immediate reporting of abuse allegations, which was not followed in this instance.
The facility failed to investigate and report multiple allegations of staff-to-resident abuse. A resident with Alzheimer's alleged rough treatment by a CNA, but the investigation was incomplete and not submitted to the SSA. Another resident with rheumatoid arthritis reported similar rough treatment, but again, the investigation was not completed. Additionally, a resident was sent to the hospital after a confrontation with a roommate, but there was no documentation of the alleged behavior, and no proper investigation was conducted.
The facility failed to implement and update care plans for two residents, leading to deficiencies in care. One resident, dependent on staff for mobility and hygiene, experienced rough handling by a CNA who did not follow the care plan requiring a two-person assist. Another resident, with a history of fractures and suicidal ideations, had no care plan updates following significant incidents, including a psychiatric evaluation and hospital transfer. These issues highlight gaps in the facility's care planning process.
The facility failed to follow professional standards in wound care and medication management for two residents. One resident's wound dressing was incorrectly dated, indicating missed care, while another resident did not receive the full course of prescribed IV antibiotics due to an error in medication order entry. These deficiencies highlight issues in adherence to physician orders and documentation accuracy.
A resident with severe cognitive impairment developed a stage III pressure ulcer on their right ear due to the facility's failure to prevent and timely identify the condition. The resident was observed lying on their right side for extended periods without repositioning, and the facility's skin assessments did not document the issue until the family reported it. The facility's policy on pressure injury prevention was not followed, leading to the deficiency.
A resident with anemia was not transferred to the hospital despite a low hemoglobin level, as staff failed to notify the Physician or NP due to difficulty accessing lab results. The facility's policy on reporting critical lab results was not followed.
The facility failed to provide adequate physician oversight and supervision for residents requiring ventilator care, leading to a systemic failure in the interdisciplinary approach. One resident, with serious health conditions, experienced a significant change in condition during an attempted weaning process without proper physician assessment or notification. Interviews revealed unclear protocols and communication issues, with the pulmonologist rarely present and lacking documentation in medical records.
The facility failed to ensure the Medical Director was aware of their responsibilities in coordinating respiratory care for ventilator residents. The Medical Director, MD L, was not involved in respiratory care, believing a Pulmonologist was responsible. Interviews with Nurse Practitioners revealed confusion and lack of oversight in ventilator care. The facility could not provide documentation outlining MD L's responsibilities, indicating a systemic failure in care coordination.
The facility failed to implement consistent infection control practices, affecting all 66 residents. Observations included staff not performing hand hygiene and improper gown usage. The Infection Surveillance Program lacked documentation and analysis for several months. The Infection Control Nurse acknowledged these deficiencies.
A facility failed to ensure the correct individual signed an advanced directives/DNR form for a resident with intact cognition. The form was signed by the resident's son, despite no documentation of the resident being mentally incapacitated. Facility policy requires residents to be informed of their rights and any existing directives to be documented, which was not adhered to in this case.
A resident with a history of severe medical conditions experienced a decline in health, including labored breathing and signs of sepsis. Despite being a full code, the facility failed to timely assess and follow up on the resident's condition, leading to an increase in oxygen without a physician's order and unsuccessful attempts to contact the attending physician. The resident was found unresponsive and expired after resuscitation efforts, highlighting a breakdown in communication and timely response.
The facility failed to implement range of motion and splinting interventions for two residents with contractures, leading to potential pain and worsening of their conditions. One resident with severe cognitive impairment and bilateral knee contractures had no restorative interventions in place, while another quadriplegic resident with hand contractures lacked a care plan despite recommendations. The facility's policy on range of motion was not followed, and poor communication between departments contributed to the deficiency.
A resident with heart failure and other conditions experienced delays in receiving assistance due to insufficient staffing at the facility. Staff interviews revealed challenges in meeting residents' needs, particularly on weekends, despite recent hiring efforts. Reports from meetings and council minutes highlighted ongoing issues with call light response times and service inconsistencies.
A facility failed to attempt non-pharmacological interventions before administering PRN psychotropic medication to a resident with moderately impaired cognition. The resident received PRN alprazolam multiple times without documentation of alternative interventions. The Nurse Manager confirmed the standard practice of attempting non-pharmacological interventions first, but the facility's policy did not specify this requirement.
The facility failed to maintain proper sanitation and disposal of medication tablets in a medication cart. Unidentified pills were found in multiple drawers, and an LPN was unable to identify them. The DON confirmed that the drawers should be clean and pills discarded per policy, but no further documentation was provided.
A resident with diagnoses of adult failure to thrive and dementia did not receive physician-ordered lab tests, including CBC, BMP, and troponin, due to a miscommunication where the lab was not informed of the order. The facility's guidelines for tracking and completing lab tests were not followed, resulting in the oversight.
The facility failed to implement an effective antibiotic stewardship program, as evidenced by inappropriate antibiotic use for three residents with UTIs that did not meet McGeer's criteria. The Infection Control Nurse could not provide documentation on the oversight of the program or the review of antibiotic appropriateness, indicating a lack of proper stewardship efforts.
During a power outage, the facility failed to maintain a backup for the resident call system, affecting all residents on one hall. Residents with various medical conditions, including heart failure and COPD, reported non-functional call lights and emergency outlets. They were left without a means to alert staff, as no backup system was provided. Interviews with staff revealed a lack of awareness of the issue, and no immediate alternative solutions were offered.
The facility failed to provide adequate assistance with activities of daily living for three residents. A resident reported not receiving scheduled showers, confirmed by missing documentation. Another resident, with moderate cognitive impairment, was left unsupervised during meals, unable to open milk and juice cartons. A third resident, also with cognitive impairment, was observed eating in a reclined position without staff supervision, contrary to their care plan. The DON acknowledged these issues.
A resident was observed without required splints, despite documentation indicating they were applied. The resident's legal guardian raised concerns about the lack of restorative services and the resident's pressure injury. Interviews revealed discrepancies in care, with the Therapy Manager and Restorative Nurse providing conflicting information about the resident's treatment. The DON was unaware of inaccurate documentation by staff.
Failure to Monitor and Assess Significant Weight Loss
Penalty
Summary
The facility failed to adequately monitor and assess residents for weight loss and failed to implement documented interventions for two residents reviewed for nutrition. One resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living, and received all nutrition through a PEG tube, had a documented weight of 182.2 lbs on 11/5/25 and 163.7 lbs on 1/3/26, a 10.15 percent loss. The record also showed a 5.54 percent loss between 11/5/25 and 12/3/25. There was no documentation in the progress notes addressing either weight loss, and a Nutrition Data Collection/Evaluation assessment was blank or incomplete. The dietician stated she typically assessed residents right away once weight loss was triggered, but she could not explain what interventions were put in place for this resident and was unsure whether the resident had been seen by a medical provider. A second resident, admitted with aphasia and dysphagia and assessed as dependent on staff for most activities of daily living, had a diet order for regular pureed texture with nectar/mildly thick consistency and setup support, with upright positioning for all intake. The resident was observed with enteral feeding infusing, a half-filled bottle of thin soda at the bedside, and later a half-eaten lunch tray despite a meal ticket indicating 1:1 supervision with meals. The resident stated that staff usually did not help with meals and that the wife helped on one day. The weight record showed 196 lbs on admission, 218.3 lbs on 1/1/26, and 180.6 lbs on 1/6/26, but there were no documented weights for the period from 12/19/25 through 12/30/25. The resident’s dietary notes showed only an initial evaluation on 12/30/25, which noted the resident was added to weekly weights to establish trends, but there were no further dietary progress notes or evaluations. The record did not show medical provider evaluations or documentation addressing the severe weight gain and subsequent severe weight loss. The dietician stated she had not been made aware of the weight changes and had not reassessed the resident since the initial evaluation, and the physician reported they had not been made aware of the severe weight swings and had not assessed the resident for the weight changes.
Widespread Environmental Uncleanliness and Linen Shortages Compromise Resident Living Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, including failure to ensure clean linens and properly maintained resident care equipment and rooms. Surveyors observed multiple residents lying on worn, ripped, stained, and visibly unclean fitted sheets, with bed frames and mechanical areas under mattresses soiled with dried substances and debris. Tube feeding pumps, poles, and bases for several residents were observed with dried, splattered brown or tan substances, and some ceiling tiles and vents above beds were coated with similar debris. Privacy curtains in several rooms were heavily soiled, torn, or ripped, and some walls and ceilings showed water damage and peeling wallpaper. In one room, sharp metal poles remained attached to a bed where the resident reported sometimes grabbing them when being rolled, and the Physical Therapy Director later identified them as remnants of assist bars without a current order. The facility’s shower rooms and bathrooms were repeatedly found in unclean and unsafe condition. In multiple shower rooms, floors were grimy, with pooled water, hair, caked-on substances in floor drains, and visibly dirty shower beds and chairs, including padding that was torn and exposing foam. One shower room toilet contained bowel movement that staff reported had been present for approximately a week due to a non-functioning flush, and the room also contained clutter such as Hoyer lifts, wheelchairs, ripped floor mats, and oxygen cylinders stored inappropriately. Several resident bathrooms and shared toilets were observed with bowel movement matter inside and outside the toilet bowls, heavily soiled floors and walls, thick dust on ceiling fans and vents, and no toilet paper available, with tissues placed along handrails instead. In some rooms, overbed lights and wall coverings were pulled away or broken, exposing sharp edges accessible to residents and staff. Surveyors documented persistent environmental uncleanliness and lack of basic housekeeping over multiple days. Bedside tables in several rooms remained soiled with sticky, dried food and unknown substances despite being used to serve meals, and floors in those rooms were littered with food crumbs, paper debris, discarded gloves, and even a tracheostomy inner cannula, with no indication of sweeping or mopping between observations. Residents reported that their rooms were rarely cleaned, that dirty linens had been left on the floor for days, and that there were no housekeeping staff present on at least one weekend day. Window blinds in multiple rooms were damaged or missing, several wall clocks throughout resident rooms and the dining/activity room displayed incorrect times, and some trash cans lacked liners while still being used for waste. The facility also failed to maintain adequate, clean linen supplies and to ensure linens were in good repair. Multiple linen rooms on different units were repeatedly observed with no or very limited supplies of towels, fitted sheets, flat sheets, gowns, draw sheets, or bariatric gowns, and the linens that were present were often thin, frayed, dingy, yellowed, or had holes. A resident with intact cognition reported ongoing issues with the facility running out of clean sheets, towels, and washcloths, stating that sheets were rarely changed and that they had been left in wet sheets for hours after a bed bath because no clean sheets were available. The same resident reported that staff were cutting towels in half to use for wiping and then discarding them, contributing to shortages. During a resident council meeting, several residents reported that linens were ripped and had holes, that they had to remain in chairs for hours due to lack of clean sheets, and that there were no trash bags for commodes or for dirty linens. Storage and backup supply areas were also found in disrepair and unsanitary condition. The basement storage area used for backup linens and resident care equipment contained uncovered carts of linens and heel protectors, with visible debris on the linens. Inside a locked storage room, shelves held emergency water, backup linens, COVID tests, masks, and blankets, but the floor was heavily soiled with dark stains, debris, and trash. The ceiling showed visible water damage with broken, bubbling, and discolored areas, and ceiling particles had fallen onto the floor and onto stored items, including emergency water supplies. Cardboard boxes of blankets were stored directly under damaged ceiling pipes and were compromised by water damage, and an exposed wire protruded from the ceiling and was wrapped around a metal shelving unit. Staff interviews revealed that environmental concerns identified by surveyors had not been reported through the facility’s electronic work order system, and existing housekeeping checklists and linen policies did not address linen condition or replacement criteria. Staff interviews further demonstrated confusion and gaps in responsibility for cleaning and environmental maintenance. The Environmental/Housekeeping Manager stated that housekeeping staff did not clean bedside carts or tube feeding poles and that maintenance or “anyone that saw it” would be responsible for cleaning inside vents, while the DON stated that housekeeping was ultimately responsible for cleaning resident equipment such as tube feeding poles and communication boards. The Environmental/Housekeeping Manager confirmed multiple observations of soiled rooms, equipment, and privacy curtains over two days and acknowledged that some areas, including the backup storage room, had not previously been inspected. Review of the electronic work order log over a two-month period showed no staff-reported concerns corresponding to the numerous environmental and safety issues observed by surveyors, despite the presence of broken handrails, unsecured wall coverings, malfunctioning toilets, and widespread uncleanliness throughout resident care areas.
Insufficient Nursing Staff Leading to Delayed Care and Unanswered Call Lights
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly on weekend and night shifts, resulting in significant delays in incontinence care and response to call lights. Payroll Based Journal (PBJ) staffing data for a specified fiscal quarter showed the facility triggered for excessively low weekend staffing. Multiple residents reported inadequate staffing, including a ventilator-dependent resident who stated he activated his call light at 4:00 AM for an incontinence brief change and did not receive the needed care until 7:00 AM, despite staff entering his room twice without providing the requested care. His family member also believed there was not enough staff on weekends. Additional residents on the first floor reported that during a specific midnight shift there was only one CNA on the floor from 2:00 AM to 7:00 AM, which interfered with timely assistance for a roommate who was scheduled to get out of bed by 6:00–6:30 AM and left two residents on the hallway screaming at one another without staff able to calm them. Another resident, who required two-person assistance, stated they did not believe there was enough staff to meet their needs and cited this as a reason for choosing hospice services to obtain more help with care. During a confidential resident council meeting with 12 residents, eight residents reported there was not enough staff, especially on weekends, describing situations where no staff appeared to be present, managers arriving late in the day, and call lights being ignored or passed by, resulting in waits of over an hour. Staff interviews further supported the deficiency. One CNA reported that on a day when one CNA had called in, only two CNAs were working on the first floor for 33 residents. Another CNA, assigned 17 residents, acknowledged difficulty in providing timely assistance, including leaving a resident’s bedside table out of reach while preparing for a shower and then having to leave to help others. A CNA assigned to the ventilator unit reported working alone on multiple occasions, including a Sunday evening into the midnight shift, and stated that residents had to wait longer for assistance when call lights were activated while they were helping another resident. A nurse confirmed that on a specific Sunday midnight shift there was only one CNA on the first floor from 2:00 AM to 7:00 AM, with many unanswered call lights. The DON, responsible for staffing and scheduling, stated staffing was based on PPD and census and that managers filled in when staff called off, but initially reported being unaware of staffing problems on the cited night; subsequent review of schedules and time punches showed that two CNAs punched out at 2:30 AM, leaving only one CNA on the ventilator unit and one CNA on the first floor for the remainder of the shift, and the DON and on-call manager were not notified.
Failure of QAA Process to Address Abuse Investigation Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to identify and implement effective plans of action through its Quality Assessment and Assurance (QAA) process to correct system failures related to its abuse policy. The facility’s written abuse, neglect, and exploitation policy dated 1/10/2024 requires immediate investigation of suspected or reported abuse, including identifying and interviewing all involved persons, focusing the investigation on whether abuse occurred, its extent and cause, and providing complete and thorough documentation. The policy also requires protecting residents from physical and psychosocial harm during and after the investigation, and mandates reporting alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, as well as coordination with QAPI so that cases of physical or sexual abuse are reviewed and tracked by the QAA Committee. Surveyors’ review of a facility reported incident involving a resident and an alleged perpetrator, a CNA, identified multiple concerns with how the facility handled the investigation. These concerns included lack of timely notification to the State Agency, no police report being filed, failure to suspend the alleged perpetrator pending the investigation, and lack of a complete and thorough investigation into the allegation. When interviewed, the Administrator stated that abuse allegations, including this resident’s allegation, were reviewed as part of QAA and that no concerns were identified, indicating that the QAA Committee did not recognize or address the documented investigative and reporting deficiencies related to this abuse allegation.
Failure to Maintain Comprehensive Infection Control Program and Adhere to EBP, PPE, and Linen Handling Standards
Penalty
Summary
Surveyors identified a failure to maintain an ongoing, comprehensive infection prevention and control program. Review of infection surveillance data for several months showed that the facility did not compile ongoing data to identify appropriate antibiotic usage, track trends, clusters, or outbreaks, conduct ongoing surveillance, or provide staff education on infection control principles. For January, no ongoing data had been compiled at all. For December, November, and October, there were no monthly summaries documenting the prevalence of different types of infections or calculated infection rates, despite surveillance reports listing 27, 28, and 36 total infections respectively. In the monthly surveillance reports reviewed, there were no documented signs and symptoms for any of the infections to demonstrate that they met appropriate criteria for antibiotic usage. In December, 17 infections were treated with antibiotics, 3 infections were left blank regarding whether they met criteria, and 7 were documented as meeting criteria despite no documented signs and symptoms. In November and October, the "Criteria Met" column documented infections as either True or False without any recorded signs and symptoms, and many entries had "No Response" for test results, test type, and infection type. The origin of infections was inconsistently and unclearly documented, with categories such as "Acquired Prior," "NA," and "Null" used without clear definitions, and the DON later stated infections should only be categorized as present on admission or developed in the facility. Mapping for trends, clusters, and outbreaks was incomplete and did not clearly correspond to all infections listed in the surveillance reports. Interviews further demonstrated a lack of oversight and continuity in the infection control program. The DON reported that the facility had four different infection preventionists over the last year and acknowledged that the data should list signs and symptoms, accurately document whether infections were present on admission or facility-acquired, and include completed maps to demonstrate trends or outbreaks. The DON could not explain the terms "Prior" and "NA" used in the surveillance reports. The Administrator stated they were not aware of the status of the infection control program and reported that the last infection preventionist did not report to the QAPI committee. The facility’s own infection prevention and control policy required a program designed to prevent the development and transmission of communicable diseases and infections, but the documented practices did not align with this policy. Surveyors also observed deficiencies in environmental infection control related to linen storage. In the basement storage area, two large metal carts containing linens and resident care equipment were not covered, and several shelves of linens were visibly soiled with debris particles. Inside a locked storage room, the floor was heavily soiled with dark stains, debris, and trash, and the ceiling showed visible water damage with broken, bubbling, and discolored areas. Ceiling particles were observed on the floor, on top of shelves, and on the emergency water supplies. Cardboard boxes containing blankets were stored directly under damaged ceiling pipes, and the boxes were compromised by water damage. These conditions conflicted with facility policies requiring clean linens to be handled, transported, and stored in a manner that prevents contamination by dust, debris, and other soiled items. Additional observations showed noncompliance with hand hygiene and personal protective equipment (PPE) requirements under Enhanced Barrier Precautions (EBP). Rooms for multiple residents had EBP signage and PPE available, indicating the need for gowns and gloves. A respiratory therapist was observed providing tracheostomy tubing care and checking oxygen levels for a resident under EBP while wearing only gloves and then exiting the room without performing hand hygiene. The same therapist later provided respiratory care to another resident under EBP wearing only gloves and again did not perform hand hygiene after care. On another occasion, the respiratory therapy manager provided respiratory care to a resident under EBP while wearing only gloves. The respiratory therapy manager acknowledged that staff must wear proper PPE, including gowns, when providing care and touching residents. These practices were inconsistent with facility policies requiring appropriate PPE use and proper hand hygiene for all staff having contact with residents and their environment.
Food Storage and Dishwasher Sanitization Deficiencies
Penalty
Summary
The facility failed to maintain food service safety practices during an initial kitchen tour with the Kitchen Manager present. Scattered pieces of food debris and trash were observed behind both ovens. In the walk-in refrigerator, a bowl of chicken salad was found with a used-by date of 1/24/26, a tray of single-serving yogurt containers also had a used-by date of 1/24/26, multiple single-serving bowls of salad were undated, and an opened container of vegetable soup had a used-by date of 1/24/26. A pan of uncooked bacon strips was left unsealed and open to air in the walk-in refrigerator, and an opened bag of frozen garlic bread was unlabeled in the freezer. A bag of frozen cooked chicken was also found in the freezer with a used-by date of 1/23/26.
QAPI Program Failed to Identify Environmental and Infection Control Deficiencies
Penalty
Summary
The facility failed to identify areas of deficiency and maintain an effective QAPI program related to a clean, comfortable, homelike environment and the facility's infection control program. During an interview with the administrator, it was stated that the facility did not identify any environmental concerns or issues with the comprehensive infection control program through its QAPI process. The administrator also reported that the facility had four different infection control preventionists over the previous year and that the most recent prior infection control preventionist did not provide the QAPI members with any monthly report. A review of the facility's QAPI plan showed that the facility's policy was to systematically collect data as part of the QAPI program to ensure the care and services delivered meet acceptable standards of quality in accordance with recognized standards of practice.
Failure to Thoroughly Investigate Abuse and Poisoning Allegations and Protect Residents
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely, thorough, and accurately documented investigations into multiple allegations of staff-to-resident physical and sexual abuse and poisoning, and failure to implement adequate protections for residents during those investigations. For one resident with severe cognitive impairment and limited ability to communicate, an allegation was made that a CNA remained in the room for an unusually long period while providing care, was seen bent over the roommate, and was reported to have held the resident’s wrists down. Initial witness statements documented that the roommate observed the CNA bent over the resident, holding her wrists, and that the resident appeared upset. Another statement noted the resident seemed nervous and reluctant to speak and that her nails were not clipped, despite the CNA’s later claim that he had clipped and cleaned her nails during the extended care episode. These details, including the allegation of the CNA holding the resident’s wrists tightly and the discrepancy about nail care, were not included in the investigation summary or in the report submitted to the State Agency. The facility’s documentation regarding this incident was inaccurate, disorganized, and inconsistent. Witness statements showed the incident was reported internally on one date and alleged to have occurred on an earlier date, while the FRI submitted to the State Agency listed different discovery and incident dates. Key allegations, such as the CNA holding the resident’s wrists down and the roommate’s detailed observations, were omitted from the investigation summary and the FRI. The facility’s investigation summary stated that a skin and pain assessment was completed immediately, but the only documented skin assessments for the cognitively impaired resident were dated before the alleged incident and then ten days later. Additionally, the CNA continued to work several shifts after the initial allegation was identified, and there was no evidence that law enforcement or other agencies were notified, despite the nature of the allegations. For another resident with intact cognition and a diagnosis including schizoaffective disorder, the facility failed to fully investigate multiple serious allegations. One incident report documented that the resident told staff that a nurse aide raped her while providing care, yet the investigation summary submitted to the State Agency only described that the resident felt someone entered her room and did something to her, without mentioning rape. In separate incidents, the same resident alleged that another resident poisoned her coffee and that an LPN poisoned her coffee or otherwise poisoned her, contacted police, and was transferred to the hospital. The FRI for the allegation against the other resident was submitted 12 hours after discovery, and no investigation was submitted within the required five-day timeframe. For the poisoning allegations against the LPN, the facility’s investigation relied on interviews with the LPN and the roommate and review of surveillance video and lab work, but there was no documented interview of the resident for either poisoning allegation, and the investigation for a later poisoning allegation reused interviews from an earlier, different allegation. There was also no evidence that the LPN was suspended pending investigation of the poisoning allegations. The Administrator, serving as Abuse Coordinator, was unable to explain the omissions, lack of investigations, reuse of prior interviews, and failure to suspend staff or notify law enforcement in connection with these allegations.
Failure to Secure and Properly Label Medications on Second Floor Carts
Penalty
Summary
The deficiency involves failure to ensure medications and biologicals were securely stored and properly labeled on the second floor. During an observation of medication cart #3 with a nurse, surveyors found an opened can of energy drink in a large drawer, a box of Dulcolax suppositories with an expiration date of 11/2025, and a bottle of redness-relieving eye drops in an opened box without a label identifying the intended patient. The nurse stated that expired medications should be discarded and that all medications in the cart should be labeled with a patient name. In a separate observation, the second-floor respiratory cart was found unlocked and not under direct observation of authorized staff; a second respiratory cart was also unlocked with a key left in the lock, and medications were accessible in the drawers. The respiratory therapist later confirmed that the respiratory carts contained breathing supplies, equipment, and medications. Additional observations showed a treatment cart on the second floor left unlocked and unattended outside a resident room, with the unit manager later approaching and locking the cart only after the surveyor’s presence. During a medication administration observation, an LPN retrieved medication from the narcotic box of the second-floor medication cart, where two clear medicine cups containing a cloudy gel-like substance were found lying sideways between narcotic blister packs. The LPN stated these cups were for a resident, that the substance had been taken from the treatment cart and placed into the cups, and then stored in the narcotic box, but the LPN was unsure of the medication’s name and had to look it up in the MAR. The DON later acknowledged that all respiratory, medication, and treatment carts must be locked, that storing medication in cups in this manner was unsanitary, and that medications without patient identifiers or labeling were not acceptable, in contrast to the facility’s written Medication Storage Policy requiring proper sanitation and security.
Failure to Timely and Accurately Report Abuse and Poisoning Allegations
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately report multiple allegations of abuse and poisoning to the State Agency and law enforcement, and to submit required five‑day investigation reports. For one resident with severe cognitive impairment, unclear speech, and dependence on staff for most care, the facility submitted an FRI that only stated a CNA was in the room caring for the resident’s roommate for an extended period of time and did not identify the specific allegation of mistreatment. Internal witness statements, later found misfiled in other FRI folders, documented that the cognitively intact roommate reported seeing the CNA bent over the resident, holding her wrists down, and that the resident appeared upset. Another statement documented that during an interview the resident seemed nervous and reluctant to speak, and that her nails were not clipped, which conflicted with the CNA’s account that he had clipped and cleaned her nails. These details, including the allegation that the CNA held the resident’s wrists tightly and later spoke with the roommate to say he would never hurt a resident, were not included in the documentation submitted to the State Agency or in the facility’s investigation summary. The surveyors found that the facility’s documentation for this incident was inaccurate, incomplete, and disorganized. The FRI reported the incident as occurring on one date and being discovered the following day, but witness statements showed the allegation was initially reported to the former DSS on an earlier date and identified a different date and time of occurrence. The facility’s investigation summary stated that a skin and pain assessment was completed immediately, but the only skin assessment located for the resident around that time was dated prior to the alleged incident, with the next assessment not until many days later. The FRI also indicated there were no witnesses and that law enforcement and other agencies were not notified, despite internal witness statements describing specific observations of the CNA’s actions and the resident’s demeanor. When interviewed, the Administrator could not explain the inaccurate, unorganized, and misleading documentation, the omission of the allegation that the CNA held the resident’s wrists, the failure to notify police, or the delay in reporting the allegation to the State Agency. The facility also failed to timely and fully report separate allegations made by another resident with intact cognition and a diagnosis including schizoaffective disorder. In one incident, this resident reported to an LPN that a CNA raped her while providing care; the LPN’s incident report documented this allegation and showed the DON was notified the same day and the Administrator the following day. However, the investigation summary submitted to the State Agency only stated that the resident felt someone entered her room and did something to her and identified the CNA, without mentioning the specific allegation of rape. There was no indication that law enforcement was contacted regarding the sexual abuse allegation, and the Administrator later acknowledged that the allegation of rape was not reported to law enforcement and did not explain why it was omitted from the report and investigation summary. Additional failures occurred when the same cognitively intact resident alleged that another resident poisoned her coffee and later alleged that an LPN poisoned her, prompting the resident to call 911 to be transferred to the hospital. For the allegation that another resident poisoned her coffee, the FRI showed the incident was discovered in the morning but not reported to the State Agency until 12 hours later, and no five‑day investigation was submitted within the required timeframe; the Administrator confirmed an investigation was not completed and could not explain the failure. For the allegation that the LPN poisoned her, the FRI documented that the incident was discovered in the afternoon and not reported to the State Agency until 22 hours later. In interviews, the Administrator stated that staff were to contact her immediately for any abuse allegation and that all such allegations were to be reported to the State Agency within two hours and to law enforcement when abuse was involved, but she did not provide explanations for the delays in reporting or the missing and incomplete investigations identified by surveyors.
Failure to Accurately Assess and Document Gluteal Wound and Treatment Orders
Penalty
Summary
The facility failed to ensure ongoing assessment and accurate treatment orders for wound care for one resident with a new skin tear in the left gluteal sulcus. A complainant reported concerns that the resident had developed a new wound in the left thigh/buttock area and that the facility was not properly addressing it. On observation with a nurse, the wound was seen as a skin tear approximately 3 cm in length in the skin fold where the thigh meets the buttock, and the nurse stated the treatment was triple antibiotic ointment with a foam dressing. Review of the resident’s progress notes showed an entry indicating a new area on the right leg under the buttock in the crease, but subsequent weekly wound assessments on multiple dates did not document the presence of this wound on either buttock or thigh, with the first documented assessment of the wound not appearing until later in the month. Record review showed an order entered earlier in the month for treatment to the right gluteal fold and a wound care consult, but without specified directions for the consult order. A new wound care order was later entered by the wound care nurse for the rear right thigh, directing cleansing with normal saline, application of triple antibiotic ointment, and coverage with border foam once daily. In interview, the wound care nurse stated they had not been made aware of the new wound until the morning of the later observation date and identified the wound as being on the left gluteal side. It was then noted that all treatment orders since the initial date, including the new order, incorrectly indicated the wound was on the right gluteal area. The wound care nurse acknowledged this error. The facility’s provided policy addressed pressure ulcers/skin breakdown and stated that all pressure ulcers or other skin-related issues are to be measured, documented, and subject to continued assessment and management, but the documented practice for this wound did not reflect ongoing assessment or accurate localization in the orders.
Failure to Respond to Tube Feeding Pump Alarms and Follow Enteral Feeding Orders
Penalty
Summary
The deficiency involves the facility’s failure to administer tube feeding according to physician orders for one resident who was ventilator-dependent and received all nutrition via a PEG tube. On multiple observations throughout the same day, the resident’s tube feeding pump was either inactive or alarming, with the pump screen displaying messages such as “Pump inactive. Pump has been idle for 10 minutes” and “Tube slip detected. Remove and reload cassette.” Despite these alarms and error messages, the pump was not restarted or corrected, and the volume of formula in the bottle remained unchanged at 850 ml, indicating that the ordered continuous feeding at 50 ml/hr for 20 hours per day was not being delivered. There were no physician orders to hold the tube feeding. The resident had diagnoses including COPD, acute respiratory failure with hypoxia, CHF, and dysphagia, required a mechanical ventilator, and did not take any nutrition by mouth, making the PEG tube the sole source of nutrition. The resident’s husband reported that the pump had been alarming all day and he did not know why it was alarming or why a nurse had not addressed it. A respiratory therapist who had been in the room stated she did not notice the alarm and, being new, did not alert anyone. A RN who was not the assigned nurse for the resident stated that nursing staff should be alerted to pump alarms so they can be addressed and acknowledged that a nurse should have been notified. The DON similarly stated that nursing should be made aware of any alarm or error message on a tube feeding pump so it could be reset, and that anyone who noticed it was responsible for reporting it to a nurse. The facility’s policy stated that feeding tubes will be utilized according to physician orders.
Failure to Maintain Acceptable Medication Error Rate During Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent when surveyors observed three medication errors out of 32 opportunities, resulting in a nine percent error rate. In one instance, an LPN administered Metoprolol ER 25 mg, ordered by mouth with explicit "do not crush" instructions, by crushing the tablet, mixing it with water, and giving it through a PEG tube to a resident. This action was contrary to the medication order and the facility’s medication administration policy, which specifies that medications are to be administered in accordance with professional standards of practice and that medications with "do not crush" instructions are not to be crushed. In another instance, an LPN administered Miralax 17 g to a resident but measured only approximately half the ordered dose by filling the granules in the cap up to the inside threading rather than to the stamped 17 g line. When questioned, the LPN stated they had been told by another nurse to measure to the threading and believed filling the entire white portion of the cap was "too much" based on a prior experience with another resident. Later, the unit manager demonstrated that the correct 17 g dose corresponded to filling the entire white portion of the cap up to the purple part, and acknowledged that the amount previously administered by the LPN was not the full ordered dose. The DON also acknowledged these observations as medication errors.
Failure to Complete PASARR Level II Evaluations for Two Residents
Penalty
Summary
The facility failed to submit required PASARR/OBRA Level II evaluation consideration for two residents with significant mental health or cognitive-related conditions. One resident had diagnoses including schizophrenia and severe cognitive impairment, with care plans addressing behaviors related to schizophrenia and impaired mood/psychiatric status. The clinical record showed no available psych consultations, and the initial social service assessment did not identify specific details of the resident’s mental health history. For this resident, the admission PASARR from the previous facility identified all “No’s,” but the facility later completed a change-in-condition PASARR form documenting schizophrenia, dementia, and no medications. There was no indication that the change in condition had been completed with OBRA at the time of review. Interviews with social services staff and the regional social service consultant confirmed uncertainty about whether the Level II evaluation had been submitted after the resident returned to the facility, and the OBRA letter in the record stated the recipient did not require a Level II evaluation at that time because the patient had been discharged from the facility. The second resident was admitted with ventilator dependence due to COPD and respiratory failure, along with impaired neurological and cognitive function related to long-term toxic encephalopathy. The resident was legally incapacitated and had full guardianship, but the facility had an outstanding PASARR Level II issue. OBRA correspondence stated the resident could not be evaluated for a Level II because proof of guardianship was missing, and the record showed the guardianship had expired. The Director of Social Services reviewed the chart and confirmed there was no updated guardianship and the resident still had not been evaluated.
Failure to Evaluate Severe Weight Changes
Penalty
Summary
The facility failed to ensure that a medical provider was notified and that an assessment or evaluation was completed for two residents who experienced severe weight changes. One resident was observed in bed receiving nutrition through a PEG tube and mechanical ventilator support. That resident’s record showed a weight of 182.2 lbs on 11/5/25, then 172.1 lbs on 12/3/25, and 163.7 lbs on 1/3/26, reflecting significant and severe weight loss. The record did not show that the weight loss between 11/5/25 and 12/3/25 or between 11/5/25 and 1/3/26 was evaluated by a medical provider, and the nutrition assessment documentation was incomplete or blank for the later assessment. Interviews with the RD and DON indicated the RD was expected to identify and notify the medical provider about significant weight loss, but the RD was unsure whether the resident had been evaluated. The DON later confirmed there was no evidence that the resident had been evaluated by a medical provider for the severe and significant weight loss. The resident had diagnoses including acute and chronic respiratory failure with hypoxia, COPD, type 2 diabetes, dysphagia, and a history of accidental heroin poisoning, and was dependent on staff for all ADLs, bed mobility, and transfers. A second resident with aphasia and dysphagia had enteral feeding and was observed with a half-filled soda bottle and later a half-eaten lunch tray despite an order for 1:1 supervision with meals. The resident’s weight record showed a 196 lb admission weight, then 218.3 lbs, followed by 180.6 lbs and 181.0 lbs, but there were no documented weights for part of the admission period and no medical provider evaluation for the severe weight gain or subsequent severe weight loss. The RD stated they had not been notified of the weight changes and had not reassessed the resident since the initial evaluation, and the physician reported they had not been made aware and no assessment had been done.
Failure to Complete Ordered Laboratory Tests in a Timely Manner
Penalty
Summary
The facility failed to ensure physician-ordered laboratory diagnostics were completed in a timely manner for three residents. R2 was admitted with acute and chronic respiratory failure with hypoxia, cardiac arrest, type 2 diabetes mellitus, and hypertension, and was dependent on a mechanical ventilator and feeding tube. A UA C&S was ordered for elevated WBC, and later additional urine studies were ordered for leukocytosis, but the record showed repeated problems with specimen collection and handling, including an unlabeled specimen and a specimen rejected for stability issues. Progress notes documented that the urine culture remained pending over multiple days, and no UA C&S result was found in the record. R80 was admitted with aphasia and dysphagia and was dependent on staff for most ADLs. A physician ordered CBC/diff, CRP, ESR, and BMP after evaluation for a stage IV sacral pressure ulcer with concern for possible osteomyelitis and exposed bone. The medical record did not reveal results for the ordered CBC, BMP, CRP, or ESR. During interview, the DON stated that the facility had issues with the lab company coming out and completing lab orders, and that the facility would have to draw the blood and contact a new lab company to analyze it. R33 was admitted with epigastric pain and major depressive disorder and required assistance with most ADLs. After a reported episode of emesis with nausea and fatigue, the physician ordered CBC, BMP, and an abdominal X-ray. The record did not show results for the CBC or BMP. During interview, the Unit Manager and DON stated the lab company came daily but did not come to draw R33's blood, and the DON reported the facility would need to draw the blood and arrange for a new lab company to pick it up for analysis.
Failure to Timely Assess and Escalate Care for Resident in Respiratory Distress
Penalty
Summary
A deficiency occurred when facility staff failed to provide adequate monitoring, thorough assessment, timely notification to a medical provider, and accurate documentation for a resident experiencing a change in condition. The resident, who had a history of acute and chronic respiratory failure with hypoxia, asthma, anoxic brain damage, dysphagia, and was dependent on a mechanical ventilator, began to show signs of respiratory distress. The family noticed abnormal breathing and alerted the RN, who assessed the resident, took vital signs, and administered pain medication, but did not escalate the situation or notify a medical provider at that time. Despite the resident's elevated heart rate and labored breathing, the RN did not reassess the resident or contact the respiratory therapist or physician promptly. Approximately 30 minutes later, the resident's condition worsened, with lips turning blue and continued respiratory distress. The respiratory therapist was called, provided manual ventilation, and the RN eventually called 911. Documentation was inconsistent, with missing or unclear vital signs, incomplete progress notes, and medication administration records not reflecting the administration of ordered respiratory treatments. Interviews with staff revealed a lack of clear communication and timely intervention. The Director of Nursing stated that the expectation would have been to escalate the situation and contact the medical provider and respiratory therapist for a ventilator-dependent resident with an elevated pulse and respiratory distress. However, this did not occur, and there was no evidence of a facility investigation into the incident at the time of the survey. Facility policy required prompt notification of changes in condition, especially life-threatening situations, but this protocol was not followed in this case.
Lack of Physician Oversight for Wound Care
Penalty
Summary
The facility failed to ensure adequate physician oversight for wound care in two residents, resulting in incomplete and non-comprehensive care. For one resident with a history of traumatic brain injury and severe cognitive impairment, weekly skin assessments documented a worsening, facility-acquired unstageable pressure ulcer over several weeks. Despite multiple physician notes during this period, there was no mention of the pressure ulcer, no assessment of its avoidability, and no documented treatment plan. One physician note incorrectly stated that the resident had no current wounds, despite clear evidence to the contrary in the clinical record. For another resident with Alzheimer's disease and muscle weakness, a wound care assessment and consult order were present following readmission, but there was no documentation of physician oversight or notes regarding the resident's wounds. Interviews with facility staff, including the wound care coordinator and DON, revealed that the facility had been without a wound care provider for several months, and that weekly wound rounds were conducted by the wound care coordinator without physician involvement. No documentation of physician oversight or guidance for wound care was provided for this resident.
Failure to Provide Timely and Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate wound care and prevent the development and worsening of pressure ulcers for two residents. For one resident with a history of traumatic brain injury and severe cognitive impairment, weekly skin assessments were inconsistently performed, with a significant gap of nearly a month between assessments. The resident developed a facility-acquired, unstageable pressure ulcer on the left ankle, which progressively worsened over several weeks. Documentation showed multiple missed dressing changes in both June and July, and the physician's progress notes did not reference the pressure ulcer, its avoidability, or a treatment plan. Additionally, the care plan for the wound was not implemented until over seven weeks after the wound was first identified. For another resident with dysphagia and a gastrostomy, a skin tear was identified on the right gluteus area upon admission, but no physician orders for treatment were found in the record, and no treatments were documented as administered during the resident's stay. The DON confirmed that a physician's order and care plan should have been implemented for the wound upon admission, but this did not occur. These failures demonstrate lapses in wound identification, timely assessment, documentation, and implementation of appropriate treatment protocols.
Failure to Accurately Transcribe and Administer Enteral Feeding Orders
Penalty
Summary
A resident with diagnoses including dysphagia and gastrostomy status was admitted to the facility and had physician orders for enteral feeding of Glucerna 1.2 at 40ml/hr for 16 hours. However, the transcribed admission enteral orders incorrectly specified Glucerna at 45ml/hr for 16 hours or until a total volume of 720ml. On review, it was found that the resident received a total volume of 1191ml, significantly exceeding the ordered amount. The resident was found with a hard and distended abdomen, and a residual of 1000cc was pulled from the stomach. The nurse stopped the feeding and notified the on-call NP, who ordered the feeding to be held and a STAT abdominal x-ray. Interviews with the DON and nursing staff confirmed awareness of the error, with staff indicating that the enteral pump would continue running unless a stop time was set. Facility policy required that feeding tubes be used and maintained according to physician orders and current clinical standards, including ensuring administration of enteral nutrition is consistent with practitioner orders. The failure to accurately transcribe and administer the enteral feeding order resulted in the resident being overfed.
Failure to Provide and Document Tracheostomy Care per Physician Orders
Penalty
Summary
The facility failed to assess and provide tracheostomy care according to physician's orders for one resident who was in a vegetative state, non-verbal, and had a tracheostomy. Documentation review revealed multiple instances where required assessments of the stoma site and tracheostomy care were missing on both day and night shifts across several dates. The Director of Nursing stated that responsibility for tracheostomy care had been transferred from respiratory therapy staff to nursing staff, which may have contributed to the missed treatments due to possible confusion over which staff were responsible. Facility policy required that respiratory therapy or trained and competent personnel provide and document tracheostomy care twice within 24 hours, but this was not consistently done as required.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment, dependent on staff for most activities of daily living and under a public legal guardian, was subjected to non-consensual sexual contact by another resident. The resident's medical record indicated a BIMS score of six, signifying severely impaired cognition and inability to communicate effectively. Multiple incidents were documented in which the alleged perpetrator, who had moderately impaired cognition, was observed engaging in inappropriate physical contact with the victim, including fondling the resident's breast and placing a hand between the resident's legs. On separate occasions, staff observed the perpetrator with their hand under the victim's shirt and between the victim's legs. Witness statements and progress notes described the victim as visibly shaken and trembling during and after the incidents. Despite previous observations and interventions, such as moving the perpetrator to a different area and educating them about resident privacy, the inappropriate contact recurred. Staff and administration were notified after each incident, and documentation shows that the events were reported to the DON, Administrator, physician, and the victim's guardian. The facility's failure to prevent repeated sexual abuse incidents between these two residents, despite prior knowledge of inappropriate behavior and the victim's vulnerability, resulted in the resident being subjected to non-consensual sexual contact. The facility's policies prohibit such abuse, but the documented events demonstrate that the resident was not adequately protected from sexual abuse by another resident.
Failure to Timely Report Allegation of Resident Poisoning
Penalty
Summary
The facility failed to ensure that an allegation of poisoning made by a resident was reported to the Abuse Coordinator and State Agency in a timely manner. The incident involved a resident with diagnoses including chronic obstructive pulmonary disease, schizoaffective disorder, and anxiety, who had an intact mental status as indicated by a BIMS score of 15. The resident alleged that their roommate had poisoned them, reported feeling dizzy, and subsequently called the police, resulting in a hospital transfer. Documentation shows that the resident expressed concerns about being poisoned and believed their roommate or others may have been involved. Despite the seriousness of the allegation, the initial report to the State Agency was not made until several days after the incident. The delay occurred because the nurse on duty did not notify the Administrator (abuse coordinator) immediately after the allegation was made. The facility's policy requires that all alleged violations be reported to the Administrator and State Agency within specified timeframes, but this protocol was not followed in this case.
Failure to Obtain and Implement Physician Orders at Admission
Penalty
Summary
A resident was admitted to the facility from the hospital without any discharge paperwork, including physician orders, medication lists, or care directives. Despite the resident arriving with EMS and reportedly having their paperwork handed to facility staff, the facility was unable to locate or obtain the necessary documentation at the time of admission. As a result, no medications or treatments were administered, and no care plan or directives were initiated for the resident during their stay. The facility's electronic medical record showed no physician orders, no medication or treatment administration records, and no completed pain or nursing assessments for the resident. Nursing staff, including an LPN and RN, documented attempts to obtain the missing paperwork and medication list from the hospital, and notified the DON and the resident's physician, but did not receive a response or any temporary orders. The resident, who had multiple diagnoses including spinal cord abnormalities, chronic pain, heart disease, and a history of myocardial infarction, did not receive any of their prescribed medications, such as blood pressure and pain medications, during their approximately 16-hour stay. The resident was alert and oriented, refused assessments without physician orders, and ultimately decided to leave the facility against medical advice, arranging their own transportation back to the hospital. Interviews with facility leadership and staff confirmed that the facility's policy required physician orders and care directives prior to or at the time of admission, and that the resident should not have been admitted without this documentation. The facility did not provide any skilled care or medications to the resident during their stay, and the necessary hospital discharge summary was not received until after the resident had already left. The deficiency was attributed to the failure to ensure an appropriate admission process, including obtaining and implementing physician orders and care directives for the resident's immediate care.
Failure to Provide TPN Results in Hospitalization
Penalty
Summary
A facility failed to provide necessary care and services for a resident who required Total Parenteral Nutrition (TPN) following transfer from a hospital. The resident, with a history of pancreaticobiliary cancer and recent paraoesophageal hernia surgery, was dependent on TPN for nutritional support. Upon arrival, the TPN was not available at the facility, and the staff initiated intravenous dextrose as a temporary measure per provider orders. The TPN was delivered the following day, but staff were unable to administer it due to incompatible tubing and equipment supplied by the pharmacy. Multiple staff members, including the admission nurse, LPN, and RN, identified the issue with the TPN supplies and communicated with the provider and nursing management. Despite repeated notifications to the nurse practitioner and continued attempts to resolve the equipment incompatibility, the resident did not receive the ordered TPN. The resident expressed increasing weakness and frustration, ultimately requesting to return to the hospital. Laboratory records confirmed a significant decline in the resident's potassium and magnesium levels, and the resident required hospitalization for dehydration and electrolyte replacement. Interviews with staff indicated a lack of clarity regarding responsibility for ordering TPN prior to admission and agreement among nursing leadership that the resident should have been sent back to the hospital sooner when the facility was unable to provide the required care.
Plan Of Correction
F684 Quality Of Care Severity Level D Compliance Date 4/30/2025 Element 1: What Corrective action(s) will be taken: Resident 502 no longer resides in the facility. Element 2: How Facility will identify other residents having a potential to be affected by the practice and what corrective action will be taken: All residents have a potential to be affected by the practice. Current residents residing in the facility were accessed by the licensed nurses to ensure that residents with changes in condition needs were being met on 04/17/2025. All residents identified as at risk for change in condition have been assessed by a licensed nurse. Element 3: What Measures will be put in place or what systematic changes will you make to ensure that the deficient practice does not recur: The quality assurance team reviewed the policy for Notification of Changes and deemed it appropriate on 04/17/2025. On this date, 4/30/2025 or before their next scheduled shift, we will educate nurses on the Notification of Change Policy with a focus on the following: If a resident is admitted to the facility and is to receive TPN, the nurse is to ensure the order had been received, reviewed, and signed by the physician and faxed to pharmacy to be received in time for the resident admission. When a delay in order implementation is identified, the resident will be assessed for changes in conditions and provider notified. If the TPN is not available for administration, the resident will be returned to the hospital. System Change: The clinical IDT will complete rounds Monday through Friday to identify any change of conditions. Element 4: How the corrective action(s) will be monitored to ensure the deficient practices will not recur, i.e., what quality assurance program, will you put in place: The DON/designee will audit 5 residents with change in condition weekly to ensure that staff met the residents' needs x's 4 weeks then monthly thereafter until substantial compliance is met and audits are discontinued by the QA committee. The audit period will be for 3 months, or until QAPI deems substantial compliance. The Administrator is responsible for ongoing compliance.
Failure to Provide Compatible TPN Equipment Resulting in Hospitalization
Penalty
Summary
The facility failed to ensure that proper pumps and intravenous tubing were provided by the pharmacy to administer Total Parenteral Nutrition (TPN) as ordered by the physician for one resident. The resident, who had a history of pancreaticobiliary cancer and recent surgery for a paraoesophageal hernia and gastric outlet obstruction, was admitted with an order for TPN. Upon admission, the TPN order was faxed to the contracted pharmacy, which confirmed receipt and stated the TPN would arrive in the overnight shipment due to the late hour. When the TPN and equipment arrived, nursing staff discovered that the tubing provided was incompatible with the pumps sent by the pharmacy. Multiple nurses, including an RN and LPNs, attempted to administer the TPN but were unable to do so because the 'blue key' on the tubing did not fit into the pump chamber. The pharmacy was contacted several times over the weekend regarding the incompatible equipment, but the issue was not resolved, and the correct equipment was not provided in a timely manner. The pharmacy indicated that their equipment department was unavailable on weekends, further delaying resolution. As a result of the failure to provide the necessary equipment for TPN administration, the resident did not receive the ordered nutrition. The resident subsequently experienced a significant drop in potassium and magnesium levels, leading to weakness, fatigue, dehydration, and ultimately required hospitalization for IV hydration and electrolyte replacement.
Plan Of Correction
F755 Pharmacy Services Severity Level D Compliance Date 04/30/2025 Element 1: What corrective action(s) will be taken Resident 502 is no longer resides in the facility. Element 2: How the facility will identify other residents having a potential to be affected by practice and what corrective action will be taken All residents with orders for TPN have a potential to be affected by the practice. Current residents residing in the facility were assessed by a licensed nurse to ensure that the current residents and all new admissions with TPN orders have pumps, tubing, and TPN solution to meet their needs on 04/17/2025. Element 3: What system or systematic changes you will make to ensure that the deficient practice does not recur The Quality Assurance committee reviewed the policy for Parenteral Nutrition and deemed it appropriate on 04/17/2025. On this date, or before their scheduled shift, we will educate Admission Directors and Nurse Managers on the Parenteral Nutrition Policy. The policy states that if a resident is admitted to the facility and is to receive TPN, the nurse is to ensure the order has been received, reviewed, and signed by the physician and faxed to the pharmacy to be received in time for the resident admission. Pharmacy will ensure needed supplies are sent with the TPN prior to resident admission. PharmScript Pharmacy is taking the TPN ordering and supply process through their QAPI and providing education to the staff to prevent future recurrence. Element 4: How the corrective action(s) will be monitored to ensure the deficient practices will not recur, i.e., what quality assurance program will be put in place The DON/designee will audit 5 residents with TPN orders weekly to ensure proper pumps and tubing are provided by the pharmacy and TPN is available upon admission for the first 4 weeks, then monthly thereafter until substantial compliance is met and audits are discontinued by the QAPI committee. The audit period will be 3 months or until QAPI deems substantial compliance. The Administrator is responsible for ongoing compliance.
Failure to Timely Intervene and Assess Leads to Resident Death and Worsening Wounds
Penalty
Summary
The facility failed to timely assess and intervene for a resident with a new tracheostomy who was in distress, resulting in the resident's death. The resident, who had a history of hemiplegia, respiratory failure, and dysphagia, was on tube feeding and required assistance with meals. On the day of the incident, the resident used non-verbal gestures to alert staff of their distress, but the assigned CNA did not effectively communicate the urgency to the nurse. The resident was later found unresponsive and pronounced dead after aspirating on fruit punch. In another case, the facility failed to prevent and accurately assess new skin breakdown for two residents. One resident developed an open lesion with exposed tendon behind the knee, which was not properly offloaded or treated to prevent moisture accumulation. The resident had a history of contractures and was dependent on staff for mobility and care. The wound was identified as in-house acquired and had not healed over time. The second resident had vascular wounds on the toes that were not treated according to physician's orders. The dressing on the resident's foot was not changed as required, and the LPN admitted to falsifying the treatment record due to being overwhelmed with tasks. The resident's toes showed signs of infection, and the failure to administer timely wound care could have contributed to the worsening of the condition.
Removal Plan
- Current residents residing in the facility were assessed by licensed nurses to ensure that residents with changes in condition needs were met and that physicians, RP/guardians were notified.
- Educated nurses, CNAs, and RT on head to toe observation for changes in condition for CNAs posted at nurses' station and handout given.
- Head to toe observation, clinical pathways for changes in condition and respiratory for Nurses posted at medication carts and handout given.
- Hierarchy Notification Steps handout given to nurses, CNAs, and RT.
- Notification of Hierarchy: Notify floor nurse assigned to resident of changes in condition. If nurse does not respond notify the RT. If the RT doesn't respond notify the on call manager. If the on call manager doesn't respond notify the DON.
- Verbal and non-verbal signs of distress education provided.
Inadequate Linen Supply in Facility
Penalty
Summary
The facility failed to ensure an adequate supply of linens, affecting three residents and potentially all residents on the second floor. Complaints submitted to the State Survey Agency revealed allegations of shortages in washcloths, towels, and blankets, with some linens being stained with feces. Observations and interviews confirmed these shortages, with family members and staff reporting frequent lack of clean linens and the necessity to purchase personal supplies. The facility had switched from using wipes to washcloths, exacerbating the shortage issue. During the survey, it was observed that the linen closets and laundry room were inadequately stocked, with the second-floor linen closet having only a few face towels, three big towels, and a couple of fitted sheets. The laundry room had no linen on the carts, and a washer machine was down due to a leak. The Director of Nursing and the Administrator acknowledged the insufficiency of supplies, and the Housekeeping Manager confirmed that the available linen was all that staff had access to at the time.
Medication Order Entry Error Leads to Missed Antibiotic Doses
Penalty
Summary
The facility failed to ensure that a resident's medication orders were entered correctly upon admission, leading to a significant medication error. The resident, identified as R302, was admitted with a primary diagnosis of bed sores and required IV antibiotics for osteomyelitis. The hospital discharge summary prescribed Zosyn (Piperacillin Sod-Tazobactam) to be administered every eight hours for 28 days. However, upon admission to the facility, the order was incorrectly entered for only 7 days, resulting in a lapse in the administration of the antibiotic. The medication administration record (MAR) showed that the resident received the antibiotic from 12/13/24 to 12/20/24, but there were missed doses on 12/18/24 and 12/19/24. No further attempts to administer the medication were documented from 12/21/24 to 12/30/24. On 12/31/24, attempts to restart the medication were noted, but issues with the PICC line prevented administration. The resident was sent back to the hospital for PICC line insertion on 1/1/25, where it was determined that an additional three weeks of IV antibiotics were required. Interviews with facility staff revealed that Nurse N and Nurse E were involved in the initial assessment and order entry for R302. Nurse E admitted to being reprimanded and educated by the Director of Nursing (DON) for the error. The DON acknowledged the situation and confirmed that Nurse E was reeducated, but no specific details were provided regarding the PICC line issue. The facility's medication administration policy requires medications to be administered as ordered by the physician, but this was not adhered to in R302's case.
Failure to Honor Resident's Rights Regarding Personal Refrigerator
Penalty
Summary
The facility failed to honor a resident's right to dignity and respect by not adhering to its own policy regarding personal refrigerators. A resident, who had been a chef for many years, expressed dissatisfaction when the new administrator instructed the removal of their personal refrigerator, which had been approved by the previous administrator and used for over a year. The resident felt the action was unnecessary and malicious, as they had maintained the refrigerator in a clean and orderly manner, with food containers properly dated. The administrator, when questioned, admitted to not reviewing the facility's policy, which allowed for resident-owned refrigerators with prior approval. The administrator's decision was based on practices from a previous facility and concerns about the refrigerator's size and the resident's ability to maintain it, despite the policy stating that staff were responsible for cleaning. The Regional Director of Operations indicated a review of the policy would be conducted, but no further explanation or documentation was provided by the end of the survey.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency within the required time frame for a resident who alleged rough handling by a Certified Nursing Assistant (CNA) during peri-care. The incident was first reported to the facility's Administrator on December 11, 2024, but was not reported to the State Survey Agency until December 13, 2024, exceeding the mandated two-hour reporting window. The resident, who had intact cognition and was dependent on staff for bed mobility and toilet hygiene, reported the incident to a Licensed Practical Nurse (LPN) and was subsequently interviewed by the Administrator and Director of Nursing. The resident described the incident as rough handling by the CNA, which was not sexual in nature but was perceived as mean. The CNA involved acknowledged the resident's complaint of rough handling and reported it to the nurse. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of such allegations to the Administrator and the State Agency within two hours, which was not adhered to in this case. The Administrator at the time of the survey, who was not employed during the incident, confirmed the protocol for reporting allegations of abuse.
Failure to Investigate and Report Allegations of Abuse
Penalty
Summary
The facility failed to conduct thorough investigations into multiple allegations of staff-to-resident abuse and did not report the results to the State Survey Agency (SSA) as required. In the case of a resident with Alzheimer's Disease, an allegation was made that a CNA was rough during care. Despite the CNA being suspended, the investigation was incomplete, lacking interviews with other residents or a summary of findings. The facility did not submit the investigation results to the SSA by the deadline, and the Director of Nursing (DON) could not provide an explanation for the incomplete investigation. Another incident involved a resident with rheumatoid arthritis who alleged that the same CNA was rough during peri-care. The resident reported the incident to an LPN, and the former Administrator spoke with the resident, but the investigation was not completed or submitted to the SSA. The facility's policy required a thorough investigation, including interviews and documentation, but this was not followed. The facility did not ensure that other residents were not affected by the alleged abuse. A third incident involved a resident who was allegedly sent to the hospital after a confrontation with a roommate. The facility called the police, and the resident was transferred for psychiatric evaluation. However, there was no documentation of the alleged violent behavior or suicidal ideations in the resident's records. The Unit Manager did not observe the incident and did not conduct interviews to determine what occurred. The facility failed to investigate the incident properly and did not provide any incident reports detailing the events leading to the resident's transfer.
Failure to Implement and Update Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement appropriate care plans for two residents, R303 and R305, leading to deficiencies in their care. For R303, the facility did not ensure that the care plan for activities of daily living was followed. R303, who was dependent on staff assistance for bed mobility and toilet hygiene due to rheumatoid arthritis, reported an incident where a CNA was rough during peri-care. The CNA admitted to performing the care alone, contrary to the care plan that required a two-person assist. This failure to adhere to the care plan was confirmed by the Director of Nursing. For R305, the facility did not update the care plan to address suicidal ideations and behaviors. R305, who had a history of fractures and was cognitively intact, expressed suicidal thoughts to nursing staff and was involved in an altercation with a roommate, leading to a psychiatric evaluation and hospital transfer. Despite these incidents, there was no documentation in R305's care plan regarding interventions for suicidal ideations. Interviews with facility staff revealed a lack of awareness and communication regarding the necessary updates to R305's care plan. These deficiencies highlight the facility's failure to ensure that care plans were appropriately developed and implemented to meet the residents' needs. The lack of adherence to R303's care plan and the absence of updates to R305's care plan following significant incidents demonstrate a gap in the facility's care planning process, impacting the quality of care provided to the residents.
Deficiencies in Wound Care and Medication Management
Penalty
Summary
The facility failed to adhere to nursing professional standards of practice concerning wound treatment for a resident identified as R301. During an observation, it was noted that the dressing on R301's right foot was soiled and had been incorrectly dated. The dressing was marked with a date of 2/3/25, written over a previous date of 1/31/25, indicating that the wound care had not been performed as required. Licensed Practical Nurse (LPN) 'Q' admitted to marking the dressing without performing the actual wound care due to being overwhelmed with too many residents to care for. This discrepancy was further confirmed by the Treatment Administration Record (TAR), which showed inconsistencies in the documentation of wound care treatments. The facility also failed to properly administer intravenous (IV) antibiotics to a resident identified as R302. The resident was admitted with a prescription for a 28-day course of IV antibiotics for osteomyelitis, but the facility only administered the medication for 7 days. The Medication Administration Record (MAR) showed gaps in the administration of the antibiotics, and there was confusion regarding the correct duration of the treatment. Nurse 'E', who was responsible for entering the medication orders, acknowledged the error and had been reprimanded by the Director of Nursing (DON) for not double-checking the orders. Both deficiencies highlight a lack of adherence to professional standards and proper medication management within the facility. R301's wound care was not performed as ordered, and R302 did not receive the full course of prescribed antibiotics, potentially impacting their health outcomes. The facility's failure to follow through with physician orders and ensure accurate documentation contributed to these deficiencies.
Failure to Prevent and Identify Pressure Ulcer
Penalty
Summary
The facility failed to prevent and timely identify a pressure ulcer in a resident, resulting in a facility-acquired stage III pressure ulcer on the resident's right ear. The resident, who was severely cognitively impaired and required extensive assistance for most activities of daily living, was observed lying on their right side for extended periods without being repositioned. Despite the presence of a tracheostomy and the resident's inability to communicate, the facility did not adequately monitor or document the condition of the resident's skin, particularly the right ear, in their weekly head-to-toe skin assessments. The facility's records showed inconsistencies in the resident's turn and reposition schedule, and the skin assessments failed to document any issues with the resident's ear until the family brought it to the staff's attention. The Wound Nurse and Director of Nursing acknowledged the oversight, noting that the staff should have reported the condition and that the resident should have been turned every two hours. The facility's policy on pressure injury prevention and management was not followed, as the staff did not evaluate the resident's condition, implement necessary interventions, or monitor and revise interventions as needed.
Failure to Report Abnormal Lab Results
Penalty
Summary
The facility failed to timely review and report abnormal lab results to the Physician and/or Nurse Practitioner for a resident who was reviewed for death. The resident, who had been admitted with diagnoses including dementia and anemia, had a history of recent hospitalization for anemia and had received treatment at the hospital. On a specific date, a Nurse Practitioner ordered a STAT Complete Blood Count for the resident, with instructions to transfer the resident to the Emergency Department if the hemoglobin level was below 7. However, the lab report showed a hemoglobin level of 6.415, which was below the threshold, but there was no documentation of staff notifying the Physician or NP, nor was the resident sent to the hospital as directed. Interviews revealed that the Licensed Practical Nurse on duty did not notify the Physician or NP of the low hemoglobin results because they, along with another nurse, could not find the results in the system due to the resident having a hyphenated last name. The Director of Nursing confirmed that lab results are uploaded to the resident's chart once completed, but there was no follow-up on why the resident was not sent out per the clinician's directive. The Nurse Practitioner confirmed they were not informed of the abnormal hemoglobin level. The facility's policy requires critical lab results to be communicated to the physician upon receipt, but this was not adhered to in this case.
Deficient Ventilator Care and Physician Oversight
Penalty
Summary
The facility failed to ensure that residents requiring ventilator care received ongoing medical supervision and oversight by a physician. This deficiency was identified for nine out of fifteen residents reviewed for ventilator care, indicating a systemic failure in the interdisciplinary approach and physician oversight. The lack of adequate implementation of policies and procedures to monitor and supervise the weaning process for mechanical ventilation, as well as responding to mechanical ventilation alarms and respiratory needs, increased the likelihood of serious harm, injury, or death. One resident, who was admitted with multiple serious health conditions including acute and chronic respiratory failure and was ventilator-dependent, experienced a significant change in condition during an attempted weaning process. The resident was not tolerating the weaning, as indicated by persistent low minute volume alarms, low respiratory rate, and grayish skin. Despite these signs, there was no documented physician assessment or evaluation to determine the resident's eligibility for weaning, no weaning parameter orders, and no notification to the physician about the change in condition. The resident was later found unresponsive and pronounced dead. Interviews with facility staff revealed a lack of clear protocols and communication regarding the weaning process and physician involvement. The respiratory therapist and nurse involved in the resident's care were unsure of who decided the resident was eligible for weaning and did not notify the physician of the resident's deteriorating condition. The facility's pulmonologist was not frequently present, and there was no documentation of their assessments or evaluations in the residents' medical records. This lack of oversight and documentation contributed to the deficient practice in the facility's ventilator care management.
Removal Plan
- The NHA notified the Medical Director of the incident.
- The Pulmonologist will complete physical assessments on all like residents to identify any changes in condition and confirm current ventilator settings.
- The Pulmonologist has received education outlining responsibility for oversight for respiratory care for all Ventilator residents including but not limited to completing physical assessments, monitoring ongoing care, documenting consultations/evaluations, providing orders for weaning for ventilator residents.
- The pulmonologist has agreed to round for the residents on the ventilator unit at least 2 times per week. She is available to take call 24 hours in coordination with Primary Care Provider.
- Ventilator orders sets are entered on admission.
- Oxygen: RUN @ L/MIN VIA N/C MASK TRACH HOURS PER DAY PRN CONTINUOUS.
- Assess stoma site and under trach collar.
- Trach Change. Trach brand: Trach size:
- Change trach collar/strap every 3 days and prn.
- Visual check of ventilator dependent residents per care plan and prn.
- Weaning prn, per physician order, or respiratory protocol.
- Enter time in minutes to complete airway equipment management task.
- Evaluation/Assessment of resident on (Vent/Tracheostomy).
- Oxygen saturation q shift and prn.
- Oxygen tubing/filter change every week. Enter time in minutes to complete task.
- Suction tracheostomy as needed.
- Resident/Resident Representative Education.
- Trach Care PRN (as needed).
- Trach tie change with baths and as needed.
- Settings: Mode: RR: PEEP: PS:
- Change circuits monthly and PRN. Enter time in minutes to complete circuit change task.
- Trach care every shift and as needed.
Failure in Coordination of Respiratory Care for Ventilator Residents
Penalty
Summary
The facility failed to ensure that the designated Medical Director was aware of their responsibilities, particularly in coordinating respiratory care for residents requiring mechanical ventilation. During the survey, it was discovered that the Medical Director, referred to as MD L, was not involved in the respiratory care of ventilator residents, believing that a Pulmonologist was responsible for this aspect of care. MD L acknowledged being aware of issues with the current Pulmonologist but did not take steps to ensure collaboration in respiratory care. MD L expressed that their understanding of the role was limited to caring for a specific set of residents and not the entire facility, leading to a lack of coordination in care for ventilator-dependent residents. Interviews with other staff members, including Nurse Practitioners U and T, revealed further confusion and lack of oversight regarding the care of ventilator-dependent residents. NP U did not oversee ventilator or tracheostomy orders and was unaware of which physician was responsible for respiratory orders. Similarly, NP T only coordinated care with the attending physician, who was also the Medical Director, and did not handle ventilator settings or coordinate care with the Pulmonologist. The facility was unable to provide documentation or a contract outlining MD L's job duties and responsibilities, highlighting a systemic failure in the coordination of care for residents requiring mechanical ventilation.
Inadequate Infection Control Practices and Surveillance
Penalty
Summary
The facility failed to ensure consistent standards of practice for infection control were implemented by all staff, affecting all 66 residents. Observations included a Social Service personnel entering and exiting a resident's room with Enhanced Barrier Precautions signage without performing hand hygiene. The personnel stated they did not perform hand hygiene because they were not providing care. Additionally, a Respiratory Therapist was observed improperly donning a gown, which continuously slipped from the neck and shoulder area while providing tracheostomy care. A housekeeper also failed to perform hand hygiene when entering and exiting a resident's room with Enhanced Barrier Precautions signage. The facility's Infection Surveillance Program was found lacking, with no monthly analysis or line listing completed for several months in 2024, and no documentation maintained for January. The Infection Control Nurse, who resumed the role in February 2024, acknowledged the missing documentation and improper infection control practices observed by the survey team. The facility's policy states that the Infection Preventionist is responsible for oversight of the program, including surveillance and documentation, but these responsibilities were not adequately fulfilled.
Improper Signing of Advanced Directives
Penalty
Summary
The facility failed to ensure that the correct individual signed the advanced directives/DNR form for a resident. The resident, who was admitted with diagnoses including adult failure to thrive and dementia, had a BIMS score indicating intact cognition, suggesting they were capable of making their own medical decisions. However, the advanced directives form was signed by the resident's son, despite no documentation indicating the resident was mentally incapacitated and unable to make their own medical decisions. Upon review, it was found that the form was completed by a previous social service worker, and the current social service worker confirmed that the resident had not been deemed mentally incapacitated. The facility's policy requires that residents be informed of their rights to make medical decisions and that any existing advance directives be documented in the medical record. This policy was not followed in this instance, leading to the deficiency.
Failure to Timely Address Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to timely assess and follow up on a change in condition for a resident, leading to a deficiency in care. Resident R275, who had a history of sepsis, pneumonia, respiratory failure, and dementia, was readmitted to the facility after hospitalization. Despite being a full code, indicating a wish for all life-sustaining measures, the resident experienced a decline in condition, including labored breathing and signs of sepsis. The nursing staff increased the resident's oxygen from 2 L/min to 6 L/min without a physician's order and attempted to contact the attending physician and nurse practitioner, but received no timely response. The resident's condition continued to deteriorate, with vital signs indicating respiratory distress. Despite the nursing staff's efforts to communicate the resident's condition and the need for hospital transfer, there was no follow-up from the attending physician or nurse practitioner. The resident was found unresponsive and expired at the facility after unsuccessful resuscitation efforts. The nurse practitioner later reported not receiving the voicemail about the resident's condition until after the resident had passed. The Director of Nursing acknowledged the situation, noting that it occurred over a weekend and that the staff should have contacted the medical director when unable to reach the attending physician. The failure to transcribe the physician's order to increase oxygen and the lack of timely follow-up contributed to the resident's decline and eventual death. The deficiency highlights a breakdown in communication and timely response to a critical change in a resident's condition.
Failure to Implement Range of Motion Interventions for Residents with Contractures
Penalty
Summary
The facility failed to implement range of motion and splinting interventions for two residents with contractures, leading to potential pain and worsening of their conditions. Resident R4, a long-term resident with severe cognitive impairment and bilateral knee contractures, was observed multiple times lying in bed with bent knees and no restorative or maintenance interventions in place. Despite having a care plan indicating impaired musculoskeletal status, there were no documented interventions or a range of motion program for R4's lower extremities. Interviews with the Director of Rehab and Unit Manager revealed a lack of awareness and implementation of a restorative program for R4, despite acknowledgment that such services would be beneficial. Resident R43, who was quadriplegic and had bilateral hand contractures, was observed without any devices or padding in their contracted hands. The medical record showed no implemented plan of care for the hand contractures, despite a Physical Medicine Rehabilitation note recommending the use of rag rolls for hand hygiene. The Therapy Director acknowledged that the PMR clinician's recommendations were not communicated to the therapy team, resulting in no interventions being implemented for R43's hand contractures. The facility's policy on range of motion, which includes systematic assessment and care planning to prevent decline, was not followed for these residents. The lack of coordination and communication between the therapy department and nursing staff contributed to the failure to provide necessary interventions for maintaining or improving the residents' range of motion, as outlined in the facility's policy.
Staffing Deficiency Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of its residents, as evidenced by the experience of a resident who had been admitted for skilled nursing and rehabilitation following a recent hospitalization. The resident, who had diagnoses including heart failure, atrial fibrillation, and Chronic Obstructive Pulmonary Disease, was observed with their call light on and reported waiting for assistance for an extended period. The resident expressed frustration over the slow response times, particularly at night, indicating that the call light system was ineffective in getting timely help. Interviews with staff, including a CNA and an LPN, revealed that the facility had recently hired new staff but still faced challenges in meeting residents' needs due to the high demand for assistance, especially in areas where many residents required two-person help. The staffing coordinator and the Director of Nursing acknowledged past staffing challenges, particularly on weekends, and noted improvements in recent months. However, reports from an anonymous group meeting and resident council minutes indicated ongoing issues with weekend staffing and call light response times, as well as inconsistencies in services like showering and water distribution.
Failure to Attempt Non-Pharmacological Interventions Before PRN Psychotropic Medication
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted prior to administering PRN psychotropic medication for a resident. The resident, who was admitted with diagnoses including liver disease and spinal stenosis, had a BIMS score indicating moderately impaired cognition. A physician's order for PRN alprazolam was in place without an end date, and the medication was administered multiple times in September and October. However, there was no documentation of non-pharmacological interventions being attempted before the administration of the medication. During an interview, the Nurse Manager confirmed that it was standard practice to attempt non-pharmacological interventions before administering PRN psychotropic medications. The facility's policy on PRN medications was reviewed, which outlined the need for documentation of the clinical rationale for medication use and the requirement for PRN orders to be limited to 14 days unless extended by the prescriber. However, the policy did not specify the need for non-pharmacological interventions before administering PRN psychotropic medications.
Improper Sanitation and Disposal of Medication Tablets
Penalty
Summary
The facility failed to ensure proper sanitation and disposal of medication tablets in one of the two medication carts reviewed. During an observation on 10/22/24, three unidentified pills were found in the first drawer of the medication cart in the 2 [NAME] hallway. The second drawer contained seven white and one peach tablet, while the third drawer had one green and one blue round tablet. Licensed Practical Nurse (LPN) N was unable to identify the medications or their intended recipients. The Director of Nursing (DON) confirmed that the medication drawers should be kept clean and that the pills should have been discarded according to facility policy. No further explanation or documentation was provided by the end of the survey.
Failure to Complete Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure that a physician-ordered laboratory diagnostic was completed for a resident, identified as R50, who was admitted with diagnoses including adult failure to thrive and dementia. The resident's medical record indicated a physician's order for a complete blood count (CBC), basic metabolic panel (BMP), and troponin on 9/22/24. However, upon review, there were no results for these labs in the medical record, indicating that the tests were not conducted as ordered. On 10/22/24, the Nurse Manager (NM E) confirmed that the lab tests were not completed due to a miscommunication, as the lab was never informed of the order. The facility's Laboratory and Diagnostic Guidelines outline procedures for tracking and completing lab tests, but these were not followed in this instance, leading to the oversight. The guidelines emphasize the importance of tracking lab orders through various systems and ensuring timely completion and notification of results, which was not adhered to in this case.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, as evidenced by the inappropriate use of antibiotics for three residents. The review of the infection surveillance logs for March, June, and July 2024 revealed that residents were documented to have urinary tract infections (UTIs) that did not meet McGeer's criteria, which is the standard used to determine the appropriate use of antibiotics. Specifically, Resident 223 was documented to have a UTI in March without any signs or symptoms noted, and no documentation of the antibiotic prescribed was available. Resident 3 in June and Resident 46 in July were both documented to have UTIs that did not meet McGeer's criteria, yet were prescribed antibiotics Cefdinir and Doxycycline, respectively. The medical records for these residents showed no documentation that the appropriateness of the antibiotics was reviewed. During an interview, the Infection Control Nurse, who also served as the facility's Infection Preventionist, was unable to provide further documentation regarding the oversight of the facility's Antibiotic Stewardship Program and the review of antibiotic appropriateness for the residents in question. This lack of documentation and oversight indicates a failure in the facility's antibiotic stewardship efforts, potentially affecting multiple residents prescribed antibiotics.
Failure to Maintain Backup for Call System During Power Outage
Penalty
Summary
The facility failed to maintain an effective backup for the resident call system during a partial power outage that lasted approximately 12 hours, affecting all residents on the one west hall. This deficiency was observed through interviews and record reviews of residents R26, R33, and R44, who reported that their call light systems were not functioning during the outage. The outage occurred after a generator issue, and the residents were left without a means to alert staff for assistance, as no backup system or alternative alert method was provided. Resident R26, who has a history of heart failure with a pacemaker, atrial fibrillation, chronic pain, and chronic kidney disease, expressed concern over the non-functioning call light system and emergency outlets. R26 had to resort to yelling to alert staff and reported the issue to the facility's receptionist and attempted to contact the administrator, who was unavailable. Similarly, resident R33, with diagnoses of COPD and panic disorder, confirmed the call light system was non-functional throughout the night and that no backup system was provided. Resident R44, who has COPD, heart failure, obstructive sleep apnea, and diabetes, also experienced the outage and reported that their oxygen concentrator and CPAP machine were not working, necessitating the use of a portable oxygen tank. R44 used a cell phone to call the facility for assistance with oxygen tank replacement. Interviews with facility staff, including the Assistant Administrator and Director of Nursing, revealed a lack of awareness of the call light system failure and no immediate alternative solutions were provided to the residents during the outage.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate feeding assistance and supervision, as well as regular bathing, for three residents. Resident R174, who was admitted with diagnoses including heart failure and severe calorie-protein malnutrition, reported not receiving any showers since admission, which was confirmed by a lack of documentation for scheduled bathing. The Director of Nursing acknowledged the issue but no further documentation was provided to confirm that bathing was offered as scheduled. Resident R17, who has moderate cognitive impairment and requires assistance with meals, was observed eating breakfast without any staff present to assist. Despite having an order for meal assistance, R17 was left with unopened milk and juice cartons, which they needed help to open. The care plan indicated the need for meal setup assistance, but this was not provided during the observation. Resident R20, also with moderate cognitive impairment and dependent on staff for mobility and positioning, was observed eating in a reclined Geri-chair without staff supervision. The resident's care plan required upright positioning during meals and supervision for safe eating practices, but these were not adhered to. The Director of Nursing and Unit Manager acknowledged the lack of staff presence in the dining room, which was contrary to the facility's policy for meal service and assistance.
Inaccurate Medical Record Documentation for Resident
Penalty
Summary
The facility failed to provide accurate medical record documentation for a resident, identified as R49, who was observed in bed with tube feeding running but without the required splints or adaptive devices. The resident's legal guardian expressed concerns about the lack of restorative services, noting that R49's hands were becoming more contracted due to insufficient staff to apply the splints. Additionally, the guardian mentioned that R49 did not get out of bed regularly due to a pressure injury on the coccyx, which could hinder wound healing. Interviews with the Therapy Manager and Restorative Nurse revealed discrepancies in the care provided to R49. The Therapy Manager confirmed that R49 should have splints and was not on their caseload, while the Restorative Nurse stated that R49 was on their caseload and required splints and elbow protectors. Despite this, the splint task was documented as completed and tolerated well, even though R49 was observed without the splints. The Director of Nursing was unaware that the certified nursing assistant would document the task as completed if it had not occurred.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Farmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Corewell Health Rehab & Nursing Center-commons Far | 2.2 mi | ★★★★★ | 15 | 0 |
| The Manor Of Farmington Hills | 3 mi | ★★★★★ | 14 | 0 |
| Medilodge Of Livonia | 3.2 mi | ★★★★★ | 10 | 0 |
| The Manor Of Novi | 3.6 mi | ★★★★★ | 22 | 0 |
| Novi Lakes Health Campus | 4.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.