Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Montrose Inc during CMS and state inspections, most recent first.
Failure to provide ordered ROM and splint care. A resident with severe cognitive impairment, aphasia, and dependence for ADLs, mobility, and transfers was observed without the ordered hand splint in place, and the splint was found stored on a drawer. The resident’s ROM and splint orders were not consistently carried out, restorative records showed the plan was not occurring as ordered, and family reported staff were not repositioning the resident or completing ROM, with staff citing short staffing and being pulled to the floor.
A resident with severe cognitive impairment, incontinence, and a history of coccygeal skin issues developed a red area on the coccyx that was identified by CNAs and treated with zinc oxide per nursing orders over several weeks, yet nurses and the wound care nurse failed to complete and document detailed skin assessments or progress notes describing the area’s condition. Weekly skin assessments repeatedly recorded no abnormal skin areas despite ongoing treatment and CNA charting of red and discolored skin, and staff interviews revealed reports of a very red, peeling, and leaking bottom as well as inconsistent incontinence care at night. On the rushed day of discharge, no body skin assessment was performed, the discharge summary inaccurately stated there were no skin issues, and the receiving facility and family immediately observed extensive redness, open and weeping areas from the lower back to the legs, leading to hospital transfer where the resident was diagnosed with a large area of cellulitis and treated with IV antibiotics, with hospital documentation noting a high suspicion of elderly neglect.
A resident with multiple chronic conditions, who was cognitively able to make his own decisions, reported that he had loaned a CNA $500 in cash under a verbal repayment agreement that was not being honored, and later described difficulty getting the money repaid. Another CNA overheard the resident and the CNA arguing about the unpaid balance, and the Social Work Director reported that the resident had alleged misappropriation of funds. The Administrator was informed of the situation on several occasions by different staff but did not initiate a facility-reported incident or report the matter to the state, asserting there was no proof and no allegation of theft, despite facility policy and staff training that prohibit staff from accepting or borrowing money from residents and require reporting of alleged violations.
Kitchen Sanitation and Chemical Storage Deficiencies: Surveyors observed a visibly soiled mixer, residue inside ice machines, a dirty rag sanitizer bucket with zero chlorine test results, and a soiled microwave in the kitchen areas. During lunch prep, the sanitizer bucket was stored next to the drink prep area while beverages were being poured, and the K stated it is usually kept by the hand sink.
Infection control failures involved both the facility water system and resident care practices. Surveyors found unused and shut-off water fixtures, conflicting hot water guidance, and multiple resident-area water temperatures below the facility’s stated limits, while also observing burst-pipe flooding and other plumbing concerns. In resident care, an R15 with a PICC line and IV abx was not consistently placed on EBP and staff did not use gowns during PICC care, an R7 trach care procedure broke sterile technique by reaching across the sterile field, and an R124 with sepsis, a PICC, and a G-tube had delayed temp monitoring and incomplete documentation.
A facility failed to complete monthly antibiotic stewardship monitoring, including line listings, antifungal stop dates, and tracking of a resident on prophylactic cephalexin. A resident receiving IV vancomycin for osteomyelitis and MRSA had inconsistent scheduling, no documented peak/trough monitoring for over 30 days, and multiple delays and errors in lab collection and processing, with staff and NP interviews confirming the therapeutic levels were not reviewed.
Inadequate nursing staffing and delayed resident care: Residents and staff reported chronic staffing shortages, long call light waits, frequent nurse and CNA turnover, and rushed care across shifts. The DON stated staffing was insufficient to maintain the restorative program, and staff described missed tasks, limited breaks, high acuity, and managers working carts due to shortages. Surveyors also found deficiencies in daily grooming, assessment and monitoring of skin conditions, tube feeding sites, weight loss, and resident documentation and coordination of care.
Medication administration errors exceeded the allowed rate when three errors were observed during 26 medication passes. An RN gave a resident Mirapex late because of hallway construction, another RN crushed an ER metoprolol tablet before giving it, and the same RN administered a Breo Ellipta inhaler without proper instruction or mouth rinsing afterward.
Medication storage and labeling were not properly maintained in one med room and four med carts. An RN had personal items and a beverage on top of a med cart, and multiple meds were found improperly stored, including refrigerated eye drops and insulin left unrefrigerated, expired suppositories, light-sensitive drops not kept in their protective bag, and several open or undated insulin, eye drop, and Duoneb containers.
Failure to maintain resident dignity and respectful care. Two cognitively intact residents reported long waits for call light response, delayed assistance with transfers and toileting, staff entering rooms without knocking, and rude or rough interactions. One resident, who was frequently incontinent and dependent on staff for transfers, described being left waiting and soiling themselves, while another resident with chronic pain and muscular dystrophy reported painful, hurried positioning and disrespectful comments from night shift staff.
Unassessed Seat Belt Used as a Restraint: A resident with chronic pain, anxiety, and muscular dystrophy was observed in an electric motorized wheelchair with a seat belt across the abdomen that the resident could not release independently. The record showed no HCP order, no restraint assessment, no care plan related to the seat belt, and no indication on the MDS or CMS-802 that a restraint was in use. The Administrator and DON both acknowledged the seat belt could be considered a restraint when the resident cannot undo it, and the DON confirmed no assessment had been completed.
The facility failed to update care plan interventions for two residents after changes in treatment and condition. One resident had a suprapubic catheter and was receiving antibiotics for site irritation, but the care plan did not reflect the current catheter-related needs. Another resident had IV antibiotics for sepsis, a PICC line with an unchanged dressing, and a PEG tube that had been removed, yet the care plan still included tube feeding and lacked infection, PICC, and post-removal abdominal care interventions.
A resident with COPD, epilepsy, a G-tube, TBI, anxiety, and dementia was found with poor grooming and hygiene, including unshaven facial hair, uncombed hair, and soiled clothing with unknown substances and foul odor. The resident indicated staff had not assisted with cleaning up, and the assigned CNA confirmed the resident had not yet received grooming or oral care. The DON observed the condition and acknowledged the lack of daily care.
Failure to provide appropriate treatment and care was cited for three residents. A resident who announced a hunger strike had no care plan entry or documented BG monitoring, and meal records were unclear while staff noted he was refusing food. Another resident with new bleeding skin breakdown had delayed wound assessment and treatment orders, despite nursing concerns and a text exchange requesting guidance. A third resident returned from the hospital with sepsis, fever, and a PICC line, but temperature monitoring was delayed and the transfer assessment did not fully document the line or related findings.
A resident’s PEG tube was removed, but staff were unaware of the removal and there was no documented assessment of the abdomen, dressing, drainage, erythema, or pain at the site. The resident said hospital nurses placed a taped 4x4 dressing and no one had checked it since, while the DON found no return note, no new orders, and the care plan still listed tube feeding.
Nebulizer Equipment Left Uncleaned and Improperly Stored: A resident with COPD, dementia, and other diagnoses had nebulizer equipment observed on the dresser with the mask still connected in a clear bag and visible fluid remaining in the medication chamber. The same condition was observed the next day, and an LPN stated the equipment should be taken apart and cleaned. The facility policy required nebulizer parts to be cleaned after each use, disassembled, air dried, and stored only once completely dry.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall that was not promptly reported or assessed by staff. CNAs found the resident on her knees and noted a knee abrasion but did not clearly communicate the incident as a fall to the nurse, who then failed to initiate the fall protocol. The event was not documented until days later, after family members noticed injuries and raised concerns, resulting in delayed assessment, monitoring, and notification.
A facility failed to protect a severely cognitively impaired, largely non-verbal resident from sexual abuse by another resident with a documented history of sexual inappropriateness, wandering, and aggression. Staff observed the male resident with his hand down the female resident’s shirt in the dining area, and records showed prior inappropriate touching toward her as well as repeated sexual comments and groping toward staff and other residents. The investigation documentation confirmed the breast-touching incident, while the female resident was tearful and unable to meaningfully respond when questioned.
A resident with stroke-related paralysis, ESRD on dialysis, HF, DM, and a cholecystostomy tube was discharged without confirmed home services, dialysis transport, needed DME such as a hospital bed and mechanical lift, or training for the actual caregiver. Agency on Aging staff said the facility did not coordinate the assessment or resumption of services, and the resident was sent to the wrong address before being taken to the ER because the home setup was not ready.
Incontinence care was not consistently provided or documented for residents who required frequent check-and-change assistance. Family and resident reports described repeated episodes of being found wet or soiled, including overnight and morning delays, while record review showed missing or sparse bladder/bowel documentation and staff acknowledged that care was often charted only once per shift instead of every 2 hours. The residents involved had significant functional and cognitive impairments, and one had recurrent UTI concerns.
A resident with multiple complex medical conditions was admitted with an indwelling urinary catheter, but the facility did not obtain a physician's order for the catheter or document appropriate monitoring and care. Nursing records lacked orders for catheter care, changes, or securement, and there was no evidence of ongoing assessment or documentation by staff.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual. This deficiency reflects a lack of adequate safeguards to ensure resident safety.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to individualized care.
The facility did not ensure that a resident had access to both routine and 24-hour emergency dental care, resulting in unmet dental needs.
A resident did not receive appropriate care for pressure ulcers, and necessary measures to prevent new ulcers were not consistently implemented, resulting in a deficiency related to pressure ulcer management.
Multiple residents experienced significant delays in call light response, inconsistent assistance with ADLs, and unmet care needs, including incontinence care and snack distribution. Residents reported staff inattentiveness, malfunctioning call lights, and prolonged waits for help, with some left in soiled bedding or without access to a functioning call system. Facility records and interviews confirmed repeated failures to respond promptly to resident requests, in violation of facility policy.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal, and failed to establish or implement a grievance policy or promptly resolve complaints.
Multiple residents did not receive consistent assistance with ADLs such as bathing, grooming, and nail care, despite being unable to perform these tasks independently. Residents reported missed showers, unaddressed requests for personal hygiene, and long call light response times, with staff often failing to follow up or document refusals. Facility policies requiring routine ADL and nail care were not consistently implemented, and residents' preferences were frequently disregarded.
Multiple residents experienced extended call light response times and unmet needs due to non-functional or inaccessible call light systems. Observations included call lights out of reach, malfunctioning call light cords, and staff not carrying pagers. The central monitoring screen for several halls was also inoperable for months, leaving staff unaware of resident calls. These deficiencies resulted in residents being unable to obtain timely assistance with personal care and other needs.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that staff education records were falsified, with several CNAs and nurses reporting they had not completed required online modules despite records showing completion. The SDN admitted to possible errors in documenting education, and the DON could not clarify who had access to the system. This resulted in staff being marked as trained in critical areas such as infection control and resident rights without actually completing the education.
Surveyors found that staff did not follow infection control practices or ensure emergency equipment was available for residents with tracheostomies and oxygen needs. For example, a resident's oxygen tubing was found on the floor and reattached without replacement, emergency trach equipment was not at the bedside, and supplies such as suction canisters and distilled water were undated. Care plans lacked documentation of trach size, and oxygen orders were incomplete, all in violation of facility policy.
A resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unattended after staff failed to respond to a door alarm. The resident's care plan was not updated to reflect elopement risk, and staff did not consistently carry pagers to receive door alerts, resulting in delayed response and lack of timely documentation of the incident.
Multiple residents experienced delayed responses to call lights, with some waiting over 30 minutes or being unable to reach their call light, leading to frustration and incontinence. Residents also reported not receiving meals or snacks as ordered, receiving cold or incorrect food, and having their dietary preferences ignored. Environmental needs, such as adequate lighting, were not consistently met, and staff interviews confirmed lapses in following facility policies regarding resident dignity and preferences.
A resident with severe cognitive impairment and multiple medical conditions was found with vaginal bleeding and swelling, and exhibited distress during care. Staff notified the DON and provider, leading to hospital transfer, but did not communicate suspicion of abuse to administration. The hospital initiated a rape test and notified police, prompting the facility administrator to learn of the potential abuse only after police arrived. The State Agency was not notified until the following day, resulting in delayed investigation and assessment of other residents.
The facility did not accurately update or post daily nurse staffing information as required, resulting in discrepancies between the posted BIPA forms and actual staffing schedules. The DON confirmed that new staff were not properly coded, leading to incorrect staffing information being displayed for all residents, staff, and visitors.
The facility failed to provide and document ADL and hygiene care for five residents, leading to concerns about inadequate staffing and care. Residents were often found in bed with unkempt appearances, and there was a lack of documentation for bathing and oral hygiene. The DON confirmed the lack of documentation and suggested that staff might not be documenting the care provided.
The facility's short-term units experienced a failure in the call light system, affecting the 100, 200, 300, and 400 hallways. Observations and staff interviews revealed the absence of a central monitoring screen and visual indicators, with pagers either unavailable or delayed. Staff relied on frequent room checks to assist residents, as the system had been non-functional for about a month. The administration acknowledged the issue, and the Maintenance Director noted challenges in programming replacement pagers.
A resident with severe cognitive impairment and dependency on staff experienced a change in condition that was not promptly assessed or documented by the nursing staff. Despite signs of respiratory distress, the nurse failed to apply necessary interventions, such as oxygen, and left the resident unattended. The delay in calling a code and initiating emergency measures contributed to the deficiency, as confirmed by interviews with facility staff and management.
The facility failed to maintain and label tube feeding equipment properly for several residents, leading to deficiencies in care. Observations revealed issues such as unlabeled solution bottles, inaccurate feeding volumes, and improper dressing management. The DON and other staff acknowledged these issues, indicating lapses in adherence to physician orders and facility policies.
The facility failed to provide proper respiratory care for several residents, including incorrect oxygen settings and poor management of trach supplies. A resident was found with an empty oxygen tank, while another had their oxygen set at a lower rate than ordered. Two residents with tracheostomies had improper oxygen settings and inadequate trach care, with one resident's suction canister nearly full. Another resident's oxygen was set higher than ordered, and their CPAP and nebulizer masks were not properly used or stored.
The facility failed to conduct yearly competency evaluations for RNs, LPNs, and CNAs, as identified during a survey. Six out of seven staff members reviewed lacked current evaluations for 2023 or 2024. The HR Personnel confirmed the absence of these evaluations, noting they were not completed by the previous administration. The DON acknowledged the issue and stated that evaluations were in progress with Unit Managers.
The facility failed to maintain accurate and updated nurse staffing records as required by BIPA, with discrepancies observed in the posted hours for RNs, CNAs, and LPNs. The Scheduling Coordinator acknowledged inconsistencies in the records, including missing days and conflicting data, which affected the ability of residents, their representatives, and visitors to determine the nursing staff on duty.
The facility failed to properly store and label medications, with surveyors finding loose tablets and undated multi-dose medications in several medication carts. Additionally, discrepancies in narcotic reconciliation were observed, including incorrect documentation and scribbled numbers on count sheets. The Director of Nursing acknowledged these issues, indicating a systemic problem in medication management.
The facility failed to update care plans for two residents, leading to potential unmet care needs. One resident had a urinary catheter without a care plan for monitoring, despite a history of UTIs. Another resident was prescribed Clonazepam without documented risk versus benefits or education, and the care plan lacked monitoring interventions. These deficiencies reflect a lack of adherence to care planning and psychotropic drug policies.
A resident with hypertension was administered Metoprolol despite physician's orders to hold the medication if certain blood pressure and heart rate parameters were not met. The MAR showed repeated and identical vital sign entries over several months, indicating a failure to take new readings at the time of administration. The DON confirmed that the facility's policy required obtaining and recording vital signs when parameters were specified.
The facility failed to provide adequate nail and denture care for two residents, leading to potential risks for embarrassment, skin injury, and infection. One resident had long, jagged nails and old nail polish, with no interventions for nail care refusals. Another resident's denture cup contained debris, indicating a lack of proper cleaning. Facility policies on ADL and nail care were not followed, as routine cleaning and inspection were not provided as needed.
A facility failed to coordinate hospice services for a resident with a terminal prognosis, lacking up-to-date documentation and comprehensive care. Another resident, recently admitted after sepsis, had inadequate wound care, with saturated bandages and soiled sheets observed. Facility policies on wound treatment and hospice coordination were not followed, leading to deficiencies in care.
A resident experienced a decline in range of motion and developed contractures due to the facility's failure to conduct a thorough initial therapy assessment and adhere to its range of motion policy. The resident, who was previously able to walk with a cane, reported that therapy had not attempted to stand him up. Medical records revealed that baseline range of motion was not comprehensively assessed upon admission, and contractures were not noted. The facility did not place the resident on a restorative program, leading to a decline in mobility and the development of contractures.
The facility failed to manage urinary catheters and UTIs for three residents, leading to potential complications. A resident's catheter bag was improperly placed on the floor, with no physician order or documentation for the catheter. Another resident had recurrent UTIs with no antibiotic sensitivity provided, complicating treatment. A third resident's catheter was on the floor, with no care plan or physician order for its continued use.
Failure to Provide Ordered ROM and Splint Care
Penalty
Summary
The facility failed to ensure that Restorative Therapy for range of motion (ROM) and splint application were provided as ordered for one resident with severe cognitive impairment and dependence for activities of daily living, mobility, and transfers. The resident had diagnoses including traumatic hemorrhage of the right cerebrum, disorder of the autonomic nervous system, neurocognitive disorder, and aphasia. The resident was observed lying in bed with arms and hands resting on top of the blankets and hands closed in fists, and a hand splint was observed placed on top of a drawer under the television rather than on the resident. The resident was later observed in a reclining wheelchair in the common area without the hand splint on. The resident’s restorative orders included active ROM to both upper and lower extremities 5 to 7 days per week and splint use to the right upper extremity for 2 hours on and 2 hours off, 5 to 7 times per week. The restorative documentation showed inconsistent completion, including entries indicating ROM and splint goals were not meeting the goal and that the plan was not occurring as ordered. The monthly restorative records also reflected limited participation counts for ROM and splint/brace programs. Interviews with the resident’s confidential visitors reported that staff were not repositioning the resident every two hours, were not completing ROM exercises, and were not consistently applying the hand splint. The visitors stated that staff often said they were short staffed and pulled to the floor. A CNA assigned to the resident reported being pulled to floor assignments and stated that when pulled, restorative therapy tasks could not always be completed. The MDS nurse reported that restorative tasks were entered for daily completion, that CNAs assigned to the resident were responsible if the restorative aide could not do the plan, and that she was unsure why the ROM and splint application were not being completed. The therapy director stated the ROM and splint plan was intended to maintain ROM and positioning, and the administrator and corporate nurse reviewed that the documented look-back showed ROM and splint application were not completed as ordered.
Failure to Assess, Monitor, and Accurately Report Resident Skin Condition Resulting in Hospitalization for Cellulitis
Penalty
Summary
The deficiency involves the facility’s failure to prevent neglect of a resident by not adequately assessing, monitoring, and documenting a known skin condition, and by inaccurately reporting the resident’s skin status at discharge. The resident had multiple significant diagnoses, including vascular dementia, hemiplegia, and a prior history of a coccygeal pressure ulcer that had reportedly healed months earlier. A quarterly assessment showed a BIMS score of 2/15, indicating severe cognitive impairment. Despite this, the resident’s care plan identified risks related to incontinence and impaired skin integrity, with interventions directing staff to observe for redness or breakdown, provide peri-care after incontinence episodes, apply barrier cream, and notify nursing and the physician of new skin issues. A CNA documented a new red skin area on the resident on 01/01/2026, triggering an alert note on 01/02/2026. The wound care nurse documented only that there were “no areas of concern noted at this time,” without describing the location, appearance, or size of the new skin problem, and without a detailed skin assessment note. On 01/04/2026, a nurse entered an order for zinc oxide ointment to be applied to the coccyx twice daily and as needed for a red area, and the MAR shows this treatment was documented as given 63 times from early January through the resident’s discharge on 02/05/2026. However, there were no supplemental progress notes or skin assessments describing the coccygeal area’s condition, progression, or resolution, and weekly skin assessments repeatedly documented “no new” and “no existing” abnormal skin areas, despite the ongoing treatment order for a red coccyx. CNA point-of-care charting in February continued to note red and discolored skin areas, marked as not new, but these findings were not reflected in nursing skin assessments. Interviews with staff and others further demonstrated inconsistent recognition and follow-through on the resident’s skin condition. The resident’s former roommate reported that at night CNAs would sometimes only ask if the resident was wet and, if he said no, would not check or change him, resulting in the resident “sitting in piss.” CNAs who provided care stated that the resident’s bottom was very red, with dead skin and leaking fluid, and that nurses were aware and applying treatment creams, but they could not specify what was reported or when. Nurses recalled the resident having eczema and dry skin, and one nurse acknowledged the coccyx was red but not open, yet no detailed assessments were documented. The wound care nurse stated that she did not follow blanchable redness and did not document an assessment beyond the alert note. On the day of discharge, the discharge was described as rushed, no body skin assessment was performed, and the nurse completing the discharge summary documented “no skin issues noted” in the nursing skin/wound section. The receiving facility and family, upon assisting the resident to the restroom shortly after arrival, observed extensive redness from the lower back to the legs, open and weeping areas on the buttocks, and bloody fluid on the brief, leading to hospital transfer where the resident was diagnosed with a large area of cellulitis on the lower back and suspicion of elderly neglect. The hospital records documented redness along the sacral region extending to the back, excoriation throughout the coccygeal region, hyperemia, satellite lesions compatible with possible fungal infection, and evidence of secondary infection. Laboratory results showed an elevated white blood cell count, and the resident reported pain at 10 out of 10. The resident required IV antibiotics, antifungal cream, and narcotic pain medication during a five-day hospitalization and was discharged with continued oral antibiotics. The facility’s own abuse, neglect, and exploitation policy defined neglect as failure to provide necessary goods and services to avoid physical harm and pain, and job descriptions for RNs and LPNs required assessment, documentation of resident condition and nursing needs, and documentation of treatments and pertinent observations. Despite these requirements, the facility did not complete or document adequate skin assessments after a new skin concern was identified, did not ensure appropriate treatment follow-up and monitoring, and inaccurately documented that there were no skin issues at discharge, while the resident’s skin condition had progressed to cellulitis requiring hospitalization. Family members and the evaluating agency reported that they had not been informed of any ongoing skin issues prior to discharge and that the discharge paperwork and verbal report from the facility indicated no skin problems other than use of barrier cream. The family and receiving facility staff were shocked by the condition of the resident’s skin upon arrival, and the hospital documented a high suspicion for elderly neglect. The DON, upon review of the records, acknowledged that the wound care alert note lacked essential information, that the coccyx area being treated was not documented in skin assessments, and that there was no documentation to show whether the skin condition improved, worsened, or resolved from the time it was first identified until discharge. This sequence of incomplete assessment, lack of monitoring and documentation, and inaccurate discharge information constituted the neglect that led to the resident’s hospitalization for cellulitis and treatment with IV antibiotics. The facility’s own policies and staff job descriptions required prevention of neglect, ongoing oversight, and documentation of resident conditions and treatments. However, the record shows that after the CNA’s initial identification of a new red area, the wound care nurse did not document a detailed assessment, nurses did not create progress notes describing the coccygeal skin condition despite repeatedly applying treatment, and weekly skin assessments failed to acknowledge any abnormal skin areas. On the day of discharge, no skin assessment was performed, yet the discharge summary stated there were no skin issues. These actions and omissions, combined with reports of inconsistent incontinence care and the subsequent findings at the receiving facility and hospital, demonstrate that the resident was not protected from neglect related to skin care and monitoring.
Failure to Report and Investigate Alleged Misappropriation of Resident Funds
Penalty
Summary
The deficiency involves the facility’s failure to implement policies and procedures to ensure reporting and investigation of a reasonable suspicion of a crime, specifically an allegation of misappropriation of a resident’s money by a CNA. A resident, who was his own decision-maker and able to clearly articulate his needs, reported that he had loaned a CNA a total of $500 in cash over a weekend, with a verbal agreement that she would repay him every paycheck. He stated that the CNA initially repaid only $30 and that he became upset when she did not abide by their agreement, although she later returned the remaining $470. The resident’s medical record, which included diagnoses of diabetes, atrial fibrillation, hypertension, chronic kidney disease, anxiety disorder, and major depressive disorder, contained no documentation of any allegation or follow-up regarding misappropriation of money. Another CNA reported overhearing the resident and the CNA arguing in the resident’s room with the door closed, during which the resident yelled that the CNA had agreed to pay him $30 every pay period and had not done so, and that she had until the end of the week to pay the balance or he would report the incident to the Administrator. The CNA who left the room was observed to be visibly crying. The Social Work Director stated that around December the resident had described loaning money to a “good employee” to pay a ticket, with payment arrangements that were not being honored, and that she informed him she would have to report this allegation to the Administrator/Abuse Coordinator. She stated the resident reported misappropriation of funds and it was assumed this was reported to the State Agency. The Administrator acknowledged being informed of the situation multiple times but did not treat it as a reportable allegation of misappropriation. He stated that initially the Social Work Director told him the resident had given money to an employee but would not provide the staff name, and that at that time the resident was not alleging theft. He also learned at a resident council meeting that the resident had loaned money to an employee with payment terms, and later received a phone call from a nurse again informing him that the resident had loaned money to the CNA, but he did not ask the nurse for further details. The Administrator stated there was no proof of the transaction and no allegation of misappropriation, and therefore no Facility Reported Incident was submitted to the state agency, despite the facility’s abuse, neglect, and exploitation policy defining an alleged violation as any observed or reported situation that, if verified, could indicate noncompliance with federal requirements. Staff, including the Staff Development Coordinator, confirmed that it was against company policy for staff to accept or borrow money from residents.
Kitchen Sanitation and Chemical Storage Deficiencies
Penalty
Summary
The facility failed to maintain kitchen sanitation standards in multiple food service areas after surveyors observed a mixer visibly soiled with accumulated debris during the initial kitchen tour. In the short-term satellite kitchen, surveyors observed brown and pink residue on the interior walls of the ice machine and a rag sanitizer bucket that was visibly soiled with dark discoloration; testing of the bucket with Sunburst Chemical chlorine test strips showed a result of zero. Kitchen Manager K stated the mixer is cleaned after every use, the ice machine is cleaned every three months by maintenance, and the sanitizer bucket is changed after every meal. In the long-term satellite kitchen, surveyors also observed the interior ceiling of the microwave visibly soiled and the interior wall of the ice machine visibly soiled with brown residue, despite the manager stating the microwave is cleaned every morning. During lunch observation in the short-term satellite kitchen, the rag sanitizer bucket was stored next to the drink prep area while drinks were being poured into glassware. After the surveyor pointed out the chemicals near the drink prep area, the bucket was removed. When interviewed, Kitchen Manager K stated the sanitizer bucket is usually stored by the hand sink. The report also cited the facility's kitchen sanitation policy and food code requirements related to clean food-contact and nonfood-contact surfaces, proper sanitizer concentration, and separation of poisonous or toxic materials from food and equipment.
Infection Control Program Deficiencies
Penalty
Summary
The facility failed to maintain an active infection prevention and control program for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. Survey observations and interviews documented multiple water system concerns, including unused or shut-off drinking fountains, an unused filter still plumbed into a beverage machine backflow preventer and carbonator, a utility sink with an atmospheric vacuum breaker and attached hose, water flooding in the 700 hall coordination center from a burst pipe, and water streaming from a light fixture above a hand sink. The facility’s water management plan stated that low-flow pipe runs, dead legs, and infrequently used fixtures were to be flushed weekly, and the hot water logs and binder contained conflicting temperature guidance. Surveyors also measured hot water temperatures in resident areas at 104, 107, 106, 103, 105, 91, 105.1, 105.3, and 105.5 degrees F, while the water management plan stated that hot water temperatures below 110 degrees F required corrective action. The facility also failed to have a comprehensive infection control program for residents residing in the facility. Resident #15 was admitted for cellulitis, abscess of the right lower limb, osteomyelitis, MRSA infection, and IV Vancomycin through a PICC line, with additional diagnoses including COPD, muscular dystrophy, hypokalemia, and weakness. The resident’s record and care plan identified enhanced barrier precautions for impaired skin integrity and IV access, including use of gown and gloves for direct care and device care. However, during an initial unit walk-through, no EBP sign or PPE cart was posted for this resident’s room. The resident stated staff wore gloves but no gowns during PICC dressing care, and a nurse confirmed the resident had a PICC line and should have been on EBP. Later observations showed the EBP sign and PPE cart were placed outside and inside the room, but the resident again reported that gown use had not occurred during morning IV administration. Resident #7 was admitted with anoxic brain damage, chronic diastolic heart failure, diabetes, a tracheostomy, and a gastrostomy tube, and had severe cognitive impairment. During observed tracheostomy care, the nurse used a bath towel as a barrier, opened a sterile suction pack, placed sterile gloves on, and then reached over the sterile field to retrieve sterile water from a supply cart and place it into the field. The nurse also reached across the sterile field to turn the suction machine on and off and acknowledged not being supposed to reach over the table. The ICP nurse confirmed that trach care and suctioning were sterile technique and that reaching across the sterile field and placing nonsterile items within it was not appropriate. Resident #124 returned from the hospital with fever, a PICC line, a gastrostomy tube, and treatment for sepsis with IV Meropenem. The resident was observed diaphoretic and had a PICC dressing dated several days earlier; the LPN stated the dressing was due to be changed and only wore gloves during the observation without hand hygiene before or after. The resident’s temperature was documented as 101.3 on admission, but the temperature log showed no repeat temperature checks until several days later, after the surveyor identified the concern. Progress notes documented a later temperature of 102.6 with altered mental status, and the resident was sent to the hospital. Interviews with the NP and RN confirmed the lack of temperature monitoring and documentation.
Antibiotic Stewardship Monitoring and Vancomycin Therapeutic Level Deficiencies
Penalty
Summary
The facility failed to complete monthly infection control antibiotic stewardship data collections and related monitoring for multiple residents. The report states that monthly line listings and summaries were missing for many months, that antifungal monitoring lacked stop dates and body site/location information, and that Resident #6’s prophylactic cephalexin was not included on the line listing. The facility’s antibiotic stewardship policy required monitoring of antibiotic use, laboratory results when available, and monthly tracking of antibiotic use measures, but the record review found no monthly analysis or summary for the reviewed periods. Resident #15 was admitted with cellulitis of the right lower limb, abscess of the right lower limb, osteomyelitis, MRSA infection, and a PICC line, and was receiving IV vancomycin 1 gram twice daily for 6 weeks. The order was initially written with liberal time ranges rather than fixed administration times, and a nurse stated the medication was given once in the morning and once in the evening. The NP later confirmed that vancomycin BID should be scheduled every 12 hours and that the liberal timing was not standard. The order was then revised to scheduled times of 0700 and 1900. The record also showed that vancomycin therapeutic monitoring was not completed as ordered or expected. No vancomycin trough results were present in the chart, and staff interviews confirmed that no peak and trough labs had been done for more than 30 days while the resident remained on therapy. Multiple staff described confusion and delays around obtaining the labs, including a missed specimen drop-off, a rejected specimen, and repeated redraw attempts. The report further states that the resident missed one dose while labs were being pursued, and later returned from an infectious disease appointment with an order to discontinue vancomycin and remove the PICC line, with no therapeutic levels reviewed.
Inadequate Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift, resulting in increased call light response times, unmet care needs, and lack of resident assessment and monitoring. During Resident Council on 1/28/2026, eight attendees reported that there were not enough staff to meet their needs, that good staff were being terminated or forced out, that there was a mass exodus of nurses, that up to three different nurses might provide care during one shift, and that average call light wait time was about 30 minutes across all shifts. On 1/29/2026, the Staffing Coordinator reported that approximately ten nurses and aides had resigned over the prior three months, with additional resignations in the last month, and identified current openings for one day-shift nurse, four night-shift nurses, and one day-shift aide. The coordinator described staffing patterns in which one CNA was assigned to each hall, with staff needing to radio for help for two-person assists, and the DON stated that staffing was insufficient to maintain the restorative program. Resident Council minutes from January 2025 through December 2025 repeatedly documented concerns about challenging staffing, delayed call lights on nights and weekends, CNA call-ins, low morale, nurses moving too fast with medications, and late medication delivery. Staff interviews also reported that CNAs rarely took breaks, staffing had not increased despite higher acuity for 6-8 months, more than ten residents required feeding assistance, tasks were missed due to lack of staffing, and evening managers were often working the carts because of staffing shortages. The facility was deficient in daily grooming, assessment and monitoring of newly identified skin conditions, tube feeding site and weight loss, and resident documentation and coordination of care.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5% when three medication errors were identified during 26 observations, resulting in an 11.5% error rate. During a medication pass observation for one resident, RN AA prepared Mirapex 1 mg for administration even though the MAR showed it was due at 1:00 PM, and the nurse stated the medication was late because staff were unable to get to the resident’s room due to hallway flooring being remodeled and replaced. When questioned further, RN AA did not explain why the resident remained in the room if staff could not access the room because of the construction. During another observation, RN Z prepared metoprolol succinate 25 mg ER for a resident and crushed all medications in the cup before administration, despite the medication being an extended-release tablet. RN Z stated, “That is what we do,” and then administered the crushed medication. In a separate observation, RN Z administered Breo Ellipta inhaler to another resident, who took two rapid breaths and did not rinse and spit afterward; RN Z did not provide education on proper inhaler use and stated the resident usually does not rinse. The DON later stated extended-release medications should not be crushed, residents should rinse after Breo Ellipta use, and the late Mirapex administration was not an acceptable reason.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with accepted professional principles in one medication room and four of five medication carts. During observation, a 700 Hall medication cart had an open fabric zipper bag containing personal items, including hand lotion, hand sanitizer, pens, and a teal Yeti cup, sitting on top of the cart with no staff present. RN Z confirmed the items belonged to them and removed them after being asked about personal beverages on the cart. Additional observations found multiple medications stored improperly or left open and undated. The 600 Hall medication cart contained an unopened bottle of Rhopressa ophthalmic solution that was supposed to be refrigerated until opened. The medication room contained two boxes of hemorrhoidal suppositories that were expired. The 500 Hall medication cart contained an unopened vial of Lantus insulin that was also labeled to keep refrigerated until opened. The 300 Hall medication cart contained Latanoprost ophthalmic solution not stored inside its light-protective bag, Brimonidine ophthalmic solution that was open and undated, Lantus and Lispro insulin vials that were open and undated, and two boxes of Duoneb vials, one dated opened and one open and undated, despite labeling that the vials should be used within 2 weeks of opening.
Failure to Maintain Resident Dignity and Respectful Care
Penalty
Summary
The facility failed to ensure two cognitively intact residents were treated in a dignified and respectful manner. Resident #32, who was dependent on staff for transfers and frequently incontinent of bowels, reported that staff took an hour or more to answer the call light, that they had to wait for transfers, and that they had no privacy because staff would walk into the room without knocking. During an interview, Resident #32 stated they were left sitting outside the bathroom and soiled themselves, describing the experience as embarrassing. While the surveyor was speaking with Resident #32, a CNA entered the room without knocking. Resident #69, who was dependent on staff for ADLs and had diagnoses including chronic pain, anxiety, and muscular dystrophy, reported that staff took too long to respond to the call light and that some night shift staff spoke to them with an attitude, saying, "What do you want?" Resident #69 also stated staff were rough when positioning them and moved too fast, causing pain related to two rods in the back and the head of the femur being out. The Administrator acknowledged concerns about long call light wait times and rude staff, and stated that waiting an hour for a call light was not acceptable and that the reported behavior was not acceptable.
Unassessed Seat Belt Used as a Restraint
Penalty
Summary
The facility failed to ensure that a physical restraint was not used for Resident #69, who was observed sitting in an electric motorized wheelchair with a seat belt across the abdomen that the resident could not undo independently. During interview, the resident stated they used to be able to release the seat belt but could no longer do so, and later again stated they could not unhook it and had told staff they were unable to remove it. The resident’s record showed diagnoses including chronic pain, anxiety, and muscular dystrophy, and the MDS described the resident as cognitively intact and dependent on staff for ADLs, with no restraints indicated on the assessment or CMS-802 form. Record review also showed no HCP order for seat belt or restraint use, no documentation of an assessment for the seat belt or any restraint use, and no care plan or intervention related to seat belt use. When interviewed, the Administrator stated they were unsure whether the seat belt was a restraint and later confirmed that it may be considered a restraint if the resident cannot undo it. The DON confirmed that the resident did not have an assessment completed for the seat belt and stated that the seat belt was a restraint. The facility policy stated restraints require a physician’s written order, evaluation, and other specified conditions, including that locking devices shall not be used.
Failure to Update Care Plans for Catheter, PICC, Infection, and PEG Tube Changes
Penalty
Summary
The facility failed to update care plan interventions for two residents after changes in their conditions and treatments were identified during the survey. For Resident #55, the record showed a suprapubic catheter and self-care of catheter management, but the care plan still reflected older toileting/self-care interventions and did not reflect the January 2026 antibiotic treatment for irritation at the suprapubic site. The resident stated he had a urinary catheter for years, usually cared for it himself, and could not recall staff education on catheter care. Survey observations showed the catheter leg bag attached to the right lower leg while the resident self-propelled in a wheelchair. For Resident #124, the record showed treatment with IV Meropenem for sepsis and a right upper arm midline/PICC line, but the care plan contained no infection, antibiotic medication, or PICC line care plan. Surveyors observed the PICC dressing dated 1/20/2026 still in place on 1/27/2026 and again on 1/28/2026, and staff stated it should be changed every 7 days. The resident also had a gastrointestinal tube site observed without a split sponge gauze dressing, and staff noted she had recently returned from the hospital with a UTI and was receiving antibiotics. The record also showed Resident #124’s care plan still included tube feeding and PEG tube-related interventions after the PEG tube had been removed. The resident stated she was happy the belly tube had been taken out, but on 1/29/2026 the wound care nurse and surveyor observed a 4x4 dressing taped to the abdomen with no date, and the resident said hospital nurses had placed it and no one had looked at it since. The DON stated she was not aware the PEG tube had been removed, could not find the consultation packet, and noted there were no new orders, no progress note on return, and no updated abdominal assessment or dressing instructions in the record.
Failure to Provide Daily Grooming and Hygiene Assistance
Penalty
Summary
The facility failed to ensure the provision of services to maintain grooming and hygiene for one resident who was unable to complete activities of daily living independently. The resident had diagnoses including COPD, epilepsy, gastrostomy, anxiety, traumatic brain injury, and dementia. The MDS indicated the resident was severely cognitively impaired and required supervision to moderate assistance with ADLs. The care plan identified an ADL self-care performance deficit related to decreased functional mobility and physical limitations, with interventions including one-person assistance for dressing, bathing, transfers, and toileting, and noted a preference for no facial hair. On observation, the resident was found in bed with an unshaven face, uncombed hair, and chunks of unknown substance on the shirt. The resident indicated staff had not assisted with getting cleaned up. The following day, the resident was again observed with uncombed hair, visible flecks on the hair and shirt, and the same maroon shirt worn previously, which had dark areas, unknown substances, and a foul odor. The resident indicated the shirt had been worn for three days and again stated staff had not assisted with cleaning up. The assigned CNA confirmed the resident had not yet received cleaning or oral care and said it would be done later. The DON observed the resident’s poor hygiene and visible substances on the hair and shirt and stated the lack of daily care was not acceptable and embarrassing.
Failure to Monitor Hunger Strike, New Skin Alteration, and Post-Hospital Sepsis Care
Penalty
Summary
Failure to provide appropriate treatment and care according to orders, resident preferences, and goals was identified for Resident #57, Resident #99, and Resident #124. The facility did not address Resident #57’s stated hunger strike after he told staff and the NP that he was refusing food because of dissatisfaction with facility management issues. The chart contained a practitioner note acknowledging the hunger strike and that the IDT would offer support, but there was no care plan entry for the hunger strike, no blood glucose monitoring documented during the period reviewed, and the FAR showed refused meals with unclear documentation for one dinner entry that staff believed reflected fluid intake rather than food intake. Resident #57 also reported he had not eaten the prior evening or that morning, while CNA documentation indicated only that he drank Mighty Shakes. For Resident #99, the facility did not assess and monitor a new skin alteration in a timely manner. Nursing staff reported that the resident had multiple bandages on his arms and hands, was bleeding, and was soaking through the dressings, but the wound nurse did not come to assess him when requested. A text exchange showed a nurse asking for orders and further instruction because there were no visible orders for the bandages, while the wound nurse responded that if there was no drainage the dressings could be left off. The wound nurse later gave a different account and did not recall the exchange. Treatment orders for the left inner forearm wound were not entered until after the concern was raised. The resident had diagnoses including CHF, diabetes, atrial fibrillation, major depressive disorder, and PVD, and the NP stated that new skin alterations should be reported for assessment and appropriate orders. For Resident #124, the facility failed to ensure quality assessment and monitoring after return from the hospital with sepsis and an IV antibiotic order. The resident returned with a documented fever of 101.3 degrees, later received Meropenem IV every 8 hours for sepsis, and had a PICC line in the right upper arm. On observation, the resident was sweaty and the abdominal GI tube site had no split sponge gauze dressing noted. The PICC dressing was dated 1/20/2026 and was occlusive, but the LPN stated it was due to be changed that day and should be changed every 7 days. The temperature was not documented again until 1/28/2026, and the return-from-leave/transfer assessment did not mention the PICC dressing being occlusive and intact, include a photo, or document measurements of length or arm diameter from hospital care. The NP stated the resident had a temperature of 102.6, altered mental status, had finished IV antibiotics for sepsis, and was sent back to the hospital.
PEG Tube Removal Site and Pain Not Assessed
Penalty
Summary
The facility failed to assess and monitor the removal site of a gastrostomy tube for Resident #124 and did not monitor pain after the tube was removed. During an observation, the resident was seen in bed with a tube site on the abdomen, and no split sponge gauze dressing was noted. The resident later stated that her feeding/PEG tube had been removed and that she was happy it was out. Record review showed the resident had care plans related to bleeding risk from aspirin therapy, gastrointestinal complications, and tube feeding, including interventions to observe for abdominal pain, distention, tenderness at the tube site, nausea, vomiting, and complications related to the tube site. On the day after the tube removal, the wound care nurse was not aware the PEG tube had been removed, and the abdomen had a 4x4 dressing taped in place with no date on it. The resident stated that hospital nurses had placed the dressing and that no one had looked at it since. The DON was also not aware of the tube removal and found no progress note documenting the return from the appointment, no new orders entered, and no assessment of the abdomen, drainage, erythema, or pain at the site. The resident’s skilled daily record noted that the PEG tube had been removed, but the care plan still listed tube feeding and there was no documented assessment of the dressing or instructions for when it should be changed.
Nebulizer Equipment Left Uncleaned and Improperly Stored
Penalty
Summary
Safe and appropriate respiratory care was not provided for one resident when the facility failed to implement and operationalize its policies for storage and cleaning of nebulizer equipment. On 1/28/26, the resident was observed in bed in their room with a nebulizer machine on the dresser beside the bed. The nebulizer administration mask was sitting next to the machine in a clear bag, connected in the bag, and visible fluid was present in the medication administration chamber. An oxygen concentrator was also present with nasal cannula tubing connected, and the tubing was uncontained on top of multiple items on the dresser. On 1/29/26, the nebulizer face mask was observed in the same position in the clear bag on the dresser, still connected with visible fluid in the medication chamber. The resident had diagnoses including COPD, epilepsy, gastrostomy, anxiety, traumatic brain injury, and dementia, and the MDS indicated severe cognitive impairment with a need for supervision to moderate assistance with ADLs. When questioned, the LPN stated the equipment should not be left together with fluid in the chamber and should be taken apart and cleaned. The facility policy required nebulizer equipment to be cleaned after each use, disassembled after every treatment, rinsed, air dried, and stored in a zip lock bag once completely dry.
Failure to Timely Report, Assess, and Monitor Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple complex medical conditions experienced an unwitnessed fall that was not promptly reported, assessed, or documented by facility staff. The resident was found on her knees at the side of her bed by CNAs during shift change, and although the CNAs assisted her into her wheelchair and informed a nurse about a knee abrasion, they did not explicitly report the incident as a fall. The nurse, upon being notified, did not recognize the event as a new fall and therefore did not initiate the facility's fall protocol, which includes immediate assessment, documentation, and notification of the provider and responsible party. The lack of clear communication and understanding among staff led to a delay in recognizing and responding to the fall. The incident was not documented as a fall until several days later, after the resident's family noticed new injuries and raised concerns with facility leadership. During this period, required post-fall assessments, monitoring, and notifications were not completed. The resident's medical record did not reflect the fall or the resulting injuries in a timely manner, and the facility's point-of-care documentation failed to note any new skin issues or injuries during routine checks. Interviews with staff revealed confusion about the reporting process and a lack of awareness regarding the resident's fall. The nurse involved believed the knee injury was related to a previous incident and did not initiate the necessary protocols. The delay in identifying and reporting the fall resulted in a lack of comprehensive assessment and monitoring for the resident, as well as delayed notification to the provider and family. The deficiency was identified through a combination of family complaints, staff interviews, and record reviews, which confirmed that the facility failed to ensure timely reporting, notification, comprehensive assessment, and continued post-fall monitoring following the unwitnessed fall.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from sexual and physical abuse by another resident. Surveyor review found that a CNA reported observing a male resident with his hand down a female resident’s shirt while the two were seated together in the dining area. The female resident was described as severely cognitively impaired, largely non-verbal, and dependent for most ADLs; her diagnoses included dementia, MS, stroke with right-sided hemiplegia/hemiparesis, aphasia, and frontotemporal neurocognitive disorder. At the time of the observation, she was tearful, made gasping noises as though crying, and did not provide verbal responses when questioned. Record review showed the male resident had diagnoses including bipolar disorder, depression, adjustment disorder with anxiety, and dementia with behavioral disturbances. His record documented severe cognitive impairment and a history of wandering, public indecency, urinating on floors and doors, resisting care, verbal aggression, and repeated sexually inappropriate behavior toward staff and other residents, including groping and sexual comments. The care plan reflected these behaviors and included a 1:1 supervision intervention after the incident, but the record also showed that sexual inappropriateness with other residents was added to the care plan only after the incident had already occurred. Another care plan in his record stated he preferred to be sexually active and included interventions about honoring privacy for a competent, consenting partner. Interviews and incident documentation showed the male resident had previously displayed sexually inappropriate behavior toward the female resident before the breast-touching incident, including a staff report that he had placed his hand between her legs. Staff statements also described him as touching staff inappropriately and making sexual remarks. The facility’s investigation documentation confirmed the male resident touched the female resident’s breasts, but the summary concluded abuse could not be substantiated because he did not have the capacity to understand his actions. Surveyor interviews with staff and administration showed awareness of the resident’s prior sexual behaviors, but the facility had no additional documented interviews related to the abuse investigation and no additional incident reports related to the inappropriate sexual behavior were found in the records reviewed.
Unsafe discharge without coordinated services, equipment, or caregiver training
Penalty
Summary
The facility failed to implement and operationalize its discharge planning process to ensure a safe discharge home for a resident with significant care needs. The resident had diagnoses including cerebral infarction with hemiplegia and hemiparesis, heart failure, gallbladder and bile duct obstruction with a cholecystostomy tube, diabetes mellitus, and end stage renal disease requiring dialysis. The resident was cognitively intact and required moderate to total assistance with toileting, dressing, and bathing. The care plan identified the need for two-person assistance, a mechanical sit-to-stand lift for transfers, and discharge planning that included home health care, Area Agency on Aging services, and DME such as a walker, wheelchair, bath chair, and toilet riser. The resident was discharged home without coordination for resumption of services with the local Agency on Aging, without confirmed transportation for dialysis, without necessary DME including a hospital bed and mechanical lift, and without training for the family member who was actually expected to provide care. Agency on Aging staff stated the facility had not contacted them to complete an assessment in the facility before discharge and that the resident was discharged without coordination of care, DME, or training. The resident was sent to dialysis and then home by ambulance, but the ambulance initially took the resident to an old address. When the resident was finally taken to the correct address, the family member present did not have the equipment or training needed to care for the resident, including drain/wound care and transfers. The resident was then taken to the emergency room because the home discharge was not safe. Facility documentation also reflected conflicting information, including a note that the resident's niece had received training, while staff later stated the grandson was the intended caregiver and the niece was not the home care provider. The Social Services Director and the Administrator both confirmed the resident should not have been discharged without the appropriate resources, and staff acknowledged that the first discharge was a mistake. The facility policy required an individualized discharge care plan addressing the discharge destination, identified medical and equipment needs, caregiver availability and capability, and documentation of referrals to local contact agencies, but those elements were not completed before the resident's discharge.
Incontinence Care and Documentation Not Provided Consistently
Penalty
Summary
The facility failed to provide urinary incontinence care per professional standards of practice for two residents, including one resident with severe cognitive impairment, aphasia, dysphagia following cerebral infarction, diabetes type II, seizures, acute kidney failure, chronic kidney disease, and bilateral knee contractures, and another resident who was identified as at risk for bladder and bowel incontinence related to decreased functional mobility and physical limitations. The cited concern involved inconsistent check-and-change care, incomplete documentation, and delays in incontinence care for residents who were dependent or required substantial assistance with toileting hygiene and toilet transfers. For the resident with severe cognitive impairment, family members reported that during the first few weeks in the facility the resident was often found soaked in urine and sometimes feces when they visited in the mornings. The family member stated the resident had a personal caregiver who had cared for her at home for 10 years and that the caregiver also found the resident soiled on multiple occasions. The family member said she contacted the facility’s corporate hotline after repeated concerns that the resident was not being checked and changed regularly. The NHA acknowledged that the standard of care for check and change was every 2 hours and stated the resident should have been on that schedule based on her history. Record review and interviews showed that the facility’s documentation system did not consistently reflect q2-hour incontinence care. The DON reviewed the resident’s bowel and bladder task documentation and acknowledged multiple blank or NA entries across September and October, and later stated that CNA staff were only documenting incontinence care once per 12-hour shift rather than every 2 hours. The DON also stated that the care plan language of “check at regular intervals” was generic and not resident-specific, and that no additional resident-specific continence interventions were found. For another resident, the record showed a complaint of being left wet and soiled, with the resident stating she had been wet overnight and again in the morning, soaked through bedding, and embarrassed. Facility investigation records also described another episode in which the resident told staff she needed to be changed, but the CNA did not return for several hours. Documentation review for that resident showed missing bladder/bowel entries for entire shifts and a 30-day lookback with only one, two, or three documented check-and-change entries on many days.
Failure to Obtain Physician Order and Monitor Indwelling Urinary Catheter
Penalty
Summary
The facility failed to obtain a physician's order for an indwelling urinary catheter for one resident who was admitted from a hospital with the catheter in place. Upon review, there was no physician's order for the urinary catheter documented in the resident's records, including the physician order recap report, Medication Administration Record (MAR), and Treatment Administration Record (TAR) for the relevant months. Additionally, there was no documentation of monitoring or care for the urinary catheter, no order for when to change the catheter, and no order for a catheter securement device. The care plan did note catheter care, but this was not supported by corresponding physician orders or nursing documentation. The resident in question had multiple medical diagnoses, including atrial fibrillation, heart failure, renal insufficiency, wound infection, respiratory failure, cellulitis, and lymphedema. Despite these complex conditions and the presence of an indwelling catheter upon admission, the facility did not ensure that a physician's order was obtained or that appropriate monitoring and documentation of catheter care occurred. The Director of Nursing confirmed that a physician's order was required for the catheter and its discontinuation, and that monitoring should have been documented by nursing staff.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure a safe and abuse-free environment for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions at the time, are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with established directives and the expressed wishes or objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Routine and Emergency Dental Care
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for each resident as required. This deficiency indicates that residents did not have access to necessary dental services, both for regular care and urgent dental needs, as observed by surveyors during the review.
Failure to Provide Proper Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor findings that indicated lapses in the care provided to residents at risk for or experiencing pressure ulcers. The report notes that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented, as required by care standards.
Failure to Ensure Timely Call Light Response and Resident Care
Penalty
Summary
The facility failed to ensure timely response to call lights and assistance with care needs, snacks, and incontinence care for multiple residents. During a Resident Council meeting, all attendees reported excessive delays in call light response, with some residents stating that grievances were not resolved and that staff were often inattentive, distracted by personal cell phones, or socializing with each other. Residents also reported inconsistent distribution of snacks and assistance with activities of daily living (ADLs), such as showers and incontinence care, with one resident stating she had not received a shower in over a month since returning from the hospital. Specific incidents included a resident with burns and a PICC line who waited 55 minutes for a nurse to respond to a beeping IV pump alarm, ultimately having to silence the alarm himself. This resident also experienced delays in wound care and reported that a nurse refused to change his dressing, stating it was not her job. Documentation showed that staff sometimes turned off call lights without meeting residents' needs, and not all staff received education or corrective action following these incidents. Other residents reported waiting over 30 minutes for call light responses, with one resident left without a functioning call light and another left on the toilet for nearly 50 minutes waiting for assistance. Facility records, including alarm event reports, confirmed multiple instances where call lights and bed exit alerts went unanswered for extended periods, sometimes exceeding an hour. Residents described being left in soiled briefs and wet bedding overnight, and one resident had to call the front desk for help when the call light system failed. Interviews with staff and the state ombudsman corroborated these findings, noting that staff sometimes entered rooms only to turn off call lights without providing the requested assistance. The facility's own policy required prompt call light response and staff education, but these standards were not consistently met.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or implement a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's lack of appropriate procedures and actions to address resident complaints.
Failure to Provide Consistent ADL Assistance and Honor Resident Preferences
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), including bathing, grooming, nail care, and personal hygiene, for multiple residents who were unable to perform these tasks independently. Several residents, all with varying degrees of cognitive and physical impairment, were observed to have unmet personal care needs such as unshaven facial hair, long and unclean fingernails, and infrequent or missed showers. In one instance, a resident reported that he relied on his daughter to shave him because the facility did not have enough razors, and although he requested assistance from staff, it was not provided. Another resident stated he had only received three showers during his entire stay and that staff never offered to clip his nails, which he disliked being long and unclean. Resident Council meeting minutes and interviews revealed ongoing, unresolved concerns among residents regarding inconsistent shower schedules, lack of adherence to personal care preferences, and delayed call light responses. Residents described staff as inattentive, often preoccupied with personal cell phones or socializing with each other rather than responding to resident needs. Specific complaints included not receiving scheduled showers or bed baths, being left in soiled incontinence briefs for extended periods, and staff failing to follow up on requests for personal hygiene assistance. Documentation for ADL care, such as shower sheets, was often missing or incomplete, and there was a lack of evidence that refusals of care were properly documented or followed up by nursing staff. Facility policies reviewed indicated that residents unable to perform ADLs should receive necessary services to maintain grooming and hygiene, and that nail care should be routinely provided during ADL care. However, interviews with staff and review of records showed that these policies were not consistently followed. Residents repeatedly reported that staff cited lack of time as a reason for not providing nail care or showers, and there was no documentation of alternative arrangements or follow-up when care was missed. The facility also failed to make information about the Manager of the Day accessible to residents, limiting their ability to report unresolved issues.
Failure to Maintain Operational and Accessible Call Light System
Penalty
Summary
The facility failed to maintain a consistently operational and accessible call light system for multiple residents across several halls, resulting in extended call light response times and unmet resident needs. Observations revealed that call lights were not always within reach of residents, with one resident found with the call light apparatus touching the floor and not accessible, despite care plans specifying that the call light should be attached to the resident's clothing. Family concerns were documented regarding residents being left without call lights and having to call out for help without staff response. Several residents reported that their call lights were not functioning properly, with one resident demonstrating to the surveyor that the call light did not activate consistently, requiring multiple attempts before it worked. This resident also reported having to call the front desk for assistance when the call light failed. Another resident stated that their call light was not working for several days after admission, and only after reporting the issue did they receive a replacement cord. Multiple residents described slow or absent staff responses to call lights, with documented response times frequently exceeding 30 minutes and, in some cases, over an hour. Staff interviews revealed that the call light system relied on pagers and a central computer screen to alert staff to resident needs. However, several staff members did not have pagers on their person, and the central computer screen for several halls was not functioning and had not been operational for months. The maintenance director confirmed the screen had been out of service since their employment began. Without functioning pagers or the central screen, staff would not be aware of active call lights. These failures directly contributed to residents' needs going unmet, including assistance with toileting and other personal care.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Falsification of Staff Education Records
Penalty
Summary
Surveyors identified that the facility falsified documentation regarding the completion of required online education for staff, potentially affecting all 112 residents. Multiple staff members, including nurses and certified nursing assistants (CNAs), reported during interviews that they had not completed the mandatory online education modules due to issues such as lack of access, inability to log in, or not receiving login credentials. Despite these statements, facility records indicated that these staff members had completed most or all of the required education modules on the same day. Further investigation revealed that the Staff Development Nurse (SDN) acknowledged possible errors in recording education completion, including the possibility that education modules were marked as completed for staff who had not actually participated. The SDN was unable to verify when or if staff had accessed the education program and admitted to entering education completion for others during orientation, which may have resulted in inaccurate records. One CNA, upon logging into the system for the first time, found all modules marked as completed despite never having accessed the program before. The Director of Nursing (DON) and SDN were questioned about who had access to the education system and how the documentation was completed, but could not provide a clear explanation. A review of facility policy confirmed the requirement for staff to demonstrate competency through education. The falsification of education records meant that staff may not have received necessary training in areas such as infection control, emergency preparedness, and resident rights, as required by facility policy.
Failure to Follow Infection Control and Emergency Equipment Protocols for Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control practices and ensure the availability of emergency equipment for residents with tracheostomy and oxygen care. For one resident, staff were unable to locate a replacement tracheostomy tube at the bedside, and the oxygen tubing was found on the floor, disconnected from the trach collar, resulting in the resident not receiving oxygen at the time of observation. Staff placed the contaminated tubing back onto the resident's trach, and no replacement tubing was available in the room. Emergency trach equipment was eventually found on a shelf behind the phone, not at the head of the bed as required. Another resident was observed without emergency trach equipment at the head of the bed, and the oxygen tubing was kinked, potentially obstructing oxygen flow. The distilled water for oxygen use and the suction canister were not dated, and the canister contained discolored secretions. In a third resident's room, after the resident had been transferred to the hospital, the suction canister with secretions and the opened distilled water were both undated. In a fourth resident's room, oxygen tubing was found stored in a basin on the floor, and there was no storage bag available for the tubing, contrary to facility policy. Medical record reviews revealed that care plans for residents with tracheostomies lacked documentation of trach size, and oxygen orders were incomplete or missing key details such as route and duration. Facility policies required that replacement trach tubes be readily available and that oxygen delivery devices be kept covered and changed if contaminated, but these practices were not followed for the residents reviewed.
Failure to Prevent Resident Elopement and Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and a history of exit-seeking behaviors was able to leave the facility unattended. The resident, who had diagnoses including dementia, metabolic encephalopathy, bipolar disorder, and unsteadiness, was found outside the building on the front porch in a wheelchair without staff supervision. Video footage confirmed that the resident exited through the front doors after visitors left, triggering the door alarm, but staff did not respond to the alarm. The resident was outside for several minutes before being brought back inside by the DON, and there was no immediate documentation of the incident in the resident's medical record. Further review revealed that the resident's care plan was not updated to reflect his exit-seeking behaviors, despite multiple documented instances of such behavior in the medical record. The social services department was unaware of the resident's elopement risk, and the resident was not included in the elopement risk binder. Staff interviews indicated that the resident was not safe to be outside alone, and that there was a lack of communication and documentation regarding his behaviors and risk status. Additionally, the facility failed to ensure that staff consistently signed out and carried pagers that would notify them of door alarms and resident call system activations. Several staff members did not have pagers during their shifts, and there were reports of insufficient pagers for all staff. This contributed to the lack of timely response to the door alarm when the resident exited the building. Facility policies required care plan updates and documentation of elopement risks and incidents, but these procedures were not followed in this case.
Failure to Honor Resident Rights and Dignity: Delayed Call Light Response and Unmet Preferences
Penalty
Summary
The facility failed to maintain residents' rights and dignity by not ensuring timely response to call lights, not keeping call lights within residents' reach, not providing meals and snacks according to residents' preferences, and not maintaining adequate lighting in a resident's room. Multiple residents reported or were observed to have call lights out of reach, resulting in them having to yell for assistance or wait extended periods, sometimes over 30 minutes or even an hour, before receiving help. In one instance, a resident was unable to access the call light and had to rely on shouting for staff, while another resident's family member reported that the call light was activated but not answered in a timely manner, leading to incontinence due to the delay. Residents also reported issues with meal service, including not receiving meals or snacks as ordered, receiving cold or incorrect food, and not having their dietary preferences honored despite repeated requests. One resident was documented as missing meals for two days, with no record of meal intake or snacks provided on certain days, and experienced significant weight loss during their stay. Another resident repeatedly received food items they disliked or had specifically requested not to receive, such as white bread instead of wheat bread, or fish and zucchini despite these being listed as dislikes on their meal slip. Additionally, the facility did not ensure that environmental needs were met, as evidenced by a resident's request for a working light above their bed, which was found to be nonfunctional with exposed wires and no bulb. Staff interviews confirmed that call lights were not always left on until needs were met, and that residents sometimes received whatever food was being served rather than their stated preferences. Facility policies reviewed indicated requirements for timely meal service, honoring resident preferences, and maintaining dignity, but these were not consistently followed as observed and reported.
Failure to Timely Report and Investigate Alleged Sexual Abuse
Penalty
Summary
The facility failed to immediately report allegations of sexual abuse to the Abuse Coordinator and did not timely notify the State Agency regarding a suspected abuse incident involving a resident with severe cognitive impairment and multiple medical conditions. The resident, who was dependent on staff for all activities of daily living, was observed by staff to have vaginal bleeding and swelling, and exhibited increased distress during perineal care. Staff notified the DON and the on-call provider, who recommended hospital evaluation, but did not clearly communicate suspicion of possible abuse to the facility administration at that time. The resident was transported to the hospital, where a rape test was ordered and the police were notified by hospital staff due to suspicion of sexual abuse. The facility administrator was not made aware of the potential abuse until the police arrived at the facility, having been contacted by the hospital. It was only after speaking with the resident's legal guardian and learning of the hospital's actions that the administrator recognized the need to initiate an internal investigation and report the incident to the State Agency. The delay in reporting resulted in a late start to the facility's investigation and a failure to promptly assess other residents for potential abuse. The State Agency was not notified of the allegation until the day after the incident, and the facility's own investigation and interviews with staff and residents were not initiated until after the administrator became aware of the situation from external sources.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that the daily posting of nursing staff information was accurate and updated as required. During a review of the BIPA (Benefits Improvement and Protection Act of 2000) forms, which the facility used for mandatory daily staffing postings, discrepancies were found between the posted information and the actual staffing schedules for several dates. For example, the number of Certified Nursing Assistants (CNAs) and nurses, as well as their total hours worked, did not match between the BIPA forms and the staffing schedules. These errors were present on multiple dates, and the posted information was not reflective of the actual staff present on those days. When questioned, the Nursing Home Administrator (NHA) initially stated that the postings should be correct, but upon further review, both the NHA and the Director of Nursing (DON) acknowledged that the BIPA forms did not accurately reflect the staffing. The DON identified that new staff were not properly coded, resulting in their absence from the posted staffing information. The facility's policy required that staffing information be posted in an accessible area for all staff and residents, but this requirement was not met due to the inaccuracies in the posted data.
Failure to Provide and Document ADL and Hygiene Care
Penalty
Summary
The facility failed to ensure the provision and documentation of Activities of Daily Living (ADL) and hygiene care for five residents. Concerns were raised about inadequate staffing and residents not receiving proper care, including showers and grooming. Observations and record reviews revealed that residents were often found in bed with unkempt appearances, and there was a lack of documentation for ADL care, including bathing and oral hygiene. Resident #701 was severely cognitively impaired and dependent on staff for ADLs. The resident was observed with an unkempt appearance and had received only one bed bath and no showers during February 2025. There was no documentation of oral care on several days, and no records indicated that the resident refused ADL care. Similarly, Resident #702, who was cognitively intact but required total assistance for ADLs, was observed in a disheveled state and had received only one bed bath with no oral care documented during the day or evening shifts. Resident #703, who was dependent on staff for all ADLs, was transferred to the hospital and did not return. A family member expressed concerns about insufficient bathing and hygiene care due to understaffing. Resident #704, severely cognitively impaired, was observed with an unclean appearance and had received only one bed bath with minimal oral care documented. Resident #705, who was also severely cognitively impaired, received one bed bath and limited oral care before passing away. The Director of Nursing confirmed the lack of documentation for ADL care and indicated that staff might not be documenting the care provided.
Deficient Call Light System in Short-Term Units
Penalty
Summary
The facility failed to ensure an operational call light system in the short-term units, specifically in the 100, 200, 300, and 400 hallways. Observations revealed the absence of a central call light monitoring screen and visual light indicators outside resident rooms. Interviews with staff, including RNs and CNAs, confirmed that the call light system had been non-functional for about a month, with the central monitoring screen broken and pagers either unavailable or delayed in notifying staff of resident needs. Staff interviews highlighted significant communication issues due to the lack of a functioning call light system. RN I mentioned that the facility relied on a pager system, but not all staff had access to pagers, and those who did experienced delays in notifications. CNA J and CNA K reported not having pagers and relied on frequent room checks to determine if residents needed assistance. CNA M, who had a pager, noted a delay in receiving notifications from other halls, with a demonstrated 10-minute delay in one instance. The facility's administration, including the Administrator and DON, acknowledged the issues with the call light system and the lack of pagers. They confirmed that pagers should be available for all CNAs, but an inspection of the pager drawer revealed none were available for the short-term unit. The Maintenance Director, new to the role, was unaware of the pager system's issues but mentioned that replacement pagers had been purchased but could not be programmed due to a faulty docking station. The facility's policy emphasized the importance of a functional call light system, but the current situation did not align with these guidelines.
Failure in Timely Nursing Assessment and Response
Penalty
Summary
The facility failed to ensure timely nursing assessment, response, and documentation for a change in condition for a resident, leading to a deficiency. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed to have a change in condition early in the morning. Despite being a full code, the resident was found unresponsive, and a code blue was called. The timeline of events indicates that the resident was observed to be congested, and upon returning to the room, the nurse found the resident with decreased response, leading to the initiation of CPR. The documentation and interviews reveal significant gaps in the response to the resident's change in condition. The nurse failed to document any assessments or interventions in the resident's electronic medical record (EMR) related to the change in condition and subsequent death. Interviews with staff indicated that the nurse was scattered and did not perform a thorough assessment or apply necessary interventions such as oxygen administration when the resident's SPO2 was low. The nurse also left the resident unattended at a critical time, and there was a delay in calling the code and initiating appropriate emergency measures. Further interviews with other staff members, including the LPN and CNA, corroborated the lack of timely and appropriate response. The LPN noted that the resident was blue and gurgling, and upon entering the room, they found the resident in distress. The CNA also reported that the resident was breathing noisily and rapidly, yet the nurse dismissed these concerns. The facility's Director of Nursing (DON) and Administrator confirmed concerns about the lack of timely interventions and the scattered nature of the nurse's responses, highlighting a failure in the facility's processes to ensure proper care and documentation.
Deficiencies in Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper maintenance and labeling of tube feeding equipment and supplies for several residents, leading to deficiencies in care. For Resident #90, observations revealed that the tube feeding pump was alarming, and the solution bottle and tubing lacked date and time labels. The total volume fed and water flush volumes were inaccurate, and the water flush bag appeared full despite the recorded flush volume. Additionally, the insertion site had dried crusty buildup, and an undated, discolored dressing was found, which was not ordered by a physician. The facility's Director of Nursing (DON) and Unit Manager (UM) acknowledged these issues but did not provide follow-up information before the survey concluded. Resident #35's tube feeding equipment was also improperly labeled, with the enteral nutrition formula and water bag not infusing as per the physician's orders. The resident had experienced weight loss, and the Registered Dietitian (RD) had recommended increased tube feeding and water, which was not accurately reflected in the equipment observed. The Assistant Director of Nursing confirmed that the tube feeding bottle and water should have had the correct information, indicating a lapse in adherence to updated orders. For Resident #34, the enteral feeding was not running, and the tubing was not dated or capped, leaving it open to air. The DON confirmed that the tubing should be capped and dated with a time. Similarly, Resident #53's tube feeding was observed to be infusing past the 24-hour limit, with the tubing not properly labeled. The DON acknowledged that the tube feeding should have been changed the previous day, highlighting a failure to adhere to the facility's policy of changing tube feeding every 24 hours.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to ensure that residents received oxygen as ordered, leading to deficiencies in respiratory care for several residents. Resident #21 was observed with an empty oxygen tank, causing her to breathe heavily and seek assistance. Despite the resident's need for oxygen therapy, the staff did not promptly replace the empty tank, and the resident had to wait for the Assistant Director of Nursing (ADON) to provide a new one. This delay in care highlights a lack of proper monitoring and management of oxygen supplies. Resident #24, who had a tracheostomy and required continuous oxygen therapy at 8 liters per minute, was found to have her oxygen set at only 2 liters per minute. This discrepancy between the physician's orders and the actual oxygen delivery was not addressed by the nursing staff, as evidenced by the initialing of the Medication Administration Record and Treatment Administration Record (MAR/TAR) without verifying the correct oxygen settings. Additionally, the resident's trach supplies were not properly managed, with an open bottle of normal saline left undated, posing a risk of contamination. Resident #83 also experienced improper oxygen management, with her oxygen set at 4 liters per minute instead of the ordered 2 liters per minute. The resident had a history of respiratory infections and required careful monitoring of her trach secretions, which were observed to be thick and discolored. The suction canister in her room was nearly full, indicating a lack of timely trach care. Similarly, Resident #30's oxygen was set at 5 liters per minute, contrary to the physician's order of 2 liters per minute. The resident's CPAP mask was not in use, and the nebulizer mask was improperly stored, further demonstrating inadequate respiratory care management by the facility.
Lack of Yearly Competency Evaluations for Nursing Staff
Penalty
Summary
The facility failed to ensure that Licensed Nurses (RNs and LPNs) and Certified Nursing Assistants (CNAs) received yearly competency evaluations. This deficiency was identified during a survey when it was found that six out of seven staff members reviewed did not have current evaluations for 2023 or 2024. The Human Resources (HR) Personnel confirmed the absence of these evaluations, noting that the only available evaluations were from the staff's orientation period. The HR Personnel also indicated that the previous administration had not completed the required yearly evaluations. During an interview, the Director of Nursing (DON) acknowledged the lack of yearly evaluations and stated that she became aware of this issue upon starting her role two months prior. The DON reported that evaluations were in progress with the Unit Managers, who work closely with the nursing staff. The absence of these evaluations suggests that the nursing staff may not have received the necessary training and skills updates to adequately care for the residents, which could impact the residents' well-being.
Inaccurate and Incomplete Nurse Staffing Records
Penalty
Summary
The facility failed to post accurate and updated nurse staffing records, as required by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). During an interview with the Scheduling Coordinator (SC), it was observed that the nurse staffing posting for a specific day did not include registered nurse (RN) hours, which the SC attributed to a printing error. Additionally, the SC admitted that the postings were supposed to be updated daily, including weekends, but there were inconsistencies in the records. The binder containing retained nursing staffing posted hours was incomplete, with multiple days missing and conflicting data for the same day, indicating a lack of proper record-keeping. Further review of the staffing schedules compared to the BIPA documents revealed discrepancies in the number of certified nursing assistants (CNAs) and licensed practical nurses (LPNs) listed. For instance, on one day, the schedule indicated 16 CNAs, but the daily staffing record showed only 13. Similarly, another day's schedule listed 18 CNAs, but the BIPA document only recorded 14. These inconsistencies were confirmed by the SC, who was unable to determine which postings were accurate. The facility's failure to maintain accurate and complete nurse staffing records potentially affected all residents, their representatives, and visitors, as they were unable to determine the nursing staff on duty.
Medication Storage and Reconciliation Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications across multiple medication carts, leading to several deficiencies. During observations, surveyors found loose tablets in a medication cart, which were not properly disposed of, and multiple instances of opened multi-dose medications that were not dated. This included Fluticasone Propionate nasal spray, Valproic acid, and Morphine, all of which were found without an open date, potentially affecting their efficacy and safety. Additionally, Budesonide nebulizer vials were found undated and without resident identification, further indicating lapses in medication management. The facility's narcotic reconciliation process was also found to be deficient. Observations revealed discrepancies in the narcotic count sheets, including scribbled numbers and incorrect documentation of dates and signatures. For instance, Nurse O was observed signing the narcotic count sheet for a date when they were not present in the building, and there were instances where the narcotic count was not accurately reconciled, leading to potential errors in narcotic management. The Director of Nursing acknowledged these issues and noted that spot checks were conducted weekly, but the deficiencies persisted. The facility's policies on medication storage and labeling were not adhered to, as evidenced by the lack of date-opened stickers on medications and improper narcotic count documentation. The pharmacy services policy required nurses to record the date opened and expiration date on medications, but this was not consistently followed. The Director of Nursing admitted that there was a previous nurse education session on proper documentation, but the issues remained unresolved, highlighting a systemic problem in medication management and reconciliation within the facility.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update care plan interventions for two residents, resulting in potential unmet care needs. Resident #74, an elderly male with severe cognitive impairment and multiple medical diagnoses, was observed with a urinary catheter and tubing on the floor, which was not addressed in his care plan. Despite having a history of recurrent urinary tract infections (UTIs), there was no documented order for the catheter beyond a one-time insertion, and no care plan for catheter care was in place. The facility's interdisciplinary team did not ensure the care plan was updated to include catheter monitoring and care. Resident #75, a male with multiple medical conditions including dementia and anxiety, was prescribed Clonazepam without documented risk versus benefits or medication education for the resident or responsible party. The facility's policy requires documentation of the specific condition diagnosed by a physician and education on the risks and benefits of psychotropic drug use. However, the care plan for Resident #75 did not include interventions to monitor the effects of Clonazepam, and there was no evidence of consent or education provided. The deficiencies highlight a lack of adherence to the facility's policies on comprehensive care planning and psychotropic drug use. The care plans for both residents were not updated to reflect their current medical needs and treatments, potentially leading to unmet care needs and prolonged illness or injury. The facility's failure to ensure proper documentation and monitoring of medical interventions and medications contributed to these deficiencies.
Failure to Follow Physician's Orders for Metoprolol Administration
Penalty
Summary
The facility failed to adhere to physician's orders for monitoring blood pressure and heart rate parameters when administering Metoprolol to Resident #34. The resident, who was admitted with diagnoses including stroke, diabetes, and essential hypertension, had an order for Metoprolol Tartrate to be administered via PEG-Tube every morning and at bedtime, with instructions to hold the medication if the systolic blood pressure was less than 110 or the heart rate was less than 60. However, the Medication Administration Record (MAR) for October, November, and December 2024 showed repeated instances where the medication was administered despite blood pressure readings that should have prompted the medication to be held. In October 2024, there were 23 days with repeated blood pressure and pulse readings documented for both morning and bedtime administrations, with three instances where the medication was given despite blood pressure readings being outside the prescribed parameters. Similarly, in November 2024, there were 23 days with repeated readings and two days with transcription errors in blood pressure documentation. In December 2024, the MAR continued to show repeated blood pressure and pulse readings for consecutive administrations. An interview with the Director of Nursing (DON) revealed that the facility's practice allowed nurses to document the last recorded blood pressure and pulse, rather than taking new readings at the time of medication administration. The DON acknowledged the unlikelihood of consecutive identical blood pressure readings and confirmed that the facility's policy required nurses to obtain and record vital signs at the time of administration when parameters were specified. The facility's policy on medication administration emphasized the importance of holding medication for vital signs outside the physician's prescribed parameters.
Deficiencies in Nail and Denture Care
Penalty
Summary
The facility failed to provide adequate assistance with denture care and nail care for two residents, resulting in potential risks for embarrassment, skin injury, and infection. Resident #11, who had a history of stroke, dementia, and other conditions, was observed with long, jagged fingernails and old nail polish. Despite the resident's indication that the nails were too long and consent to have them trimmed, the facility did not have interventions in place to address refusals of nail care. The Unit Manager acknowledged the need for nail care during showers, but the Activities Director reported that the department had not been doing nails, leaving the responsibility to families. Resident #51, who was independent in activities of daily living, was found with a denture cup containing debris and cream-colored dots, suggesting food debris. The Infection Control Nurse confirmed the need for the cup to be cleaned. The facility's policies on activities of daily living and nail care were not adequately followed, as routine cleaning and inspection of nails and denture care were not provided as needed. The Director of Nursing acknowledged the lack of interventions for refusals in the care plans, indicating an area of improvement needed in the facility's care practices.
Deficiencies in Hospice Coordination and Wound Care Management
Penalty
Summary
The facility failed to coordinate and collaborate hospice services for a resident, ensuring comprehensive care was not provided. The resident, who had a terminal prognosis and was receiving hospice care, had a care plan that included hospice interventions. However, the facility did not maintain up-to-date hospice documentation, as the last hospice note in the electronic medical record was from a month prior. Interviews with social services staff revealed that the hospice book, which should have contained notes on services and visits, only had outdated care plans and documents. Another deficiency was identified in the facility's failure to complete timely assessment and monitoring of skin conditions and change bandages and sheets for a resident. This resident, who had recently been admitted after a septic episode, was observed with saturated bandages and soiled sheets. The resident's husband expressed concerns about the lack of dressing changes and pain management. The facility's policy required licensed nurses to notify physicians for treatment orders in the absence of such orders, but this was not adhered to, as evidenced by the lack of orders for the resident's coccyx dressings. The facility's Director of Nursing and Assistant Director of Nursing were involved in reviewing the resident's condition, but discrepancies in documentation and care were evident. The resident's medical records indicated multiple serious diagnoses, including gangrene and sepsis, yet the facility did not adequately address the resident's wound care needs. The facility's policy on wound treatment management was not followed, as dressings were not changed despite being visibly soiled, and there was no documentation of a comprehensive skin assessment upon admission.
Failure to Prevent Decline in Range of Motion and Development of Contractures
Penalty
Summary
The facility failed to ensure a thorough initial therapy assessment and prevent a reduction in range of motion and the development of contractures for a resident with limited range of motion. The resident, who had been at the facility for one year, reported that therapy had not attempted to stand him up and that he was previously able to walk with a cane but could no longer do so. Upon review of the resident's medical records, it was found that his baseline range of motion was not comprehensively assessed upon admission, with many sections marked as not applicable, and contractures were not noted. The resident's progress notes indicated a decline in functional abilities and the development of contractures, which were not present upon admission. The therapy director acknowledged that the resident's range of motion had declined since admission, and new contractures had developed. The resident's therapy discharge summaries and plans indicated a decline in overall mobility and the development of contractures, which were not initially assessed or documented upon admission. Interviews with the therapy director and physical therapist revealed that the resident was not placed on a restorative program to maintain his level of functioning, despite a decline in range of motion and the development of contractures. The facility's policy on range of motion stated that residents should not experience a reduction in range of motion and that assessments should be conducted on admission, quarterly, and upon significant changes. However, the facility failed to adhere to this policy, resulting in the resident's decline in mobility and the development of contractures.
Deficiencies in Urinary Catheter Management and UTI Care
Penalty
Summary
The facility failed to provide necessary management and care of indwelling urinary catheters for three residents, leading to potential complications. Resident #24 was observed with a Foley catheter bag improperly placed on the floor, and the catheter tubing showed signs of thick yellow urine with sediment and biofilm. There was no physician order or documentation for the presence of the catheter in the resident's medical records, and the care plan did not mention the catheter until three weeks after its insertion. The Assistant Director of Nursing confirmed the absence of a physician's order and acknowledged the improper placement of the catheter bag. Resident #73 had a history of recurrent urinary tract infections (UTIs) and was observed with a Foley catheter. The resident's urine culture identified two organisms, but no antibiotic sensitivity was provided. The facility's Infection Control Practitioner noted the high UTI rate and the lack of antibiotic sensitivity in lab results, which hindered appropriate treatment. The resident had a chronic sacral wound with osteomyelitis and had been on long-term antibiotic therapy, complicating the management of recurrent UTIs. Resident #74 was observed with a urinary catheter and tubing on the floor, and the resident was unaware of the catheter's purpose. The laboratory results for the resident's urine identified multiple pathogens, but there was no recommendation for colonized organisms. The facility's records lacked a physician order for the catheter beyond a one-time order, and there was no care plan for catheter care. The Regional Clinical Consultant acknowledged the absence of a proper catheter care plan and the need for a physician order if the catheter was to remain in place.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 221 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Montrose
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maple Woods Manor | 6.7 mi | ★★★★★ | 2 | 0 |
| Majestic Care Of Flushing | 7.6 mi | ★★★★★ | 6 | 0 |
| Kith Haven | 11.5 mi | ★★★★★ | 15 | 0 |
| Wellspring Lutheran Services | 12.5 mi | ★★★★★ | 17 | 0 |
| Villa At Beecher Place | 12.5 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.