Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Medilodge Of Westwood during CMS and state inspections, most recent first.
A resident with dementia, diabetes, HTN, CKD, and bipolar disorder received another resident’s meds, including insulin, a beta blocker, a blood thinner, and other drugs not ordered for him. The nurse asked if he was the roommate and accepted his response before giving the meds and insulin. The resident then developed hypoglycemia, bradycardia, and hypotension, required EMS treatment, and was admitted to the ICU.
Food items were not stored and maintained under sanitary conditions in the kitchen and resident dining room refrigerator. Surveyors observed no sanitizer test strips for the 3-compartment sink, wet-stacked clean pans, a cracked and loose dish machine rinse gauge, and a resident fridge containing dated and undated leftovers, an open beverage past the discard timeframe, and strawberries covered in white fuzz. The plate warmer also had excess debris, crumbs, silverware, and plastic wrappers inside.
Unsafe and Deteriorated Parking Lot and Driveway Areas: The facility failed to maintain a safe and functional entry area, with numerous potholes and severe disrepair observed in the parking lot, driveway entrances, employee parking, visitor parking, and main entrance. A resident had to cross the unrepaired driveway to reach the smoking area, and the Maintenance Director stated the parking lot had been an ongoing challenge with no completion timeline provided for repairs.
Failure to provide Medicare non-coverage notices for a resident receiving Part A skilled services. The facility did not issue a NOMNC when covered services ended, and the ABN listed room and board with the cost marked TBD and was signed after coverage had already ceased. The BOM stated he did not know the cost, and the facility policy required timely notice of potential liability and issuance of a NOMNC when Medicare-covered services end.
Unclean Resident Room and Shared Bathroom: Two residents shared a room and bathroom that were repeatedly observed with trash on the floor, sticky and stained floors, soiled tray tables, an overflowing trash can, and brown stains on the toilet rim. One resident with moderate cognitive impairment reported housekeeping was not thoroughly cleaning her room, while the other resident reported her sheets had not been changed and that she had been lying in blood-stained sheets. The residents also reported frustration that staff were not responding to their requests for cleaning.
A facility failed to fully develop and implement care plans for 3 residents. One cognitively intact resident with chronic respiratory failure had prolonged tooth pain and a cracked tooth that was not addressed in the care plan, despite repeated complaints and delayed dental follow-up. Two other residents had ordered splints/palm protectors for contractures and hemiplegia, but staff observed the devices were not in place during multiple checks, and staff confirmed the interventions were missed.
Failure to Provide Needed ADL Care: A cognitively intact resident who required assistance with bathing, dressing, and personal hygiene was observed with long dirty fingernails and clothing on backwards, and repeatedly stated he needed help getting his nails cut. Staff reported nail care would be done during second-shift bathing, while the bathing record showed a bed bath with no documentation related to fingernails.
Failure to Implement Ordered ROM and Splinting Interventions Two residents with contractures and stroke-related weakness were observed without ordered palm protectors or a hand splint in place during care and while in the dining room. The RD stated the devices were intended to prevent further contractures and should be worn during morning care and as tolerated. Records also showed incomplete TARs and CNA documentation that did not consistently confirm the ROM or splinting tasks were completed or tolerated, and the DON stated nurses were expected to verify splints were in place per orders.
Failure to monitor weight and honor nutritional preferences. A resident with severe cognitive impairment, malnutrition, cancer, wounds, bilateral AKA, and esophageal ulcer disease had no documented weights for weeks after admission and was not set up for weekly weight monitoring. Ordered supplements such as Health Shakes were left unopened at bedside, and the resident stated he did not like them and usually did not drink them. The DON and RD both noted the resident’s weight monitoring was not completed as expected.
Delayed Dental Care for Resident With Tooth Pain and Infection: A cognitively intact resident with chronic respiratory failure reported months of tooth pain, difficulty eating, and concern for infection before dental treatment progressed. Records showed the broken tooth was noted, but the care plan lacked dental interventions and documentation of referral follow-up was incomplete. The resident later developed facial swelling and a tooth abscess, and extraction was delayed because she was on Xarelto.
Food was not served at a palatable temperature and was described as unappetizing by residents. One resident with moderate cognitive impairment reported cold eggs and ham that were too cold to eat, while another resident reported cold eggs, bland oatmeal, greasy bacon, and poorly prepared alternate meals, leading her to order food out more often. In a resident council meeting, all residents present reported receiving cold food, and prior minutes noted trays were not being passed out fast enough.
Incomplete and inaccurate documentation of resident treatments and assessments: A resident with contractures had palm protectors and PROM ordered, but observations showed the devices were not in place and the TAR/CNA records did not consistently show completion or resident tolerance. Another resident with hemiplegia had a right hand T-bar orthosis ordered, yet observations found the splint absent and the TAR/CNA documentation was incomplete. A third resident reported a hot beverage spill to the groin and legs, but skin assessments were not current and no recent assessments were available in the record.
Failure to ensure informed consent for ADR agreements: two residents signed ADR forms without understanding that they were waiving the right to litigate in court. One resident was cognitively intact with chronic pain and anemia, and the other had HTN and anxiety disorder. Both later stated they had not received the ADR education they needed and would not have signed the forms if the process and loss of court rights had been explained.
A resident with multiple serious comorbidities and intact cognition was discharged home despite repeatedly stating she could not safely enter her house or care for herself, and despite her family’s clear objections and inability to prepare the home environment. Staff, including RNs and therapy, documented and reported that the resident was distraught, crying, and fearful about going home, and one RN refused to sign the discharge paperwork due to safety concerns. The facility proceeded with discharge after managed care coverage ended, requiring advance private payment and refusing a personal check, while a second-level insurance appeal was still in process. On arrival home, the transport driver could not get the resident’s wheelchair through the doorway and noted additional obstacles inside, leading the family to call an ambulance and the resident to be sent to the hospital, demonstrating that the discharge planning process did not ensure a safe and appropriate transition.
A resident with dementia, intellectual disability, epilepsy, HF, anxiety, muscle weakness, and reduced mobility had a care plan that still listed fall mats and a scoop mattress as interventions even though observations showed a regular mattress and no fall mats in use. The DON stated those interventions had been added after a prior fall but were no longer needed, and the care plan had not been revised to reflect the resident’s current status.
Two residents with significant mobility and cognitive impairments did not receive adequate supervision or consistent implementation of care planned fall prevention interventions. One resident suffered a fall resulting in a fracture after being found unsupervised in a hallway, with required safety equipment not in place. Another resident was transferred by a CNA without the use of a gait belt or prescribed walker, contrary to care plan and facility policy.
The facility did not adequately follow up or resolve grievances related to missing personal items for several residents, with incomplete documentation and lack of communication regarding investigation outcomes. Residents, including those with cognitive and visual impairments, reported missing money, clothing, and unauthorized debit card charges, and staff interviews confirmed that investigations and resolutions were not consistently completed or communicated.
Multiple failures in infection prevention and control were observed, including lack of proper PPE use and signage for residents requiring enhanced barrier precautions, inadequate hand hygiene and glove use during insulin injections, and unclean shared equipment. These lapses involved residents with wounds or surgical sites and staff who were unaware or did not follow required protocols, increasing the risk of infection transmission.
Surveyors identified multiple deficiencies in environmental safety and sanitation, including moisture accumulation and insect presence in the kitchen, unsanitary conditions and missing supplies in shower and utility rooms, and unclean, poorly maintained resident rooms. Staff interviews confirmed lapses in cleaning routines and maintenance reporting.
Two residents experienced a lack of dignified dining when they were not served their meals in a timely manner while others at their table were already eating. One resident waited so long that he ate leftover bread from another's place, and another left the table with her meal untouched after finally being served. The Regional Registered Dietitian confirmed that such delays were not normal and that residents seated together should receive meals at the same time.
Two residents with complex medical needs were discharged without being provided the required SNF-ABN and NOMNC forms. Due to a transition in social services leadership, the forms were not completed or documented, and staff were unable to produce them during the survey.
The facility did not provide required discharge notifications to the State LTC Ombudsman for two residents who were transferred to the hospital. Documentation confirmed the transfers, but the ombudsman's office had not received notifications for several months. Interviews indicated a lack of clarity regarding staff responsibilities for this process.
A resident was inaccurately coded as having schizophrenia on the MDS assessment, despite no evidence of psychosis-related behaviors or treatment for schizophrenia. Staff interviews confirmed the resident was not being treated for this condition, and the diagnosis was based on outdated documentation rather than current clinical findings.
Two residents did not receive physician-ordered medications and wound care treatments as documented, with staff admitting to false documentation and failure to notify providers of missed doses or treatments. One resident with psychiatric diagnoses missed an antidepressant dose without provider notification, while another with a surgical wound did not receive required dressing changes despite records indicating completion. Nursing staff confirmed lapses in documentation and communication, contrary to facility policy and professional standards.
A resident with hemiplegia and reduced mobility was repeatedly observed with greasy, unkempt hair and wearing the same clothing, despite scheduled showers and bed baths. Staff interviews revealed that hair washing was expected as part of ADL care but was not consistently performed or documented, and the resident reported her hair was not washed as often as she preferred. Documentation gaps and lack of clarity among staff contributed to the resident's unmet hygiene needs.
Two residents did not receive care in accordance with physician orders and professional standards. One resident with a mental health disorder missed doses of prescribed Wellbutrin due to staff not locating available medication and failing to notify the provider, with inaccurate documentation of administration. Another resident with a recent foot amputation and diabetic wound did not receive ordered wound care, as dressing changes were omitted for several days without documentation of refusal. Nursing staff confirmed treatments were not provided as ordered, and required documentation and provider notifications were not completed.
A resident with right-sided contracture following a stroke did not consistently receive prescribed hand splinting and positioning devices as outlined in the care plan and Kardex. Observations showed the resident without any splint, and interviews with a CNA and LPN revealed they were unaware of the need for such devices. No documentation was found to indicate the devices were applied, despite care plan directives.
Two residents did not receive safe respiratory care as required: one received supplemental oxygen at a rate higher than the physician-ordered range, with the nasal cannula sometimes improperly applied, while another used a CPAP machine without an active physician order and with inadequate cleaning of the mask and straps. Staff interviews and documentation revealed inconsistent practices and lack of adherence to facility policy regarding respiratory care.
A resident with end stage renal disease who required dialysis did not have post-dialysis assessments and monitoring completed or documented as required. Nursing staff confirmed that vital signs, weight, and access site checks were expected after dialysis, but records showed these were not performed or recorded for several months after related orders were discontinued. The DON acknowledged the lack of documentation and missing orders for post-dialysis monitoring.
Two residents with significant trauma histories did not have their trauma triggers identified or addressed in their care plans. One resident with a history of psychiatric illness, substance use, and recent amputations, and another who lost her home and pets in a fire, both lacked trauma-informed interventions. Staff were not informed of their trauma histories, and social services did not conduct adequate trauma assessments or referrals, resulting in unmet emotional needs and the potential for re-traumatization.
A resident with anxiety and depression, admitted for rehabilitation after a traumatic event, did not receive ordered psychological support services. Despite a physician's order and care plan interventions for behavioral health, the resident was not referred to counseling or psychological services, and the DSS was unaware of the order.
Two residents experienced medication errors when a nurse administered insulin from a pen past the recommended discard date and failed to provide a scheduled antidepressant dose due to not checking all storage areas. Additionally, a resident received the wrong opioid medication, with inaccurate documentation. These actions led to a medication error rate above 5%.
Staff failed to store and manage medications according to manufacturer and facility guidelines, including using insulin pens beyond recommended discard dates, leaving an inhaler unsecured in a resident's room, and maintaining a disorganized medication cart. These actions resulted in medications being administered past their safe usage period and improper storage of drugs and biologicals.
Surveyors found that food items brought in by family and visitors for a resident were not consistently labeled with opened or discard dates, and some items were stored past their safe consumption period. The facility's policy required labeling and timely consumption of such foods, but this was not followed, as confirmed by the RRD during an interview.
Two residents in a LTC facility experienced preventable falls due to inadequate supervision and improperly secured equipment. One resident, with Alzheimer's and a history of falls, was left unattended despite requiring 1:1 supervision, resulting in a head injury. Another resident fell out of bed when an enabler bar was not properly engaged, causing a skin tear. Both incidents highlight lapses in safety protocols.
The facility did not adequately address resident concerns about long call light wait times, as documented in Resident Council Minutes and confirmed by resident and staff interviews. Residents reported waiting up to an hour for responses, particularly during understaffed shifts, leading to dissatisfaction and potential care issues.
The facility failed to serve food at a palatable temperature, leading to dissatisfaction among two residents with type 2 diabetes. Both residents, who were cognitively intact, reported that meals were often not hot enough, especially breakfast. Staff interviews confirmed these complaints, and temperature logs lacked documentation for certain days, indicating a failure to ensure food was served at a safe and appetizing temperature.
The facility failed to provide two residents with the food items they requested, leading to dissatisfaction and potential nutritional decline. A resident with diabetes did not receive the correct breakfast items or substitutions for items she did not eat. Another resident did not receive the cottage cheese she ordered. Staff reported frequent complaints about incorrect meal deliveries and communication issues with the kitchen.
A resident with severe cognitive impairment and multiple health issues was not administered oxygen as per physician orders. Observations showed the oxygen concentrator was off and tubing improperly stored. Staff interviews revealed confusion about the resident's oxygen orders, with a CNA adjusting the concentrator to the correct flow rate after noticing it was set incorrectly.
The facility failed to maintain sanitary conditions in the kitchen, risking foodborne illness for 87 residents. Observations revealed a reach-in refrigerator with temperatures above the recommended 41°F, packed with food. The Maintenance Director's attempts to fix the issue increased temperatures further. The Dietary Director discarded perishable items, and a follow-up found improper storage and unidentified solutions in the kitchen, violating FDA Food Code standards.
The facility failed to control hot water temperatures in the B hall, with measurements showing 127°F in the shower room and 128°F in the utility room, exceeding the safe limit of 120°F. The Maintenance Director confirmed that each hall has its own hot water system, and there were no mixing valves to temper the water. Maintenance staff typically checks temperatures in the morning but does not track fluctuations throughout the day.
The facility failed to implement proper infection control protocols, including Enhanced Barrier Precautions, for residents with indwelling devices. Staff did not consistently use PPE, and medical equipment was inadequately cleaned, posing risks of infection. Observations revealed improper wound care practices and poorly maintained resident equipment, indicating systemic issues with infection control.
The facility failed to protect residents from abuse, involving two cognitively impaired residents who engaged in verbal and physical altercations. One resident, with a history of aggression, admitted to slapping another and continued to exhibit inappropriate behavior without adequate supervision. Staff were unable to prevent a physical altercation despite attempts to intervene, and ongoing concerns about the residents' interactions were noted.
The facility failed to prevent further abuse during an ongoing investigation involving two cognitively impaired residents. One resident, with a history of aggressive behavior, was not adequately monitored, leading to a physical altercation with another resident. Despite interventions in place, the facility did not effectively supervise or separate the residents, resulting in repeated conflicts.
The facility failed to provide required transfer/discharge notices to two residents when they were transferred to the hospital. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews revealed a lack of adherence to the facility's policy on transfer notices.
The facility failed to provide two residents with a written bed hold policy notice upon their transfer to a hospital, as required by the facility's policy. Both residents, who were cognitively intact, did not receive the necessary documentation, and staff interviews confirmed the absence of such notices in their records.
A resident with severe sepsis and cellulitis received IV antibiotics inconsistently, with all doses administered outside the prescribed timeframe. Nursing staff interviews revealed confusion about administration times, and the Medication Administration Record showed significant deviations from the recommended schedule.
A resident with pyogenic arthritis experienced worsening knee pain and was unable to walk safely, yet the facility failed to provide a wheelchair despite the resident's requests. Staff interviews revealed a lack of awareness and communication regarding the resident's increased needs, resulting in struggles with mobility, incontinence, and personal hygiene.
A resident with cognitive impairment and a history of heart and respiratory failure did not receive necessary care for pressure ulcers, resulting in infrequent dressing changes and potential infection. The care plan required daily dressing changes, but observations showed dressings were not changed as ordered. Interviews with the resident and family member expressed dissatisfaction with care, and documentation was inconsistent, indicating a lapse in care.
A facility failed to maintain communication and documentation for a resident with end-stage renal disease who required dialysis. The resident's dialysis communication binder was missing, and no communication forms had been received or documented in the medical record for three months. Staff interviews confirmed the lack of communication and documentation, and the facility could not provide any records of communication with the dialysis center during this period.
Significant Medication Error With Wrong-Resident Administration
Penalty
Summary
The facility failed to prevent a significant medication error for one resident who had diagnoses including bipolar disorder, dementia, insomnia, anxiety, hyperlipidemia, type 2 diabetes, hypertension, and chronic kidney disease. The resident was given another resident’s medications, including atorvastatin, Eliquis, lorazepam, metformin, metoprolol, Lyrica, tizanidine, Toujeo insulin, and trazodone, even though none of those medications were ordered for him. The record also showed that the resident had a documented Lipitor allergy, and Lipitor was among the medications administered in error. According to the incident report and hospital records, the resident was found to have an acute change in condition after the wrong medications were given. He developed low blood sugar, decreased heart rate, and low blood pressure, and EMS administered atropine and glucagon before transport. In the emergency department, he was noted to have hypotension and bradycardia, and he required treatment including epinephrine, glucagon, dextrose, and potassium chloride. He was admitted to the ICU for symptomatic hypotension and bradycardia after the accidental administration of another resident’s medications. Staff interviews and the witness statement showed that the nurse entered the resident’s room, asked if he was the roommate, and accepted his response before administering the medications. The nurse then gave the pills and insulin, and later realized the error when she checked the roommate’s medications. The nurse stated that the resident answered yes to everything and that she should have asked him to say his name. The report also states that the nurse was new to the facility and was not familiar with the resident at the time of the error.
Food Storage and Sanitation Deficiencies in Kitchen and Resident Refrigerator
Penalty
Summary
Food items were not stored, prepared, and maintained under sanitary conditions in the kitchen and resident dining room areas. During observation, the three-compartment sink had a sanitizer pre-dispense system, but no test strips were available to verify the sanitizer concentration, and the cook line preparation table had clean pots and pans stored underneath with two half pans and two quarter pans stacked and stored wet with moisture between them. The dish machine rinse gauge was also observed cracked and loose on the dial, leaving the needle open and exposed. In the resident refrigerator in the dining room, surveyors observed multiple improperly stored food items, including a container of spaghetti dated 7/7, leftover baked potato and meatloaf with no name or date, an unopened whipped topping container, an open container of caramel macchiato dated 6/17/26 with manufacturer instructions to discard after 7-10 days after opening, and a grocery bag containing strawberries and whipped topping with no name or date, with the strawberries covered in white fuzz. The facility document for the refrigeration unit stated that prepared food items would have a 3-day use-by date and then be discarded. On follow-up, the plate warmer was observed with excess accumulation of debris, crumbs, silverware, and plastic wrappers stacked in the inside bottom of the unit.
Unsafe and Deteriorated Parking Lot and Driveway Areas
Penalty
Summary
The facility failed to maintain a safe and functional entry to the building, affecting all residents who use the exterior spaces. Numerous potholes were observed in the parking lot when entering through the north entrance, and the Maintenance Director stated the parking lot had been an ongoing challenge and that a repair plan was in progress but he could not provide a completion timeline. A resident was later observed sitting outside near the driveway to enter the parking lot smoking and had to cross the parking lot from the front entrance across the unrepaired driveway to reach the required smoking area. A subsequent tour with the Maintenance Director identified multiple areas of severe disrepair, including potholes exceeding three inches in depth in the south driveway entrance, back service area, employee parking, visitor parking, main entrance, and north driveway entrance, with significant deterioration noted near the south entrance by the dumpster, the south drive curve to staff parking, and most of the north entrance. Facility records also included an asphalt vendor proposal dated 07/09/26 with a field review date documented as 10/03/25.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to issue a Notice of Medicare Non-Coverage (NOMNC) and an Advanced Beneficiary Notice of Non-Coverage (ABN) for Medicare Part A services for Resident #33. Review of the resident’s SNF Beneficiary Notification Review showed a Medicare Part A skilled services episode start date of 1/12/26 and a last covered day of Part A service of 4/9/26, and the facility/provider initiated discharge from Medicare Part A services when benefit days were not exhausted. The record indicated that a NOMNC, Form CMS-10123, was not provided to the resident. Review of the ABN for Resident #33 showed room and board as the care listed, with the reason documented as therapy complete/benefits exhausted and the estimated cost listed as TBD. The ABN was signed verbally on 4/10/26, one day after coverage ceased. During interview, the Business Office Manager stated he did not know the cost the resident would incur for room and board, so he entered TBD in the form. The facility policy stated that Medicare beneficiaries are to be informed of potential liability for payment and that a NOMNC shall be issued when Medicare covered services are ending, whether the resident is leaving the facility or remaining.
Unclean Resident Room and Shared Bathroom
Penalty
Summary
The facility failed to maintain a clean, comfortable environment for two residents who shared a room and bathroom. Resident #8, who had essential hypertension, need for assistance with personal care, and a BIMS score of 11/15 indicating moderate cognitive impairment, reported concerns that housekeeping was not thoroughly cleaning her room. During observation, her floor had several pieces of trash and was sticky, her bathroom had trash on the floor, soiled washcloths in the sink, an overflowing trash can, and brown stains on the toilet rim. Resident #94, who had essential hypertension and an anxiety disorder, reported that she had not seen her room cleaned since admission and that she had family bring bleach wipes so she could clean the shared bathroom herself because of infection control concerns. She also reported her sheets had not been changed since admission and that she had been lying in sheets soiled with blood shortly after admission. Observations confirmed a large red stain on the sheets, crumbs and dried liquid stains on the bedside tray table, black and brown stains and stickiness on the floor, and a full trash can with trash on the floor. On later observations, the room remained in similar condition, with trash on the floor, sticky and stained floors, soiled tray tables, and the shared bathroom still showing overflowing trash and brown stains in the toilet rim.
Incomplete Care Plans and Missed Splint and Dental Interventions
Penalty
Summary
The facility failed to develop and/or implement comprehensive care plans for 3 residents, resulting in potential unmet medical, physical, mental, and psychosocial needs. One resident with chronic respiratory failure and intact cognition reported that she had complained of tooth pain to multiple nurses for several months before seeing a dentist, and she was still waiting for a tooth extraction. She stated that she had been told she was on the dental list, but when she was seen in April it was by a dental hygienist who was unaware of her tooth pain and said she needed to see the dentist. She later saw the dentist in June, but extraction could not be done because she needed to be off blood thinner medication for 3 days before the procedure. The resident reported that the physician prescribed pain medication and antibiotics for the tooth infection until the tooth could be removed. The resident’s record showed the first documented mention of the broken tooth in a social services note, which stated nursing had been notified and social services had been notified, but the resident/family involvement and notification section was blank. A nurse practitioner note later documented that the right upper last molar was cracked and injuring the oral mucosal lining, with no facial swelling or local abscess at that time, and a STAT in-house dental appointment was ordered. Subsequent notes documented tooth ache, right facial swelling, and a periapical abscess, with antibiotics and ibuprofen ordered and the resident scheduled for extraction. The care plan did not contain a dental services or tooth pain care plan. For the other two residents, care plans included splint or brace interventions, but observations showed the devices were not in place. One resident with contractures had palm protectors ordered for both hands, yet was observed with tightly closed hands and no palm protectors in place in bed and later in the dining room. Another resident with hemiplegia and hemiparesis following cerebral infarction had a right hand T-bar orthosis ordered, but was observed multiple times in bed and in the dining room without the splint/brace in place. Staff interviews confirmed the devices were not applied as planned, including a CNA stating she had forgotten to apply the hand splint that morning.
Failure to Provide Needed ADL Care
Penalty
Summary
The facility failed to provide necessary ADL care to Resident #16, who was cognitively intact with a BIMS score of 14 and required substantial to maximal assistance with bathing. The resident’s care plan identified an ADL self-care performance deficit related to impaired mobility and weakness, with interventions indicating assistance from one person for bathing, dressing, and personal hygiene. During observation on 7/14/26, the resident was seen in his room with long dirty fingernails and his shirt on backwards, and he stated that he needed his fingernails cut and did not remember when they had last been cleaned. On 7/15/26, the resident was again observed with long dirty fingernails and said he needed someone to cut them. On 7/16/26, the resident was observed with the fingernails on his left hand cut short while the fingernails on his right hand remained long and dirty; he stated that he had tried to cut them himself that day but was unable to cut the nails on his right hand. A CNA reported that the resident had been seen cutting his fingernails that morning and stated that the resident was scheduled for baths on second shift, when his nails would be cleaned and cut, and that first shift CNAs were not responsible for his nails. The bathing record documented a bed bath on 7/15/26, with no documentation related to fingernails.
Failure to Implement Ordered ROM and Splinting Interventions
Penalty
Summary
The facility failed to implement ordered interventions to maintain range of motion for two residents with contractures and neurologic impairment. Resident #3 had diagnoses including contractures and a care plan directing staff to apply palm protectors to both hands with AM care and remove them at HS, with skin checks at each application and removal. During observation, Resident #3 was seen in bed with both hands tightly closed and no palm protectors in place, and later was observed in the dining room without the palm protectors. The Rehabilitation Director stated the palm protectors should be worn as much as possible to prevent skin breakdown and further contractures. Resident #65 had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and the care plan directed staff to apply a right hand T-bar orthosis in the morning and remove it in the afternoon, as tolerated, with skin monitoring. Resident #65 was observed in bed and later in the dining room on multiple occasions without the splint/brace in place. The Rehabilitation Director stated the splint should be applied during morning cares and could be removed at lunch time or as tolerated to prevent contracture due to the stroke affecting the right side. Record review showed incomplete and inconsistent documentation for both residents. For Resident #3, the TAR showed restorative ROM and palm protector application were initialed on most days, but CNA documentation did not show whether the tasks were completed or how the resident tolerated them. For Resident #65, the TAR was not completed on several days, CNA documentation showed the splint/brace task often did not occur or was not scheduled, and ROM documentation did not show whether the task was performed, how the resident tolerated it, or how long it took. The DON stated nurses were expected to verify splints were in place per orders and should not wait until the afternoon to review treatment orders because morning orders were scheduled.
Failure to Monitor Weight and Honor Nutritional Preferences
Penalty
Summary
The facility failed to obtain weights and ensure nutritional preferences were met for a resident who was admitted at 126 pounds and had multiple serious diagnoses, including cancer, malnutrition, a sacral pressure ulcer, bilateral above-knee amputations, esophageal ulcer with bleeding, peripheral vascular disease, and renal disease. The resident’s MDS showed severe cognitive impairment, and the record also documented a Mini Nutritional Assessment score of 5.0 indicating malnutrition, with severe decreased food intake and significant recent weight loss. The resident was not on a physician-prescribed weight-loss program, yet the record showed a loss of 5% or more of body weight in the prior month. The resident’s hospital discharge instructions and facility orders included a regular diet with nutritional supplements, including Health Shakes three times daily and Prostat twice daily. The care plan identified the resident as at risk for altered nutritional status and malnourished, with interventions to periodically obtain weight, monitor food preferences, provide meals and fluids based on preferences, and provide supplements as ordered. The Nutrition Data Collection noted the resident stated his appetite had returned and that he was eating well, but also documented that Health Shakes were started on admission to meet caloric needs related to variable intake, weight loss, and wounds. During observation, unopened Health Shakes were found at the bedside, and the resident stated he did not like the taste and did not drink them. On another observation, the resident again stated he did not usually drink the Health Shakes and preferred water; no Health Shake was present at that time. Record review showed no documented weights from 6/25/26 until the start of survey, and the DON stated the resident had been refusing weights, although the progress notes did not document refusals. The DON also stated the admission weekly weights were not set up for staff to know to take them weekly for four weeks, and the RD stated the resident should have been weighed weekly to establish a baseline and that his weights were not done weekly.
Delayed Dental Care for Resident With Tooth Pain and Infection
Penalty
Summary
The facility failed to provide prompt dental services for a cognitively intact resident with chronic respiratory failure who reported ongoing right-sided tooth pain and difficulty eating. The resident stated she had complained to multiple nurses for several months before being able to see a dentist, and that she was still waiting for the tooth to be extracted. She also reported concern about infection and said she had been eating softer foods because of the pain. Record review showed the first documented mention of the broken tooth was in a social services note that identified a broken right tooth and stated nursing was notified. The resident’s care plan contained no dental services or tooth pain-related interventions. A provider note later documented that the resident’s right upper last molar was cracked and injuring her oral mucosal lining, and a STAT in-house dental appointment was ordered. Subsequent notes documented tooth ache, swelling, right facial swelling, and treatment with antibiotics and pain medication, with the resident later diagnosed with a periapical abscess and scheduled for extraction. The record also showed gaps in documentation and follow-up regarding the dental referral and appointment process. The social services director could not state when the referral was first sent, whether urgency was communicated to the dental office, or whether the resident was followed up with about appointments. The dental office schedule and notes showed the resident was seen for cleaning and later for the fractured tooth, but the extraction was delayed because the resident was taking Xarelto and needed medication adjustment before the procedure. The resident remained concerned about the timing of the extraction and reported that another antibiotic had been prescribed to prevent infection until the tooth could be removed.
Food Served Cold and Unappetizing
Penalty
Summary
The facility failed to provide appetizing and palatable food at a safe and appetizing temperature for 2 residents reviewed for food palatability and for 4 of 4 residents who spoke during a confidential resident council meeting. One resident, who had diagnoses including hypertension and needed assistance with personal care and had a BIMS score of 11/15, reported that meals were often served cold and that she would not eat food when it was cold. She stated that breakfast eggs were too cold to eat and that she believed her tray was delayed because her room was toward the end of the hall, leaving her as one of the last residents to receive her meal tray. During observation, a test tray left on the food cart until it was checked had a large piece of ham with a temperature of 113 degrees. Another resident, who had diagnoses including hypertension and anxiety disorder, reported repeated concerns with the food served. She stated that she received cold eggs and cereal, then was given oatmeal and bacon as an alternate meal, but the oatmeal was bland and the bacon was covered in grease. She showed a sandwich bag containing bacon with an estimated 1/4 cup of grease and a photo of a peanut butter and jelly sandwich with a small dab of jelly and a large amount of peanut butter. She reported that she had started ordering food out more because she was frustrated with spending money on food at the facility when the meals were not palatable. An RN reported awareness of her ongoing concerns and said she seemed to only order food for delivery now. In the resident council meeting, 4 of 4 residents reported receiving cold food that should have been served hot, and prior meeting minutes documented that meal trays were not being delivered timely and that food was cold.
Incomplete and inaccurate documentation of resident treatments and assessments
Penalty
Summary
The facility failed to maintain accurate medical records for 3 residents reviewed for complete and accurate documentation of treatments completed by licensed nurses and tasks performed by CNAs. For Resident #3, who had contractures and required palm protectors with AM care and removal at HS, observations showed the resident’s hands closed tightly without palm protectors in place during the survey. The July 2026 TAR showed the licensed nurse initialed 14 of 15 days for maintenance restorative nursing and palm protector application, including 7/14/26 and 7/15/26, but the record was not completed for 7/11/26. The CNA documentation for the past 30 days did not include data showing whether PROM and palm protector tasks were completed or how the resident tolerated them. For Resident #65, who had hemiplegia and hemiparesis following a cerebral infarction and was ordered to have a right hand T-bar orthosis applied in the morning and removed in the afternoon, observations on multiple occasions showed the resident without the splint/brace in place. The CNA reported the resident did not refuse the splint, and the LPN stated she had not yet documented the TAR for that day because she typically reviewed treatment orders in the afternoon. The July TAR showed the licensed nurse initialed 10 of 15 days, with several dates not completed, and the CNA documentation for splint/brace assistance and PROM did not include documentation of whether the task was performed, how the resident tolerated it, or how many minutes were spent providing ROM. For Resident #46, who had frontal lobe and executive function deficits, chronic pain, and bed confinement status, the resident reported that hot coffee had spilled on his groin and legs when a staff member knocked a beverage off his breakfast tray. A CNA confirmed the spill occurred and that the nurse was notified immediately. Although the resident later reported pain and the provider documented groin pain after the spill, the last skin assessment in the record was dated 4/28/26, and no skin assessments for the last 30 days were provided. The DON stated weekly skin assessments and incident/accident reports were expected, and confirmed the resident had not been assessed since 4/28/26.
Failure to Ensure Informed Consent for ADR Agreements
Penalty
Summary
The facility failed to explain the terms of an Alternate Dispute Resolution (ADR) agreement and failed to ensure that residents understood and validly consented before signing. For Resident #32, the record showed a cognitively intact resident with a BIMS score of 15/15 and diagnoses including chronic pain and anemia. Although the ADR agreement stated that the resident consented, the resident later reported not recalling any education about the agreement, could not explain the arbitration process, did not know that signing waived the right to litigation in court, and stated she would not have signed if she had understood that right was being given up. For Resident #94, the record showed diagnoses including essential hypertension and anxiety disorder. The resident signed an ADR agreement, but later stated she had not received any education on the form, did not understand the ADR process, and would never have signed away the right to litigation in court. The NHA initially stated the facility offered arbitration agreements and that she was completing the education for new residents, but later said the RDBD would complete the education if a resident was interested in signing. The RDBD then stated she did not complete the education for Resident #94 and that the Admissions Director was supposed to verbally educate residents and show a video explaining the ADR process; Resident #94 also reported that no video had been provided.
Unsafe Discharge Home Despite Resident and Family Objections
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and appropriate discharge for a cognitively intact female resident with multiple serious medical conditions, including left lower limb cellulitis, diabetes, morbid obesity, peripheral atherosclerosis with gangrene, heart disease, hypertension, anemia, anxiety, and severe chronic kidney disease. Her care plan documented that she planned to discharge home, with interventions to involve her and her family in discharge planning, coordinate home care agencies and community supports, and provide written instructions for a safe return to the community. Despite this, the discharge planning process did not adequately address her and her family’s expressed concerns about the safety and feasibility of returning home, particularly regarding access to the home and the availability of care. In the days leading up to discharge, the resident, her family member, and multiple staff members reported significant distress and concern about the planned discharge home. The resident’s MDS showed she was cognitively intact, and she repeatedly stated she could not go home and could not get into the house, which was corroborated by a physical therapy note documenting that she was very emotional and requesting to stay longer. The family member told staff, including the DON, that the resident was in no condition to be discharged and that there was no way to get the resident into the home due to an electric wheelchair blocking the door and the resident’s own wheelchair being too wide. Nursing staff, including RNs, reported that the resident was distraught, crying, and verbalizing that she could not care for herself and would have to call 911 after discharge. Staff nurses expressed that they did not feel safe discharging her and one RN refused to sign the discharge paperwork because she felt it was inappropriate. Financial and insurance issues were central to the decision to proceed with discharge despite these concerns. The business office manager reported that the resident’s managed insurance coverage ended with a last covered day and that a Notice of Medicare Non-Coverage was issued and appealed, with the first appeal rejected. The facility informed the resident and family that, without a secondary payer source, continued stay would require private payment in advance, and the DON and regional director stated that facility policy did not allow acceptance of personal checks for room and board, requiring cash, debit/credit card, or certified check. The family member attempted to pay the requested amount with a personal check but was told it would not be accepted and was unable to obtain a certified check before the scheduled discharge. Despite ongoing appeals and later confirmation that a second-level appeal had been approved, the facility proceeded with the planned discharge when transportation arrived. On the day of discharge, multiple staff and the transport driver observed that the resident was upset, crying, and apprehensive, and upon arrival at home, the wheelchair would not fit through the door and the path inside was blocked, leading the family member to call an ambulance and the resident to be rehospitalized. These events demonstrate that the facility did not ensure the discharge plan met the resident’s needs and preferences or that she was prepared for a safe transfer home, as required by its discharge planning policy.
Inaccurate Care Plan Not Updated for Resident With Removed Fall Interventions
Penalty
Summary
The facility failed to revise the care plan for Resident #105, resulting in a care plan that did not accurately reflect her current status. Resident #105 was admitted with diagnoses including dementia, intellectual disability, high blood pressure, heart failure, epilepsy, anxiety, muscle weakness, and reduced mobility. Her MDS assessment with a reference date of 9/5/25 showed severe cognitive impairment and no history of falls since the prior assessment. However, the current care plan accessed on 10/29/25 still listed her as being at risk for falls/injury related to a history of falls, pain, epilepsy, atrial fibrillation, intellectual disabilities, respiratory failure, dementia, and osteoarthritis, with interventions including a floor mat next to the bed and a scoop mattress, both initiated on 3/27/24. Observations on 10/29/25 and 10/30/25 showed Resident #105 in bed or in her wheelchair, with no fall mats observed beside her bed and a regular mattress in use. A CNA reported that the resident previously had fall mats placed along the sides of her bed but did not know where they were at the time and did not recall a scoop mattress being used. The DON stated the fall mat and scoop mattress interventions had been put in place after a fall more than a year earlier and that Resident #105 no longer required them, but the care plan had not been updated to remove those interventions.
Failure to Implement Fall Prevention and Supervision Interventions
Penalty
Summary
The facility failed to provide adequate supervision and implement appropriate care planned interventions to prevent accidents for two residents. One resident with a history of dementia, multiple fractures, unsteadiness, and cognitive deficits was care planned for fall prevention measures, including keeping the bed in a low position, using a fall mat, ensuring the call light was within reach, and maintaining a hazard-free environment. Despite these interventions, the resident experienced an unwitnessed fall in the hallway, was found sitting on the floor, and later was diagnosed with a closed fracture of multiple pubic rami. Observations after the fall revealed that the fall mat was not consistently placed next to the bed as required, and the wheelchair was not within reach. The resident was also observed unsupervised in the dining room, attempting to pick up items from the floor without staff present, despite her impulsiveness and cognitive impairment. Another resident with a history of stroke, right-sided paralysis, muscle weakness, and reduced mobility was care planned for two-person assistance with transfers and ambulation, and the use of a gait belt for safety. During an observed transfer, a CNA assisted the resident from the wheelchair to the bed without using a gait belt and did not utilize the prescribed walker. The resident was prompted to hug the CNA for support during the transfer, and the wheelchair was placed out of reach afterward. The facility's policy and staff interviews confirmed that a gait belt should be used for all transfers involving residents who are weak or unsteady. The facility's fall prevention program required that residents at risk for falls receive care and services according to their assessed risk, and that interventions be monitored for effectiveness and revised as needed. However, direct observations and interviews indicated that care planned interventions were not consistently implemented for both residents, resulting in a fall with injury for one and the potential for harm for the other.
Failure to Resolve and Communicate Outcomes of Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for multiple residents regarding missing personal items, including money, clothing, and other belongings. Documentation for grievances submitted by residents was incomplete, with forms lacking information on whether concerns were resolved, if results were communicated to residents, and whether residents were satisfied with the outcomes. In several cases, there was no evidence that investigations were completed or that residents were informed of the findings, despite facility policy requiring such actions. Residents reported missing items such as cash, clothing, and personal care items, and in one case, a resident with visual impairment reported unauthorized charges on his debit card after staff assisted him with purchases. Interviews with staff revealed that some were not involved in investigations or were unaware of the outcomes, and that the previous administrator was responsible for handling certain incidents but did not complete the required documentation. Resident Council minutes and group interviews further confirmed that concerns about missing items and unresolved grievances were ongoing and not addressed in a timely or effective manner. The facility's Quality Assistance Policy required that grievances be investigated, findings reported to the administrator, and results communicated to the resident or their representative. However, review of records and interviews indicated that these steps were not consistently followed. The lack of a specific policy regarding missing items and the absence of thorough documentation and communication contributed to the deficiency, resulting in unresolved grievances and dissatisfaction among residents.
Failure to Implement Infection Control Protocols and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement proper infection prevention and control protocols for multiple residents, specifically regarding enhanced barrier precautions (EBP), injection practices, and the handling of soiled shared equipment. For three residents requiring EBP due to wounds or surgical sites, there were lapses in the use of personal protective equipment (PPE), signage, and care plan documentation. One resident with a deep tissue injury to the left heel had a care plan indicating the need for EBP, but no interventions were listed, and the EBP signage was inconsistently posted. Another resident with a right foot surgical incision had orders and care plans specifying EBP, but staff were observed providing high-contact care without donning the required PPE, and the EBP sign was missing until after surveyor intervention. A third resident with a coccyx wound had no EBP signage or care plan documentation, and an LPN provided direct care without PPE, stating she was unaware of the EBP requirement. Additionally, infection control practices during medication administration were not followed. A nurse was observed preparing and administering an insulin injection without performing hand hygiene or wearing gloves, and later reported that she did not typically use gloves for injections, nor was she trained to do so. This practice deviates from standard infection control protocols and increases the risk of cross-contamination. The facility also failed to ensure that shared equipment was properly cleaned between uses. A hoyer lift was observed in the hallway with a resident grasp cover that had dried, soiled material, indicating it had not been cleaned after use. These deficiencies collectively increased the potential for the spread of infection, bacterial harborage, cross-contamination, and disease transmission among residents.
Failure to Maintain Sanitary and Safe Environment in Multiple Facility Areas
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment in multiple areas, as evidenced by direct observations and staff interviews. In the kitchen, worn and missing grout, as well as raised tiles under the dish machine and garbage disposal, allowed moisture to accumulate, creating conditions conducive to insect and bacterial growth. Multiple gnats were observed in these areas, particularly around an unused floor drain and sections with low grout. The lack of a functioning exhaust for the high-temperature dish machine further exacerbated moisture accumulation and humidity in the area. During a tour of resident care and utility areas, additional deficiencies were noted. In the B hall shower room, crusted white powder debris was found on the commode seat, and there was no paper towel holder or paper towels available. The shower bed had accumulated trash, debris, and staining under the mat, with care staff reportedly responsible for cleaning between residents. In the central supply room, boxes of briefs were stored directly on the floor, and shelving units were made of press-board that was not smooth or easily cleanable. The C Hall Soiled Utility room had vinyl coving that had fallen and lacked proper structural support, while the D Hall Soiled Utility room had a non-functioning exhaust fan, affecting the entire hall. Resident rooms were also found to be unsanitary and in disrepair. Observations included dried liquid spills and brown stains on floors and walls, cobwebs and dust on window sills and blinds, and dirty thresholds. One room had a wall bead strip detached and leaning against the wall, chipped paint on the heater, cracks on the wall, and exposed nails or screws. Housekeeping staff described a multi-step cleaning process but noted that rooms could be skipped if residents were present, and maintenance issues were reported through an electronic work order system.
Failure to Provide Dignified Dining Experience Due to Delayed Meal Service
Penalty
Summary
The facility failed to ensure a dignified dining experience for two residents by not serving their meals in a timely manner while others at their table were already eating. During a dining observation, one resident was served and began eating, while another at the same table waited without a meal. Two more residents joined, and one of them received his meal and finished eating before the two waiting residents were served. One of the waiting residents eventually took uneaten bread left by another and began to eat it, while the other left the table with her meal untouched after finally being served. The last resident was served his meal after being left alone at the table. The Regional Registered Dietitian confirmed that residents seated together should receive their meals at the same time or as soon as possible, and that waiting 20 minutes or more was longer than normal.
Failure to Provide Required Medicare Coverage Notices to Discharged Residents
Penalty
Summary
The facility failed to provide required Skilled Nursing Facility-Advanced Beneficiary Notice of Non-coverage (SNF-ABN) and Notice of Medicare Non-coverage (NOMNC) forms to two residents prior to their discharge. Both residents had significant medical conditions, including metastatic lung cancer, COPD, malnutrition, and cognitive deficits. Review of records and interviews confirmed that these forms were not issued as required, and no documentation of the forms could be located for either resident. The Social Services Director, who became responsible for issuing these forms in mid-February, reported that she did not provide the SNF-ABN or NOMNC forms to the affected residents prior to their discharge. The Regional Director of Operations also confirmed that, due to a transition in social services leadership during the residents' stays, the required forms were not completed and could not be found. No copies of the SNF-ABN or NOMNC forms were provided to surveyors for either resident by the time of the survey exit.
Failure to Notify State LTC Ombudsman of Resident Discharges
Penalty
Summary
The facility failed to ensure that proper discharge notifications were completed for two residents who were transferred to the hospital. In both cases, documentation showed that the residents were sent to the emergency department or hospital, and all physician orders were discontinued for one of the residents. The State LTC Ombudsman reported not receiving any discharge notifications from the facility for several months. Interviews revealed that the social worker was not involved in notifying the ombudsman's office and had only recently received official training, while the nursing home administrator stated that the social worker was responsible for these notifications and that reports should be sent monthly. As a result, the required notifications to the State LTC Ombudsman regarding resident discharges were not completed.
Inaccurate Schizophrenia Diagnosis Documented on MDS Assessment
Penalty
Summary
The facility failed to ensure that a resident received an accurate clinical assessment reflective of their current status, resulting in an inaccurate diagnosis of schizophrenia being documented on the Minimum Data Set (MDS) assessment. The MDS for the resident indicated an active diagnosis of schizophrenia, despite no evidence of psychosis-related behaviors during the assessment period and no treatment or prescription of antipsychotic medication for schizophrenia while at the facility. The resident's medical diagnosis list included schizophrenia, but this was based on a historical entry and not on current clinical findings. Interviews with facility staff confirmed that the resident was not being treated for schizophrenia and had no related behaviors observed. The social worker stated that the resident's depression medication was managed by a psychiatrist, but there was no treatment for schizophrenia. The MDS nurse acknowledged that the resident was coded as having schizophrenia on the MDS, despite the absence of supporting clinical evidence or treatment. Review of the MDS 3.0 RAI manual emphasized the requirement for accurate assessments based on validated information from the observation period, which was not met in this case.
Failure to Follow Professional Standards in Medication and Treatment Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice regarding the administration and documentation of physician-ordered medications and treatments for two residents. For one resident with a history of bipolar disorder, depression, and suicidal ideation, the Medication Administration Record (MAR) indicated that an antidepressant medication was administered on specific dates, but a nurse admitted to falsely documenting the administration when the medication was not actually given. There was also no documentation that the provider was notified of the missed dose, as required by professional standards and facility policy. For another resident with a complex medical history including a right foot amputation, diabetes, and impaired skin integrity, the Treatment Administration Record (TAR) showed multiple omissions in the documentation and completion of wound care treatments as ordered by the physician. Observations revealed that the resident's wound dressing had not been changed for several days, despite documentation indicating otherwise. The wound care nurse confirmed that the dressing had not been changed since a specific date, and the wound was observed to be swollen and at risk of dehiscence. There was no documentation of treatment refusals or provider notification regarding missed treatments. Interviews with nursing staff and the Director of Nursing confirmed that treatments and medications were not administered or documented according to orders and policy. Staff acknowledged that refusals and missed treatments were not consistently documented, and that provider notification did not occur as required. Facility policy and professional nursing standards require accurate documentation and timely communication with providers regarding missed medications and treatments, which was not followed in these cases.
Failure to Provide Adequate ADL Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) for a dependent resident, specifically in the area of hair care. The resident, who had hemiplegia and hemiparesis following a cerebral infarction and required assistance with personal care and had reduced mobility, was observed on multiple occasions with greasy and unkempt hair. Documentation showed that showers or bed baths were scheduled and recorded on certain days, but there were gaps in documentation and no record of refusals or incomplete care. The resident reported that her hair was not being washed as frequently as she preferred, and staff interviews confirmed that hair washing was expected to be part of shower or bed bath routines, but it was not always performed or documented. Observations over several days revealed the resident wearing the same clothing and with consistently greasy hair, despite scheduled care. Staff interviews indicated confusion or lack of clarity regarding whether hair washing had been completed, and there was no separate documentation for shampooing in the CNA records. The care plan indicated a preference for bed baths, but there was no evidence that hair care was consistently provided as part of this routine. The lack of documentation and inconsistent care led to the resident's unkempt appearance and unmet personal hygiene needs.
Failure to Administer Medications and Provide Wound Care per Physician Orders
Penalty
Summary
The facility failed to ensure that residents received care and treatment in accordance with physician orders and professional standards, as evidenced by two separate incidents involving two residents. In the first case, a resident with a history of bipolar disorder, depression, and suicidal ideations did not receive her prescribed Wellbutrin XL 150 mg for depression as ordered. During a medication administration observation, the registered nurse reported the medication was not available and did not notify the provider or search for extra medication in the designated area. Further review revealed inconsistent documentation, with one nurse falsely documenting administration of the medication and later admitting the error. The medication had been available in the medication cart, but it was not administered as ordered, and the provider was not notified of missed doses. The nurse practitioner was unaware of the missed doses, despite the resident's complex psychological needs and recent medication adjustments due to worsening symptoms. In the second case, a male resident with a right foot trans metatarsal amputation, diabetes, and a history of foot ulcers did not receive wound care as ordered. The resident's care plan and physician orders specified twice-daily wound care, including cleansing and application of Bacitracin Zinc Ointment, as well as daily monitoring for signs of infection. However, review of the treatment administration record (TAR) revealed multiple omissions in the documentation and completion of wound care treatments. During an observation, the wound care nurse discovered that the resident's dressing had not been changed for several days, with the last documented change occurring several days prior. The nurse confirmed that the dressing should have been changed twice daily, as ordered, and that the omission was not due to resident refusal, as no refusals were documented in the record. Interviews with nursing staff and the director of nursing confirmed that treatments were not provided as ordered and that refusals, if they had occurred, were not documented according to facility policy. The facility's wound management policy requires that wound treatments be provided in accordance with physician orders and that refusals be documented and communicated to the provider. The failure to administer medications and provide wound care as ordered resulted in residents not receiving care in accordance with professional standards and physician directives.
Failure to Apply and Document Prescribed Positioning Devices for Resident with Contracture
Penalty
Summary
The facility failed to ensure that a positioning device was consistently applied for a resident with a right-sided contracture following a stroke. The resident's care plan and Kardex specified that a right upper extremity hand splint should be applied for four hours daily in the morning and a carrot splint should be used as tolerated during the day and night. However, during multiple observations, the resident was seen without any splint or positioning device on his right hand. Interviews with staff, including a CNA and an LPN, revealed that they were unaware of any splint or device to be used for the resident, and the CNA reported never having seen a splint on the resident in her seven months at the facility. Further review of the resident's medical record showed no documentation that the splint or carrot device had been applied as directed in the care plan and Kardex. The Senior Director of Nursing confirmed that the care plan and Kardex included instructions for splinting, and that staff should have documented the application of these devices, but there was no such documentation present. This lack of consistent application and documentation of the prescribed positioning devices constituted a failure to provide appropriate care to maintain or improve the resident's range of motion.
Failure to Ensure Safe Respiratory Care and Adherence to Physician Orders
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents, resulting in deficiencies related to oxygen administration and CPAP use. For one resident with a history of hemiplegia, hemiparesis, and congestive heart failure, observations revealed that her oxygen concentrator was consistently set above the physician-ordered range of 2-4 liters per minute, with settings noted at 4.5 to 5 liters. The nasal cannula was also observed to be improperly applied on several occasions, and staff interviews indicated a lack of clarity regarding responsibility for verifying and adjusting oxygen settings. Another resident with diagnoses including pulmonary embolism and obstructive sleep apnea was observed using a CPAP machine without an active physician order for its use. The resident reported that her CPAP mask had never been cleaned since admission, and the mask was visibly soiled. Although there were orders for daily rinsing of the mask and weekly cleaning of the straps, staff interviews and documentation review revealed inconsistent cleaning practices and a lack of documentation for some days. Staff confirmed that a physician order was required for CPAP use, but none was present in the resident's record. Facility policy required review of physician orders for respiratory equipment and specified cleaning protocols. However, the observed practices did not align with these requirements, as evidenced by improper oxygen administration, lack of active orders for CPAP use, and inadequate cleaning of respiratory equipment. These failures were confirmed through staff interviews, record reviews, and direct observation.
Failure to Document and Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that post-dialysis assessment and monitoring were completed and documented for a resident with end stage renal disease who was dependent on renal dialysis. Review of the resident's records showed there were no current physician's orders for monitoring and assessment upon return from dialysis, and no documentation of post-dialysis assessments, including vital signs, weight, and monitoring of the dialysis access site, after a certain date. Interviews with nursing staff confirmed that the expected practice was to obtain post-dialysis weight, vital signs, assess the dialysis access site, and document findings in a progress note and on the hemodialysis communication record form. However, these assessments and documentation were not completed as required. Further review of medication and treatment administration records revealed that orders for post-dialysis monitoring, including weight, vital signs, and assessment of the AV shunt site, had been discontinued and not reinstated, resulting in a lack of documentation for these parameters over a period of several months. The Director of Nursing acknowledged that the orders had been discontinued and that there was no evidence to show that post-dialysis assessments were completed during this time. This failure resulted in the potential for the resident to not achieve his highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Trauma-Informed Care and Individualized Interventions
Penalty
Summary
The facility failed to identify and address trauma-related triggers and develop individualized care plan interventions for two residents with significant trauma histories. For one resident, who had a complex medical and psychiatric background including bilateral below-knee amputations, schizoaffective disorder, substance use disorder, and a history of homelessness, sexual abuse, and family suicide, the care plan did not include trauma-informed interventions. Despite documentation of nightmares, anxiety, and a history of psychiatric hospitalizations, the social services director confirmed that no trauma assessment or trauma-specific care plan was in place, and staff were not informed of the resident's trauma history or potential triggers. Another resident, who experienced the traumatic loss of her home and pets in a house fire, was observed to be emotionally distressed and reported ongoing anxiety, depression, and stress related to her circumstances. Although her care plan addressed general psychiatric needs such as anxiety and depression, it did not include interventions specific to her trauma from the fire or the loss of her pets. The director of social services was unaware of any trauma-related care plan interventions for this resident and had not referred her to psychological services, despite a physician order for such a consult. The resident expressed that her emotional needs were unmet and that she had not received counseling or guidance regarding her living situation or trauma. Both cases demonstrated that the facility did not conduct adequate trauma assessments or develop trauma-informed care plans, despite clear evidence of traumatic experiences and ongoing emotional distress. The lack of individualized interventions and failure to inform staff of residents' trauma histories resulted in the potential for re-traumatization and unmet emotional needs, as staff were not equipped to recognize or mitigate trauma-related triggers during care.
Failure to Provide Ordered Behavioral Health Services
Penalty
Summary
A deficiency occurred when a resident with diagnoses of acute respiratory failure, generalized anxiety disorder, and major depressive disorder did not receive the necessary behavioral health care and services as required. The resident, who was cognitively intact and admitted for rehabilitation after being rescued from a house fire, reported that she was told she would receive emotional support upon admission but had not received any such services. She expressed a need for psychological support due to trauma from the fire and the loss of her belongings, and stated she previously had a counselor at home. Record review showed a physician's order for a psychological consult for anxiety and a care plan that included behavioral health consults and referrals to social services as needed. However, the Director of Social Services confirmed that no referral to psychological services or counseling had been made, citing the resident's short-term stay as the reason and stating she was unaware of the physician's order. As a result, the resident's psychological support service recommendations were not addressed and support services were not initiated as ordered.
Medication Error Rate Exceeds 5% Due to Insulin, Antidepressant, and Opioid Administration Failures
Penalty
Summary
The facility failed to maintain a medication error rate below 5% during medication administration observations, as evidenced by errors involving two residents. For one resident, a registered nurse administered Lantus insulin from a pen that had been opened 38 days prior, exceeding the manufacturer’s guideline to discard after 28 days from opening. The nurse stated she followed the manufacturer’s expiration date rather than the open date, and the unit manager confirmed that while facility policy required discarding insulin pens 30 days after opening, this was not included in orientation education and was expected knowledge from nursing school. Another resident did not receive a scheduled dose of Wellbutrin 150 mg because the nurse reported the medication was not available and did not check the medication cart’s bottom drawer, where extra medications were stored. The medication administration record showed inconsistent documentation, with the medication marked as given on days when it may not have been administered. Additionally, the same resident was given Oxycodone 5 mg instead of the scheduled Morphine Sulfate ER, and the nurse documented that Morphine had been administered. The nurse later acknowledged the error and indicated she would correct the documentation. Facility policies required medications to be stored according to manufacturer recommendations and for staff to verify medication details, including expiration dates, prior to administration. Observations and interviews revealed lapses in following these policies, including inadequate checks for medication availability and improper administration and documentation of medications. These actions resulted in a medication error rate above the acceptable threshold.
Failure to Store and Manage Medications per Manufacturer and Facility Policy
Penalty
Summary
Facility staff failed to store and manage medications according to manufacturer instructions and facility policy. During medication administration, a registered nurse was observed using an insulin pen that had been opened 38 days prior, despite manufacturer guidelines stating it should be discarded 28 days after opening. Additional insulin pens on the medication cart were found to be opened for 51 and 33 days, both exceeding the facility's policy of discarding after 30 days. The unit manager confirmed that monitoring medication storage was assigned to the third shift, but acknowledged that all nurses should check expiration dates before administering medications. It was also noted that knowledge of insulin pen disposal was not included in the facility's orientation education. Further observations revealed an inhaler left out in a resident's room instead of being stored in the medication cart, and the medication cart itself was disorganized, with medication cards not alphabetized or separated by room. Another inhaler was found in the cart without an open date, making it impossible to determine if it was still within the 6-week usage period specified by the manufacturer. Review of facility policies confirmed that medications are to be stored per manufacturer recommendations and that medication carts should be kept clean and organized, with expiration dates checked prior to administration.
Failure to Implement Policy for Storage of Resident Food Brought by Visitors
Penalty
Summary
The facility failed to fully implement its policy regarding the use and storage of foods brought in by family members and visitors for residents. During a kitchen tour, surveyors observed several food items in the resident refrigerator that were not labeled with opened or discard dates, including prepared macaroni salad, sweet tea, thickened lemon water, and ranch dressing. Additionally, prepackaged apples were found with a 'good through' date that had already passed. These observations indicated that the facility was not consistently ensuring that food items were properly labeled and discarded according to policy. In an interview, the Regional Registered Dietitian (RRD) acknowledged that the resident refrigerator was often in poor condition after weekends and that the Dietary Manager typically checked and discarded unlabeled or outdated items on Monday mornings. The facility's policy required all prepared foods brought in by family or visitors to be labeled with content and date, and to be consumed within three days. The lack of adherence to these procedures resulted in unknown discard dates and potentially hazardous foods being stored past their safe consumption period.
Failure to Implement Safety Measures Leads to Resident Falls
Penalty
Summary
The facility failed to ensure the safety of residents by not fully implementing a documented intervention of 1:1 supervision to prevent a fall for one resident and not ensuring an enabler bar was securely engaged before moving another resident in bed. Resident #102, who had Alzheimer's disease and a history of repeated falls, was supposed to be under 1:1 supervision due to her fall risk. However, the CNA assigned to her left her unattended to assist another resident, during which time Resident #102 attempted to walk without her walker and fell, resulting in a head injury. Resident #102's fall occurred after she was found on the floor by a nurse, having self-transferred without her walker. Despite being on 1:1 supervision, the CNA left her to address another resident's needs, leading to Resident #102 falling and sustaining a head injury. The resident was later found to have multiple hematomas and a large scalp hematoma, indicating a significant injury from the fall. Resident #103, who was cognitively intact, experienced a fall due to an improperly secured enabler bar. While receiving morning care, the resident rolled over and grabbed the bar, which was not locked in place, causing him to fall out of bed and sustain a skin tear on his right forearm. The CNA providing care at the time confirmed that the bar was not properly engaged, leading to the resident's fall.
Failure to Address Call Light Response Concerns
Penalty
Summary
The facility failed to address resident concerns regarding lengthy call light wait times, as documented in the Resident Council Minutes from meetings held on 7/18/24, 10/24/24, and 1/15/25. Despite repeated mentions of the issue, there was no indication of follow-up actions being taken to resolve the concerns. The minutes from these meetings highlighted ongoing dissatisfaction with call light response times, particularly during the 2nd and 3rd shifts and on weekends. Interviews with residents and staff further corroborated the issue. Resident #107 reported waiting up to an hour for call light responses, while Resident #106 experienced wait times of up to 30 minutes, especially during late-night and early-morning hours. Resident #101 noted that response times varied depending on staffing levels, with longer waits occurring when only one CNA was available. Staff members, including CNA J and CNA F, confirmed that residents had complained about long wait times, which were exacerbated by staffing shortages and breaks.
Failure to Serve Food at Palatable Temperature
Penalty
Summary
The facility failed to provide food at a palatable temperature for two residents, resulting in dissatisfaction with meals. Resident #106, who has type 2 diabetes mellitus with diabetic nephropathy and is on long-term insulin use, reported that the food was hardly ever hot enough. Similarly, Resident #101, also diagnosed with type 2 diabetes mellitus, expressed that the food was not always hot, particularly during breakfast. Both residents were cognitively intact, as indicated by their Brief Interview for Mental Status (BIMS) scores of 15. Interviews with multiple staff members, including Certified Nurse Aides (CNAs) and a Registered Nurse (RN), confirmed that residents had complained about the food being served cold. The review of temperature logs showed that while there were no concerns documented for 2/16/25, there were no recorded temperatures for 2/17/25, and no documented temperatures for breakfast or lunch on 2/18/25. This lack of documentation and the consistent complaints from residents and staff highlight the facility's failure to ensure that food was served at a safe and appetizing temperature.
Failure to Provide Requested Food Items
Penalty
Summary
The facility failed to ensure that residents received the food items they requested, leading to dissatisfaction with meals and the potential for nutritional decline. Resident #106, who has type 2 diabetes mellitus and diabetic nephropathy, reported not receiving the correct breakfast items and not getting the substitutions she requested for items she did not eat, such as pork or shellfish. Similarly, Resident #101, also with type 2 diabetes mellitus, reported not receiving the cottage cheese she ordered, instead receiving a hot dog and coleslaw, which she did not request. Interviews with staff, including an LPN, CNAs, and an RN, revealed that residents frequently complained about not receiving their ordered meals. The LPN noted that there was often a delay in updating meal preferences on tray tickets, and sometimes preferences were not communicated to the kitchen. CNAs and the RN reported that residents sometimes did not receive requested beverages, nutritional supplements, or specific meal items, and when attempts were made to retrieve the correct items, they were told the kitchen did not have them. This issue led to residents ordering food from local restaurants instead of eating the meals provided by the facility.
Failure to Administer Oxygen Per Physician Order
Penalty
Summary
The facility failed to administer oxygen to a resident according to the physician's order and professional standards of practice. The resident, who had severe cognitive impairment and multiple diagnoses including obstructive lung disease and heart failure, was observed multiple times without the prescribed continuous oxygen therapy. The oxygen concentrator in the resident's room was found turned off, and the oxygen tubing was improperly stored, not in the designated storage bag, which could lead to cross-contamination. Interviews with staff revealed a lack of awareness and adherence to the resident's oxygen orders. A Licensed Practical Nurse initially stated that the resident did not have orders for oxygen, but later confirmed the resident was on oxygen after reviewing the orders. A Certified Nursing Assistant was observed adjusting the oxygen concentrator to the correct flow rate after noticing it was not set properly. The facility's policy on oxygen administration emphasized the need for proper storage of oxygen delivery devices and adherence to physician orders, which was not followed in this case.
Sanitary Conditions and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all 87 residents. During an initial kitchen tour, it was observed that the reach-in refrigerator had an outside temperature gauge reading of 53 degrees and an inside temperature gauge reading of 46 degrees, both above the recommended 41 degrees Fahrenheit. Despite these high temperatures, the refrigerator remained packed with food. The Maintenance Director attempted to fix the issue by chipping away ice from the fan and using a flame to remove ice, which further increased the temperature. The Dietary Director instructed staff to avoid opening the refrigerator to prevent further temperature increases and later decided to discard all perishable food items. Further observations revealed that the refrigerator was eventually cleared of most food items, except for some condiments and tomatoes, which were later removed. The Nursing Home Administrator was initially unaware of the temperature issue. A follow-up tour found that the three-door continental refrigeration unit was struggling to maintain temperature, and a vendor was scheduled to assess it. Additionally, a spray bottle containing an unidentified green solution was found in the kitchen, and shredded lettuce was improperly stored behind raw pork chops, posing a risk of cross-contamination. These findings indicate a failure to adhere to safe food handling practices as outlined in the FDA Food Code.
Hot Water Temperature Exceeds Safe Levels in B Hall
Penalty
Summary
The facility failed to minimize the risk of scalding and burns by allowing domestic hot water to exceed 120°F in the B hall, resulting in an increased risk of injury among residents. During a tour of the B hall shower room, the hot water was measured at 127°F using a rapid read digital thermometer. Similarly, the hot water in the B hall soiled utility room sink reached 128°F. The Maintenance Director (MD) confirmed that each hall has its own hot water system, and the outgoing hot water to the B hall domestic fixtures was recorded at 128°F without any mixing valves to temper the water. The Maintenance Director was unsure if the temperatures varied throughout the day, as the Maintenance staff typically checks the temperatures in the morning and does not track fluctuations during the day as demand changes.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to ensure proper infection control protocols and practices for several residents, leading to potential risks of infection and cross-contamination. Observations revealed that Enhanced Barrier Precautions (EBP) were not consistently implemented for residents with indwelling medical devices, such as catheters and feeding tubes. For instance, residents with catheters did not have EBP signs posted outside their rooms, and staff did not consistently use personal protective equipment (PPE) when providing care. Additionally, CPAP machines and tubing were not properly cleaned or stored, increasing the risk of infection. In several instances, staff failed to adhere to proper wound care protocols. During wound dressing changes, supplies were placed directly on bed linens without barriers, and contaminated items were not disposed of properly. Staff did not change gloves between tasks, and contaminated scissors were used repeatedly without cleaning. These practices were observed during wound care for residents with pressure ulcers and other wounds, further compromising infection control measures. The facility also demonstrated lapses in maintaining cleanliness of medical equipment and resident areas. Nebulizer machines, IV poles, and feeding pumps were observed with splatters of substances and dust, indicating inadequate cleaning. Feeding tube lines were found on the floor without end caps, posing a risk of contamination. Wheelchairs and other resident equipment were not properly maintained, with non-cleanable surfaces and debris present. These deficiencies highlight a systemic issue with infection control practices within the facility.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from verbal and physical abuse, specifically involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal threats and physical aggression towards staff and other residents. On one occasion, Resident #15 admitted to slapping another resident and expressed a willingness to repeat such actions. Family members were aware of Resident #15's violent behavior, which had occurred multiple times in the past. Resident #40, also cognitively impaired with a BIMS score of 12, was involved in a physical altercation with Resident #15. An incident report detailed that Resident #15 punched Resident #40 in the face after a verbal exchange, where Resident #40 allegedly insulted Resident #15. Staff attempted to intervene but were unable to prevent the physical altercation. Observations noted that Resident #15 continued to exhibit loud and inappropriate behavior, including making sexually inappropriate remarks, without adequate supervision. Interviews with staff revealed ongoing concerns about the interactions between Resident #15 and Resident #40, as both residents were known to treat staff poorly. Despite attempts to monitor and separate the residents, they continued to have verbal and physical altercations. The Nursing Home Administrator was unaware of a recent verbal altercation between the two residents, indicating a lack of effective communication and supervision within the facility.
Failure to Prevent Resident Abuse During Investigation
Penalty
Summary
The facility failed to implement interventions to prevent further abuse during an ongoing investigation involving two residents. Resident #15, who was cognitively impaired with a BIMS score of 11, had a history of aggressive behavior, including verbal aggression and physical altercations with other residents. Despite these behaviors, the facility did not adequately monitor Resident #15, as evidenced by an incident where he punched Resident #40 in the face after a verbal altercation. The care plan for Resident #15 included monitoring when he was around other residents, but this intervention was not effectively implemented. Resident #40, also cognitively impaired with a BIMS score of 12, reported being easily irritated by Resident #15. On one occasion, Resident #15 was left unsupervised in the hallway, where he engaged in loud and inappropriate behavior, leading to another altercation with Resident #40. Staff interviews revealed that the residents frequently encountered each other, exacerbating tensions. Despite the ongoing investigation and previous incidents, the facility did not ensure adequate supervision or separation of the residents to prevent further conflicts.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide the required transfer or discharge notice to two residents, R43 and R30, when they were transferred to the hospital. R43, who was cognitively intact with a BIMS score of 15/15, was transferred to the hospital on 1/27/24 due to an emergency but did not receive the necessary transfer documentation. The Nursing Home Administrator confirmed the absence of the emergent transfer notification for R43. Similarly, R30, who also had a high BIMS score indicating cognitive intactness, was discharged to the hospital due to congestion and shortness of breath but did not receive a written notice of transfer. The medical records for R30 lacked evidence of the required transfer notice documentation. Interviews with facility staff revealed a lack of adherence to the policy regarding transfer/discharge notices. RN AA admitted that she does not send written transfer notices with residents when they are discharged to the hospital. The Director of Nursing, DON B, acknowledged that the transfer/discharge notice should be included in the packet sent to the hospital and recorded in the electronic medical record, but was unsure if this was being consistently done. The facility's policy requires that transfer notices be provided as soon as practicable, but this was not followed in the cases of R43 and R30.
Failure to Provide Bed Hold Policy Notice
Penalty
Summary
The facility failed to notify two residents of the bed hold policy in writing upon their transfer to a hospital, as required by the facility's policy. Resident #30, who was cognitively intact, was discharged to the hospital due to congestion and shortness of breath but did not receive a written bed hold policy notice. During interviews, both the resident and the Director of Nursing confirmed the absence of such documentation in the resident's electronic medical record. The Registered Nurse also admitted that she does not provide a written bed hold policy to residents upon hospital discharge. Similarly, Resident #43, who was also cognitively intact, was transferred to the hospital and did not receive a written bed hold policy notice. The facility's records and an email from the Nursing Home Administrator confirmed the lack of documentation regarding the bed hold policy for this resident. The facility's policy, revised in 2022, mandates that residents or their representatives receive written notice of the bed hold policy at the time of transfer, which was not adhered to in these cases.
Inconsistent IV Antibiotic Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice for medication administration, specifically concerning the administration of IV antibiotics to a resident. The resident, who was admitted with severe sepsis and cellulitis, was prescribed Cefazolin to be administered intravenously three times a day. However, the medication was consistently administered outside the physician-ordered parameters. Observations and interviews revealed that the medication was given late multiple times, and the resident expressed uncertainty about whether the medication was administered at all on some occasions. The Medication Administration Record showed that all 17 doses were administered outside the recommended timeframe. Interviews with nursing staff and the Director of Nursing highlighted a lack of clarity and consistency in administering the medication. A registered nurse admitted to administering the medication late and not labeling the IV bag or tubing. The Director of Nursing mentioned a permissible one-hour window for administration, but the medication was still given outside this timeframe. A nurse practitioner clarified that the medication should be administered every eight hours to maintain consistent blood levels, but this was not reflected in the orders or practice. The lack of specific administration times in the updated order further contributed to the inconsistency in medication administration.
Failure to Provide Necessary ADL Assistance and Equipment
Penalty
Summary
The facility failed to identify and address the need for increased assistance with Activities of Daily Living (ADL) for Resident #67, who was dependent on staff for assistance due to pyogenic arthritis. Despite being cognitively intact, Resident #67 reported worsening knee pain and an inability to walk safely with a walker, which was not addressed by the facility. The resident communicated his need for a wheelchair to the nursing staff, doctor, and therapy department, but no action was taken to provide one. This lack of response resulted in the resident struggling with mobility, experiencing incontinence, and being unable to maintain personal hygiene. Interviews with facility staff revealed a lack of awareness and communication regarding Resident #67's increased needs. The Certified Occupational Therapy Assistant (COTA) assumed the resident had informed the nurses, while the Registered Nurse (RN) and Unit Manager (UM) were unaware of the resident's need for a wheelchair. The resident's family member also reported the resident's inability to walk and the need for assistance, which was not addressed by the facility. The resident's care plan and progress notes indicated a high risk for falling and ongoing knee pain, yet the necessary interventions were not implemented.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary care and services to prevent the worsening of pressure ulcers for Resident #15, who was cognitively impaired and had a history of heart and respiratory failure. The resident had a chronic stage 4 surgical ulcer on the left hip and an unstageable ulcer on the left heel. The care plan required daily dressing changes, but observations and interviews revealed that the dressings were not changed as frequently as ordered. The wound dressings were dated several days prior to the observation, indicating a lack of adherence to the prescribed treatment schedule. Interviews with the resident and a family member highlighted dissatisfaction with the wound care, noting infrequent dressing changes and a foul odor suggesting infection. The wound nurse and floor nurses were responsible for the wound care, but there was a lack of documentation and accountability for ensuring daily dressing changes. The treatment administration record inaccurately documented dressing changes, and there were no physician orders for wound care on specific dates, further indicating a lapse in care. Observations of the wounds showed signs of deterioration, including black crusting and maceration, which were not adequately addressed in the resident's records.
Failure to Maintain Dialysis Communication for a Resident
Penalty
Summary
The facility failed to maintain proper communication and documentation regarding dialysis treatments for a resident with end-stage renal disease who was dependent on dialysis. The resident, who was cognitively intact, had not had any dialysis communication forms uploaded to their medical record since February 17, 2024. Interviews with facility staff revealed that the dialysis communication binder, which was supposed to accompany the resident to and from the dialysis center, was missing, and no communication forms had been received for the past three months. Staff members, including a registered nurse, medical records personnel, and a licensed practical nurse, acknowledged the absence of the communication forms and the lack of documentation in the resident's medical record. The Director of Nursing confirmed that if the binder was missing, no communication was occurring between the facility and the dialysis center. The facility was unable to provide any documentation of communication regarding the resident's dialysis treatments between February 18, 2024, and the date of the survey exit.
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What surveyors actually found near you
We read the 323 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Nursing homes near Kalamazoo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friendship Village | 0.8 mi | ★★★★★ | 15 | 0 |
| Medilodge Of Kalamazoo | 3 mi | ★★★★★ | 4 | 0 |
| Harold And Grace Upjohn Community Care Center | 5.3 mi | ★★★★★ | 34 | 0 |
| Villa At Borgess Place | 5.5 mi | ★★★★★ | 13 | 0 |
| Alamo Cove Rehab And Nursing Center | 6 mi | ★★★★★ | 34 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.