Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation At St. Francis during CMS and state inspections, most recent first.
A resident with a history of suicidal ideation and prior self-harm did not have a standard call light or any documented alternate way to alert staff, despite care plan language stating the call light should be within reach. Staff reported he had previously used the cord in a suicide attempt, but no bell was present in the room during observation. Another resident’s soft touch call light was repeatedly observed on the floor at the foot of the bed and out of reach while the resident rested in bed, contrary to the care plan and facility policy requiring call lights to be accessible.
Survey Results Binder Not Readily Accessible: A family member reported being unable to locate the survey results book for two weeks, and the lobby area where it was usually kept had no binder present. A receptionist could not locate it or recall when it was last seen, and the Administrator later brought the binder while the DON added the most recent survey results. When reviewed, the binder did not contain the facility’s February 2026 annual recertification survey results or approved POC.
Food service staff failed to follow basic sanitation and hand hygiene practices during meal service, including handling resident plates, cups, utensils, and food after touching clothing and without hand hygiene. Kitchen observations found a visibly soiled meat slicer and mixer, leaking dishwasher equipment, dishes stored wet, cut onions held at 49 degrees F, and widespread buildup of dust, debris, and residue on multiple food service surfaces and equipment. Cleaning logs were outdated or inconsistently completed, and the ice machine cleaning log showed the last cleaning on 1/2/2026.
Infection prevention and control was deficient because the facility lacked an active Legionella and OPPP water management plan, with observations of unused or obstructed plumbing fixtures, a zero chlorine reading at a hand sink, and limited flushing logs for only select areas. Staff also failed to perform hand hygiene during dining service, with CNAs and activity staff moving from resident to resident without washing or sanitizing hands, and nursing staff failed to clean glucometers after blood glucose checks before returning them to the med cart drawer.
Improper backflow prevention was observed at multiple plumbing fixtures. Surveyors found a spray nozzle downstream of a hose bib vacuum breaker in the dishwasher area, a utility sink with an attached hose and chemical feed downstream of an AVB in the wheelchair washing station room, and a spray nozzle downstream of an AVB on an outside spigot in the courtyard. The report states that AVBs cannot be under continuous pressure for more than 12 hours and that a valve on a hose downstream of an AVB is not allowed.
Multiple residents had missed meds, glucose checks, vital signs, and skilled charting when an LPN became behind during a shift involving resident concerns and a new admission. Records showed missed antihypertensives, diabetes meds, pain meds, supplements, and other scheduled treatments, and the LPN stated help was not requested and the MD was not notified of the missed care.
Medication carts and a med room had multiple labeling and storage problems. An opened Tagamet box was expired, several inhalers, a TB skin test vial, an insulin pen, a nasal spray, and an Enulose bottle lacked open dates or proper labeling, and a dirty UTI Heal bottle was also observed. Staff gave keys to a supply worker who entered the med room alone, and an unlocked med cart was left unattended near a resident at the nurses' station. Expired culture swabs and a bag of medication cards were also found in the med room, including items stored on the floor.
The facility failed to provide adequate nursing staff to meet residents’ care needs, particularly on afternoon and evening shifts, resulting in prolonged call light response times, staff turning off call lights without assisting, and repeated reports of missed or delayed care. Residents with PICC lines, dialysis access, infections, and IV antibiotics described inconsistent help, with some days having enough staff and other days very few. Multiple residents reported waiting hours for incontinence care, meal corrections, and other assistance, and resident council notes over several months documented ongoing concerns about missed showers, infrequent checks and changes, double‑briefing, CNAs using phones during care, and insufficient CNA presence in the dining room during meals. The facility’s staffing assessment listed nurse numbers by shift but did not define resident acuity or complexity despite the high‑acuity population.
A resident’s right to self-determination was not honored when staff continued giving Sodium Bicarbonate and Lexapro despite her stated wish to stop them. The resident said she had no heartburn, indigestion, or depression, and the record showed Lexapro was reduced without documentation of a discussion or informed consent, with no risk-versus-benefit documentation found for antidepressant monitoring.
A resident with ESRD and hyperphosphatemia did not receive Sevelamer carbonate for an extended period because staff could not obtain a refill through the dialysis pharmacy process. MARs and progress notes showed repeated entries that the medication was not available, while interviews confirmed the nurse, dialysis RD, and unit manager were aware of the issue but the refill was not secured in time.
Failure to implement GDR for a resident on fluoxetine. A resident with depression, anxiety, and adjustment disorder was receiving Prozac for targeted behaviors including agitation, withdrawal, and verbal aggression. Psychiatry documented that dose reduction and GDR were being pursued, but the facility did not follow through when the recommendation was made, and the DON agreed the GDR should have occurred but was missed.
A resident with a PEG tube and multiple complex medical conditions was not placed on Enhanced Barrier Precautions (EBP) despite facility policy and CDC guidance requiring EBP for residents with indwelling medical devices. Surveyors observed no EBP signage, no PPE supply or receptacle at the room, and the resident reported that staff did not wear gowns when providing care or handling tube feedings. Chart review showed multiple orders and care plan interventions related to tube feeding and site care, but no EBP order or EBP-related care plan interventions. During interviews, the DON/ICP confirmed that feeding tubes require EBP, that residents on EBP should have door signage and PPE available, and that this resident had not been identified or managed under EBP since admission, leading to the cited infection prevention and control deficiency.
A resident’s trust funds were not reimbursed after death. Record review found no scanned trust fund agreement, balance, or reimbursement documentation in the chart, and the Administrator later produced an invoice showing a $118.39 balance that was mailed to the resident’s daughter much later. The DOR stated the delay had no reason and was an oversight by multiple parties.
A resident with severe cognitive impairment, a history of falls, and multiple comorbidities experienced two falls within eight days. After the first fall, no new supervision interventions were added to the care plan. The second fall occurred when the resident, left unsupervised in a wheelchair, stood up, tripped, and sustained a head injury requiring hospitalization. Increased supervision was only implemented after the second incident.
The facility failed to administer scheduled 5:00 PM medications to multiple residents, including critical medications for conditions like DVT/PE and diabetes. An LPN left at 4:00 PM, and the oncoming RN did not administer the medications. The facility did not conduct audits to monitor medication administration compliance.
A resident experienced significant weight fluctuations, ranging from 10 to 82 pounds over short periods, which were not adequately investigated by the facility. Despite being weighed almost daily due to conditions like lymphedema and heart failure, the facility failed to address these discrepancies. The Registered Dietitian noted the fluctuations but did not take further action, and the facility's weight management policy was not consistently followed.
Surveyors found that the facility could not provide adequate documentation to verify that all fire-rated doors had been inspected annually as required. The only available record was an invoice lacking itemized inspection details or criteria, and it could not be confirmed that all necessary doors were inspected.
The facility did not provide adequate documentation to verify that all electrical receptacles in patient care areas were inspected and tested annually as required, and the records submitted lacked itemized details and inspection criteria, making it impossible to confirm compliance.
A facility failed to prevent a Stage III pressure ulcer in a resident, leading to infection and hospitalization. Another resident with existing DTIs was not repositioned as per care plan, resulting in new wounds. Inadequate documentation and communication contributed to these deficiencies.
The facility failed to conduct annual performance reviews for five CNAs, with the last evaluations completed in October 2023. The Human Resources Director noted that annual competency classes are held instead of evaluations based on hire dates. The Unit Manager/Educator, who started in October 2024, was initially focused on other tasks and became aware of the issue a month before the survey. This deficiency could lead to unmet resident care needs.
The facility failed to follow its medication management policies, resulting in unlocked medication carts, undated and expired medications, and improper storage practices. An LPN left a cart unattended, and inspections revealed open, undated, and expired medications, as well as improper storage of non-medication items. A soiled syringe was found in a cart, indicating hygiene issues. These actions violated the facility's policy for secure and accurate medication handling.
Two residents in the facility did not receive adequate bathing and hygiene care. One resident was observed with greasy, unkempt hair and reported not having a shower in a long time, preferring bed baths that did not include hair washing. Another resident had long, dirty fingernails and reported infrequent brief changes and discomfort with the shower chair, with no alternatives offered. The call light was found out of reach, and staff were slow to respond. The facility's policy on call light accessibility was not followed.
The facility failed to complete nursing assessments for two residents, leading to delays in treatment for bowel management and a skin rash. A resident developed a rash from incontinence briefs, which was not documented promptly, causing discomfort. Another resident experienced a lack of communication regarding bowel movements, resulting in delayed care for constipation. The facility lacked a bowel management policy, contributing to these deficiencies.
A facility failed to ensure safe administration and maintenance of a PowerMidline IV catheter for a resident, leading to improper medication reconstitution and inappropriate flushing technique. An LPN did not properly reconstitute Cefepime in a Duplex IV bag, used outdated IV tubing, and failed to disinfect the catheter hub correctly. The LPN also did not check for blood return, indicating a lack of knowledge of facility policies and professional standards. The resident, with a history of acute cystitis and other conditions, required ongoing antibiotic treatment, but the facility staff did not adhere to the care plan and physician orders.
A resident with severe cognitive impairment and multiple diagnoses was not provided with necessary behavioral health services, resulting in emotional distress and a lack of timely assessment and consent for mental health services. Despite frequent crying and expressions of wanting to go home, the facility did not engage a mental health provider or implement effective non-pharmacological interventions.
The facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, resulting in improper sanitization of kitchenware and soiled floors and equipment. Used gloves were found on the ground, and the floor near the stove and sink was visibly soiled. The dishwasher was not tested for appropriate sanitization temperatures, and ice machines had residue buildup. Facility policies on warewashing and equipment maintenance were not consistently followed, leading to unsanitary conditions.
The facility was found to have significant cleanliness issues, including dust-filled heater covers, cobwebs, spiders, and dirty floors in the main dining room, activity room, and several residents' rooms. Observations were made with facility staff, who acknowledged the unclean conditions. The facility's cleaning policy was not effectively implemented, leading to the deficiency.
A resident with COPD and lung cancer was left without a clean urinal, leading to the use of a dirty, discolored one. The facility's supply rooms were found to be lacking urinals, and staff initially provided an inappropriate substitute. The resident expressed that this was a recurring issue, and the Unit Manager confirmed the absence of urinals, later stating that some were purchased externally.
A resident who had undergone hip surgery experienced significant pain due to the facility's failure to provide timely pain management. Despite being in pain and crying throughout the night, the resident did not receive pain medication until the following morning. Medical records showed a delay in administering the prescribed Hydrocodone-Acetaminophen, with the first documented administration occurring nearly 15 hours after admission. Although a tablet was signed out of the Omnicell system, there was no documentation confirming its administration to the resident.
A resident with Crohn's Disease and other conditions was found with medication cups and loose pills on the floor, indicating a failure in medication administration. The resident, who did not wish to self-administer medications, was unsure about the spilled pills. The facility's policy to remain with residents until medication administration is complete was not followed.
A facility failed to prevent and document pressure ulcers for two residents. One resident was found with an abrasion and a deep tissue injury due to not wearing a prescribed Profa boot and lack of repositioning. Another resident developed a Stage III pressure ulcer and a Stage II ulcer due to inadequate monitoring and documentation. The facility's guidelines for skin and wound care were not followed, compromising residents' health.
Two residents experienced inadequate incontinence care, leading to complaints and potential health risks. One resident, with severe cognitive impairment, was found with a wet brief and an abrasion, while another resident reported long wait times for care. Both residents received insufficient incontinence changes, highlighting systemic issues in the facility's care practices.
Call Lights Not Accessible or Available to Residents
Penalty
Summary
The facility failed to ensure that Resident #2 had an appropriate means to summon staff and that Resident #6’s call light remained within reach. Resident #2 was observed in a room without a standard call light; the wall panel had a black dowel where the cord would connect, and the resident stated the facility had taken the call light because staff thought he was going to hang himself and never returned it. He reported using his roommate’s call light, but no other accommodation was in place to alert staff when he needed assistance. Record review showed Resident #2 was admitted with diagnoses including vascular dementia, Parkinson’s disease, major depressive disorder, bipolar II disorder, anxiety, and suicidal ideations. His care plan stated to anticipate and meet needs and to keep the call light within reach, but the record contained no alternative arrangement for the removed call light. Staff interviews indicated the resident had not had a standard call light for some time because he had wrapped it around his neck in a prior suicide attempt, and one nurse stated he should have a bell to ring, although no bell was present during observation. The DON also stated the resident should have his own mechanism to alert staff, but the care plan did not reflect the safety concern or alternative method. Resident #6 was observed with a soft touch call light on the floor next to the dresser at the foot of the bed while he was resting at the opposite end of the bed, making it inaccessible. The resident’s record listed diagnoses including anoxic brain damage, anxiety disorder, vascular dementia, diabetes, and hypertension, and his care plan stated he should have a soft touch call light attached to his clothing as he allowed. The call light remained on the floor during repeated observations throughout the day, and the DON acknowledged it should have been within reach. The facility policy stated call lights should be plugged in, functioning, and within reach of residents.
Survey Results Binder Not Readily Accessible
Penalty
Summary
The facility failed to have the results of the most recent survey readily accessible to residents, families, and legal representatives. On 5/7/2026 at approximately 11:00 AM, a family member reported being unable to locate the survey results book for the past two weeks and stated it was usually kept in the lobby under the bulletin board on a brown high-top table. The referenced area was observed and no survey results book or binder was present. A receptionist was asked about the binder’s location, stated it should have been on the high-top table in the lobby, and then searched her area without finding it; she also could not recall the last time she had seen the binder and contacted the Administrator. At approximately 11:20 AM, the binder still had not been provided, and it was reported that the Administrator was bringing it. The Administrator was observed reviewing the survey book, and the DON handed her the most recent 2026 survey results to add into the binder. When the binder was reviewed at approximately 11:40 AM, the facility’s February 2026 annual recertification survey results and approved plan of correction were not in the book.
Food Service Sanitation, Hand Hygiene, and Temperature Control Deficiencies
Penalty
Summary
Food service practices were not maintained in accordance with professional standards during meal service and kitchen operations. During lunch observation, a CNA carried a resident’s plate with thumbs touching the inside of the plate near the food, then handled a lidded cup and straw while removing the lid and filling the cup with juice. The CNA did not perform hand hygiene before continuing to assist other residents with meal service. In a separate lunch observation, another CNA stood up, pulled up pants with hands touching the inside of the waistband and skin, then returned to assist a resident with eating by picking up the resident’s fork and offering bites of food without performing hand hygiene. Kitchen sanitation and equipment conditions were also observed to be poor. A meat slicer in dry storage was visibly soiled, and a mixer had visible residue. Ready-to-use dishes were stacked with droplets of water running down the sides instead of being stored in a self-draining position. The dishwasher booster pump filter was leaking a steady stream of water onto the floor, and the facility’s food service manager stated the leak was already known and expected to be fixed later in the week. Cut onions were observed sitting on a lid on top of the steam table and were measured at 49 degrees F during lunch service, above the facility’s stated cold-holding expectation of 40 degrees or lower and above the Food Code requirement of 41 degrees F or less. The kitchen tour also identified widespread soiling and outdated cleaning documentation. Observations included dust, debris, food residue, stains, and unknown substances on racks, carts, microwaves, the pop station, the ice machine, the juice dispenser gun, the top of the dishwasher, refrigerator surfaces, cooler fans, freezer flaps, and other kitchen equipment. Cleaning logs in the blue binder were dated 2025, and dietary staff were unsure where the 2026 forms were. The food service manager stated daily and deep cleaning logs were completed by staff, but the January and February 2025 logs had been altered to read 2026, and the dates and days of the week did not match. Review of kitchen cleaning logs from November 2025 through February 2026 showed they were not consistently completed on a daily and/or weekly basis, and the ice machine cleaning log showed the ice machine was last cleaned on 1/2/2026.
Infection Prevention Deficiencies in Dining Hygiene, Glucometer Cleaning, and Water System Management
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an active plan for reducing the risk of Legionella and other opportunistic pathogens of premise plumbing. Survey observations found a shut-off drinking fountain with the bubbler removed near a resident room, a utility sink with a broken faucet lever in a soiled utility room, a tub in a shower room with supplies stored inside it, and another utility sink in a soiled utility room with a chair and oxygen rack stored in the basin. The Housekeeping Manager stated that the utility sinks were not used, and the Maintenance Director stated he had started at the facility 4 days earlier and was not sure whether the utility sinks in the soiled utility rooms were flushed. Record review showed the facility’s flushing logs only included weekly flushing of the janitor’s closet, bathroom in the first room, and priest hall P3 and P4, and that hot water tanks were flushed for 30 seconds monthly. During testing, the chlorine result at the hand sink in the physical therapy room was zero. CDC guidance reviewed during the survey stated to eliminate dead legs, ensure disinfectant residual is detectable throughout the potable water system, and flush low-flow piping runs and dead legs at least weekly, as well as infrequently used fixtures regularly as needed to maintain water quality parameters within control limits. The facility also failed to ensure adequate staff hand hygiene during dining service and failed to ensure nursing staff cleaned glucose monitors after use. During observation of the main dining room, CNAs and activity staff applied clothing protectors and moved from resident to resident without hand washing between residents, while nurses passed medications to residents seated at tables. During breakfast tray service, CNAs went from the kitchen window to residents at tables and back without hand sanitizing or washing, and one CNA put her hands into her pockets before touching the next resident’s meal plate. For blood glucose monitoring, one nurse returned a glucometer to the medication cart drawer without cleansing it, and another nurse returned a glucometer to the drawer after using it and gave inconsistent responses about what product was used to clean it. The DON later stated that the glucometer was to be cleaned with purple-top Sani-Cloth germicidal disposable wipes, allowed to dry, and then returned.
Improper Backflow Prevention at Plumbing Fixtures
Penalty
Summary
The facility failed to ensure that appropriate backflow prevention was installed at plumbing fixtures. During observation and record review, surveyors found a spray nozzle downstream of a hose bib vacuum breaker in the dishwasher area, a utility sink with an attached hose and chemical feed downstream of an atmospheric vacuum breaker in the wheelchair washing station room, and a spray nozzle downstream of an atmospheric vacuum breaker on an outside spigot in the courtyard. The report also notes that atmospheric vacuum breakers shall not be installed where they will be under continuous pressure for more than 12 hours and that a valve on a hose downstream of an AVB is not allowed because AVBs cannot be subject to continuous pressure.
Missed medications and required assessments for multiple residents
Penalty
Summary
The facility failed to provide nursing services for multiple residents on the [NAME] Nursing Unit, with survey findings showing missed medications, missed blood glucose monitoring, missed skilled charting assessments, and missed vital signs. The report identified residents #19, #48, #42, #58, #93, #83, #84, #86, and #89 as affected. The facility’s abuse policy defined neglect as failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and the medication administration policy required medications to be administered according to physician orders and prescribed frequency. Resident #48 had diagnoses including diabetes type 2, stroke with speaking difficulty, Alzheimer’s, and hypertension. On 2/9/2026, multiple scheduled medications were missed, including amlodipine, aspirin, vitamin D, donepezil, insulin glargine, atorvastatin, vitamin B12, acetaminophen, gabapentin, and insulin lispro. The resident also did not receive three consecutive glucose checks and scheduled insulin doses at 0700, 1100, and 1600. Nurse E stated they were busy with another resident’s concerns, then a new admission, and acknowledged they should have asked for help but did not tell the physician about the missed medications. Resident #93 had diagnoses including urinary tract infection, cellulitis of the left lower limb, and encephalopathy. On 2/9/2026, multiple medications were missed, including ferrous sulfate, folic acid, magnesium oxide, omeprazole, oxybutynin, prednisone, vitamin B12, diphenhydramine, bumetanide, metoprolol, and potassium chloride. The record also showed Nurse E did not complete the pain assessment, vital signs assessment, or physician-ordered weight assessment that day. Resident #19 also had missed medications on 2/9/2026, including bupropion and vitamin B-complex, and Nurse E stated they got busy and was not able to administer the medications and did not alert the physician. Additional residents had missed care and documentation. Resident #58 missed multiple medications including aspirin, glimepiride, hydrochlorothiazide, losartan, Steglatro, metformin, metoprolol, multivitamin, carbidopa-levodopa, and house med pass supplements. Resident #42 missed multiple medications including amlodipine, aspirin, clopidogrel, house liquid protein, losartan, omeprazole, zinc, carvedilol, hydrocodone-acetaminophen, insulin lispro, metformin, acetaminophen, and gabapentin, and Nurse E failed to assess glucose checks and skin assessment. Residents #83, #84, #86, and #89 also had missed medications, missed skilled charting, missed vital signs, and missed supplemental med pass documentation, with notes repeatedly stating medications were too late to administer due to admission, resident problems and concerns, and no documentation that the physician or resident/resident representative were notified.
Medication Labeling and Secure Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. During observation of the men's medication cart on the St [NAME] wing, an opened box of Tagamet was found with an expiration date of 6/2025, an open Ventolin inhaler did not have an open date, and an opened Combivent inhaler also lacked an open date. During observation of the Madona hall men's medication cart, a multidose vial of TB skin test solution was stored in a drawer without an open date, an insulin pen was stored without a resident name or open date, an opened nasal spray had no documented open date, and an opened Enulose bottle did not have an open date documented. UTI Heal supplement was also observed dirty with dried supplement streaks on the bottle. Medication storage was also not maintained securely. At the 100 Hall nurses' station, staff brought a cart of supplies and requested keys to the medication storage area. A nurse gave the keys to the staff member, who unlocked and entered the medication room alone while the nurse did not accompany them. On Madona hall, a resident was observed behind the nurses' station eating near an unlocked medication cart, with no nurse in the immediate vicinity. When the nurse returned, the unsecured cart was locked. Additional storage concerns were identified in the Madona hall medication room and on the medication cart. Two culture swabs with expiration dates in 2024 were found in the medication storage room, and a bag of medication cards with medications was stored on the floor next to the medication storage system. The Unit Manager stated the bag was for pharmacy return and that it should not have been stored on the floor. The Unit Manager also stated that central supply staff should be with a nurse to stock the med room and that the nurse should not hand over the keys to access the med room. Facility policy reviewed by the surveyor stated to keep the medication cart clean, organized, and stocked, and to lock the medication cart when not in direct view of the nurse administering medications.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs, particularly on the afternoon and evening shifts, despite a policy stating that staffing would be based on resident population and acuity and would ensure competent care 24/7. Multiple residents reported prolonged call light response times, sometimes up to two hours or more, and staff turning off call lights without providing the requested assistance or asking what was needed. Resident council minutes over a six‑month period documented repeated concerns about inadequate staffing, including missed showers, residents not being checked and changed every two hours, residents being double‑briefed, and CNAs disappearing from the dining room during meals. Several residents with significant medical needs described unmet care needs related to staffing shortages. One resident with a right upper arm PICC line, a dialysis port in the right chest, and scheduled hemodialysis three times weekly, as well as IV Micafungin therapy, reported that some days there were enough helpers and other days there were none, describing staffing as “feast or famine,” and noted not going to the therapy gym despite being in the facility for rehab. Another resident with a left upper arm PICC line for treatment of a right foot infection complained of call light wait times of about two hours and agreed with her roommate that the facility was short staffed. Other residents reported specific care delays and omissions tied to low staffing, especially on the afternoon shift. One resident stated she was supposed to have her brief checked or changed every two hours but sometimes waited four to six hours, had soiled herself while waiting, and once activated her call light at 8:30 p.m. and did not receive help until bedtime. Another resident reported waiting two hours after receiving the wrong lunch tray, with staff shutting off the call light and not returning. Additional residents stated that afternoon shift staff took longer to answer call lights, that aides would enter the room and shut off the call light without asking what was needed, and that aides had to be told not to use their phones in resident care areas. The facility assessment listed general nurse staffing numbers but did not define resident acuity or complexity, despite the presence of residents with high‑acuity needs.
Failure to Honor Resident Choice and Obtain Informed Consent for Medication Changes
Penalty
Summary
The facility failed to honor one resident’s right to self-determination by not respecting her wishes to discontinue medications and by not obtaining informed consent for a dosage change. The resident stated that she had told the facility she did not want Sodium Bicarbonate or Escitalopram Oxalate (Lexapro), but the medications were still being administered. She reported no heartburn, indigestion, or depression, denied suicidal ideations, homicidal ideations, and other signs or symptoms of depression, and stated she had much to live for and look forward to. Record review showed the resident was admitted with diagnoses including heart disease, major depression, diabetes, kidney disease, and hypertension, and that she was able to make her needs known. Lexapro was initially ordered at 10 mg daily and was reduced to 5 mg daily after a gradual dose reduction, but there was nothing in the progress notes showing a discussion with the resident about the dose decrease or that she was given the opportunity to express that she no longer wanted the medication. The chart also contained no risk-versus-benefit or informed consent documentation for antidepressant medication monitoring. The resident refused Sodium Bicarbonate 13 times in January 2026 and 14 times in February 2026, and the unit manager stated the resident no longer wanted the medication and had been refusing it.
Delayed Dialysis Medication Refill
Penalty
Summary
The facility failed to provide timely dialysis-related medication services for a resident with end stage renal disease who required Sevelamer carbonate 800 mg three times daily for hyperphosphatemia. The resident was admitted with diagnoses including malignant neoplasm of prostate, congestive heart failure, diabetes, end stage renal disease, and atrial fibrillation, and was observed waiting for transport to dialysis while able to make his needs known to staff. Medication administration records and progress notes showed repeated documentation that Sevelamer was not available, with entries noting that staff sent messages to dialysis, re-attempted to obtain refill instructions, and recorded the medication as not available on multiple occasions. The chart reflected that the resident had been without the medication since approximately mid-January 2026, and the MAR documentation was inconsistent regarding the missed doses. Practitioner notes did not document that the resident was not receiving Sevelamer during this period. Interviews confirmed the lapse in medication availability. A nurse stated the medication was not in the cart for the resident and that attempts to refill it were unsuccessful because the pharmacy required a dialysis clinic number and the dialysis dietitian was not immediately available. The dialysis dietitian reported the medication was ordered through the dialysis pharmacy and mailed to the facility, taking about 5 to 7 business days to arrive, and stated the facility needed to contact him before the medication was depleted. The unit manager stated she became aware the resident did not have the medication the prior week and had not followed up, and the facility policy required licensed nurses to collaborate with the physician to ensure medications were given per order, including coordination with the dialysis facility.
Failure to Implement GDR for Psychotropic Medication
Penalty
Summary
The facility failed to implement its psychotropic medication policy for one resident receiving fluoxetine for depression, anxiety, and adjustment disorder. The policy stated that residents using psychotropic medications should receive gradual dose reductions unless clinically contraindicated, and that a gradual dose reduction should be attempted in two separate quarters and then at least annually thereafter. Resident #8 was receiving fluoxetine 60 mg total daily, with medication administration records showing 40 mg and 20 mg capsules daily, and the resident’s record identified targeted behaviors of agitation, decreased socialization/withdrawal, and verbal aggression. Record review showed psychiatry documentation on 9/24/2025 stating that dose reduction and GDR were being pursued for the resident’s fluoxetine, and a later psychiatry note on 11/26/2025 stated that Prozac had been decreased from 60 mg to 50 mg daily as part of a gradual dose reduction plan. During interview and record review with the DON, the surveyor pointed out the documented GDR recommendation from psychiatry, but the DON reviewed the physician orders and MARs and agreed that a GDR should have occurred in September 2025 and was missed. The record also reflected psychiatry notes in December 2025 recommending GDR with no follow-up from facility physicians/providers.
Failure to Implement Enhanced Barrier Precautions for Resident With PEG Tube
Penalty
Summary
The deficiency involves the facility’s failure to implement its own Enhanced Barrier Precautions (EBP) policy for a resident with an indwelling percutaneous endoscopic gastrostomy (PEG) tube. The resident was admitted for skilled nursing care with multiple diagnoses including cerebral edema, oropharyngeal dysphagia, severe protein-calorie malnutrition, metastatic lung cancer with bone metastases, and had a PEG tube placed prior to or at the time of admission. The resident’s MDS showed a BIMS score of 11/15, indicating moderately impaired cognition. Facility policy and the DON/Infection Control Preventionist’s (ICP) own EBP quick reference guide both identified feeding tubes as indwelling medical devices that require EBP. On observation of the resident’s room, surveyors noted there was no EBP signage posted on the door, no PPE immediately present at the door, and no PPE receptacle in the room. The resident reported that staff assisted with daily care such as showers and that he could perform his own oral care and grooming, and ambulate to the restroom with a walker, but he stated that staff did not wear gowns when providing care or handling his tube feeding or dressing, questioning why they would need a gown. This contrasted with the facility’s EBP policy, which required gown and glove use during high-contact resident care activities and care and use of indwelling medical devices, including feeding tubes. Record review showed multiple orders related to the PEG tube, including checking the tube site every shift for signs of infection and complications, monitoring for signs of misplaced tube, changing the irrigation kit every 24 hours, and providing enteral tube site care. However, there were no orders for EBP in the resident’s chart. The resident’s care plan addressed nutritional risk and the need for a feeding tube, including interventions for tube feeding administration, tube placement checks, positioning, lab monitoring, and reporting signs and symptoms of infection, but it did not include any interventions related to EBP. The DON/ICP confirmed during interview that residents with indwelling devices such as feeding tubes are required to be on EBP, that residents on EBP should have signage on the door and PPE available, and that the facility only had EBP in place at that time. During a hall walk-through, the DON/ICP identified five residents on EBP based on posted signage, but did not identify this resident. After reviewing the resident’s chart, care plan, Kardex, and orders, the DON/ICP acknowledged there was no EBP sign, no EBP order, and no EBP care plan for this resident and stated that staff had probably not followed EBP for the resident since admission because of this lack of identification and documentation. The facility’s written EBP policy specified that residents with indwelling medical devices, including feeding tubes, are required to be placed in EBP, that a physician order is to be obtained, that EBP signage is to be posted outside the resident’s room, and that gowns and gloves are to be available outside the room and used during high-contact resident care activities and care of indwelling devices. The policy also stated that EBP should be maintained for the duration of the resident’s stay or until the indwelling device is discontinued. CDC guidance reviewed by surveyors similarly indicated that EBP are recommended for residents with indwelling medical devices, even without known MDRO colonization or infection. Despite these clear policy and guidance requirements, the resident with a PEG tube was not placed on EBP, had no related orders or care plan interventions, and staff did not use gowns and gloves for high-contact care or PEG-related care, resulting in the cited deficiency.
Failure to Reimburse Resident Trust Funds After Death
Penalty
Summary
The facility failed to reimburse trust funds for one resident after the resident died, resulting in the resident’s trust funds not being reimbursed upon death. Record review showed the resident died in the facility on 11/13/2024 at 5:35 AM, and the electronic medical record contained no scanned documentation in the miscellaneous tab regarding a trust fund agreement, balances, or reimbursements. When the Interim DON was interviewed, she confirmed the resident had passed away in November 2024. The Administrator later provided a reimbursement invoice showing a trust fund balance of $118.39 and stated the check was mailed to the resident’s daughter. During a subsequent interview, the DOR stated there was no reason the trust fund was not reimbursed when the resident died and that it was an oversight on the part of multiple parties.
Failure to Provide Adequate Supervision for High-Risk Resident
Penalty
Summary
A resident with a history of falls, severe cognitive impairment (BIMS score of 0), and multiple diagnoses including Alzheimer's disease, dementia, muscle weakness, and reduced mobility, was admitted to the facility and experienced two falls within eight days. The first fall occurred by the resident's bed, with no injury documented and no new interventions for increased supervision added to the care plan. The resident's care plan included a low bed and orientation to the call light, but did not address the need for increased supervision despite the resident's repeated self-transfer attempts, poor safety awareness, and failure to use the call light. The second fall occurred when the resident, left unsupervised in a wheelchair near fire doors, stood up, tripped over the foot pedals, and fell, striking her head on a metal door frame. The incident was captured on facility video, and staff at the nursing station did not have the resident in view at the time. The resident sustained a laceration above the left eye, a skin tear on the nose, pain, and required hospitalization and admission to the ICU. Increased supervision was only added to the care plan after this second fall with injury.
Failure to Administer Scheduled Medications
Penalty
Summary
The facility failed to ensure that medications were administered to multiple residents, including four sampled residents and ten unsampled residents, on the evening of February 25, 2025. Observations and record reviews revealed that medications scheduled for 5:00 PM were not administered to residents, including critical medications such as Xarelto for deep vein thrombosis/pulmonary embolism and insulin for diabetes management. The Medication Administration Records (MAR) for these residents were not signed, indicating that the medications were not given, and there was no documentation of medication refusal. Interviews with facility staff revealed a breakdown in the medication administration process. Licensed Practical Nurse (LPN) H, who was responsible for administering medications, left the facility at 4:00 PM, and the oncoming nurse, Registered Nurse P, did not administer the 5:00 PM medications. The facility's policy requires medications to be administered according to physician orders and documented in the MAR, but this was not followed. Additionally, the facility did not conduct audits or reviews of medication administration records to monitor compliance, contributing to the oversight.
Plan Of Correction
F760 Residents are Free of Significant Med Errors Element 1: Residents #702 and #705 continue to reside within the facility. An audit was conducted to ensure both residents have been receiving their medications per physician orders. Resident #703 and #704 no longer resides in the facility. Element 2: Like residents were identified as residents who reside in the facility. Like residents have been audited to ensure their medications have been being administered per the physician orders. Element 3: The procedure to implement the plan of correction included: 1. IDT reviewed F760. 2. IDT reviewed the Medication Administration policy and deemed appropriate. 3. RN/LPN were re-educated on the Medication Administration policy on ensuring medications are always administered. Element 4: The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly to ensure medication are signed out and administered. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.
Failure to Address Significant Weight Fluctuations in Resident
Penalty
Summary
The facility failed to address significant weight fluctuations in a resident, identified as Resident #701, who was being monitored for weight loss. The resident had a history of lymphedema, cellulitis, congestive heart failure, anxiety, and an ulcer on the left lower leg. Despite being weighed almost daily, the resident's weight varied dramatically, with differences ranging from 10 to 82 pounds over short periods. These fluctuations were not meaningfully investigated or addressed by the facility, and there was no substantial intervention to determine the accuracy of the weights recorded. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and a Certified Nursing Assistant (CNA), revealed that the weight discrepancies were noted but not adequately addressed. The ADON and CNA reweighed the resident after noticing an 82-pound drop in three days, confirming the weight but failing to investigate further. The Registered Dietitian (RD) acknowledged the weight fluctuations but attributed them to the resident's disease process and did not take further action to address the inconsistencies. The RD's progress notes were contradictory, as they mentioned both intended weight loss and a lack of discussion with the resident about such plans. The facility's policy on weights required reweighs when a resident's weight changed by more than five pounds, but this was not consistently followed. The RD's documentation did not provide a clear explanation for the extreme weight variations, and there was no documentation around the time of the most significant weight drop. The facility did not provide additional documentation to explain the weight variations, indicating a lack of compliance with their weight management program.
Plan Of Correction
F692 Nutrition/Hydration Status Maintenance Element 1 Resident #701 currently does not reside within the facility. Element 2 Like residents were identified as residents that reside within the facility. Like residents was audited to ensure they have accurate weight. A facility weight schedule was audited to ensure residents have been weighed and documented accurately. Element 3 The procedure to implement the plan of correction included: 1. IDT reviewed F692. 2. The weight schedule was reviewed and deemed appropriate. 3. The policy Weight was reviewed and deemed appropriate. 4. CNAs and Nurses were re-educated on the documentation of weight with emphasis on ensuring weights are documented accurately. 5. Dietician was re-educated on addressing fluctuations on residents weights. Element 4 The process to ensure that the specific citation remains corrected includes: 1. The Director of Nursing / Designee will audit 10 residents weekly scheduled for weights to ensure they have been provided and documented accurately. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. 2. The Administrator will be responsible for sustained compliance.
Failure to Document Annual Fire Door Inspections
Penalty
Summary
The facility failed to provide documentation verifying that all fire-rated doors were inspected annually as required by NFPA 101 and NFPA 80 standards. During a record review, surveyors were unable to obtain evidence that annual inspections of all facility fire doors had been completed, as the documentation was not immediately available and was later provided via email. Upon review, the provided document was an invoice from a door service company that did not include an itemized inspection of all fire doors or any criteria used for the inspection, making it impossible to confirm that all required doors were inspected. These findings were confirmed through an interview with the maintenance director.
Failure to Document and Verify Annual Electrical Receptacle Inspections
Penalty
Summary
The facility failed to ensure that all patient-care related electrical equipment, specifically electrical receptacles in patient care vicinities, were inspected and tested annually as required by the 2012 NFPA 99 standards. During a record review, the facility was unable to produce documentation verifying that these inspections and tests had been completed for all relevant receptacles. The maintenance director indicated that the administrator had the documentation, but the administrator was unavailable at the time of the review. Later, the inspection documentation was provided via email by the administrator. However, upon review, the document titled "Receptacle Tests (patient care vicinity)" did not contain an itemized inspection of all facility electrical receptacles in the patient care vicinity, nor did it list any criteria for the inspection of individual receptacles. As a result, it could not be verified that all receptacles were inspected as required. These findings were confirmed through an interview with the maintenance director.
Failure to Prevent and Manage Pressure Ulcers
Penalty
Summary
The facility failed to prevent the development of a Stage III coccyx pressure ulcer for a resident, resulting in an infected ulcer requiring IV antibiotics and hospitalization. The resident, who had been admitted to the facility after a hospital stay for COVID-19 and pneumonia, was found to have a large Stage III pressure ulcer on the coccyx area upon discharge to an assisted living facility. The ulcer was not documented upon admission, and there was a lack of consistent documentation and communication regarding the resident's skin condition. The resident's family member reported that the resident was often found soiled and wet, and the resident did not have any pressure ulcers upon admission to the facility. Another resident, who was admitted with deep tissue injuries (DTIs) on their left ankle and both heels, was observed with their heels positioned directly against the bed and the footrest of a Broda chair, contrary to care plan interventions. The resident was severely cognitively impaired and required maximum assistance with daily activities. Observations revealed that the resident was not repositioned for several hours, and new wounds were discovered on the resident's coccyx and left thigh, the latter potentially caused by the Hoyer sling used for transfers. The facility's documentation was incomplete, with several treatments not recorded as completed in the resident's treatment administration record. The facility's policies required weekly skin checks and documentation of any skin abnormalities, but these were not consistently followed. The lack of adherence to care plans and failure to document and communicate skin conditions contributed to the development and worsening of pressure ulcers for both residents. The facility's failure to implement meaningful and planned interventions resulted in significant harm and the potential for delayed healing of pressure ulcers.
Failure to Complete Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to complete a performance review every 12 months for five Certified Nurse Aides (CNAs) reviewed for annual performance evaluations. This deficiency was identified during a review of human resource files, which revealed that the last completed annual skills checks for CNAs S, T, U, V, and X were in October 2023, with no evaluations conducted in 2024. The Human Resources Director explained that the facility holds annual competency classes for staff instead of basing them on individual hire dates, and noted that the 2023 competencies were filed with completion dates spread over several months. An interview with the Unit Manager/Educator, who assumed the role in October 2024, revealed that his initial focus was on Unit Manager tasks, and he became aware of the incomplete skills checks about a month prior to the survey. The facility's policy, dated February 2024, requires skills evaluations to be completed during job-specific orientation, re-validated annually, and completed as needed, with the employee's immediate supervisor responsible for the annual review. The lack of timely performance reviews resulted in the potential for inadequate and unmet resident care needs.
Medication Management Deficiencies
Penalty
Summary
The facility failed to adhere to its policies and procedures for medication and medical supply labeling, storage, and disposal, as observed in one medication room and two medication carts. On one occasion, an LPN left a medication cart unlocked and unattended in a hallway, which was later confirmed by the LPN to be against facility policy. During a tour of the medication cart, several issues were identified, including open and undated medications, expired medications, and medications not stored according to manufacturer recommendations. For instance, an open and undated foil pouch of Ipratropium/Albuterol inhalation solution was found, which should have been used within a week of opening according to manufacturer guidelines. Further inspection revealed additional deficiencies, such as an earwax removal kit and several inhalers that were either expired or not dated upon opening. A Proheal Liquid Wound Recovery container was found open and undated, and insulin for a discharged resident was still present. The LPN was unable to complete a narcotic medication count due to time constraints, highlighting a lack of proper medication management. In the medication room, non-medication items like batteries were improperly stored in the medication refrigerator, and several expired medications and supplies were found, including fecal occult blood test kits and various liquid medications. In another medication cart, an expired urinary pain relief supplement and an open, undated inhalation solution were found. A visibly soiled oral syringe was stored with other medications, and the LPN confirmed that there were no extra syringes available, indicating improper storage and hygiene practices. The facility's policy requires accurate labeling, dating, and secure storage of medications, which was not followed, leading to the potential for residents to receive medications with altered efficacy.
Failure to Provide Adequate Bathing and Hygiene Care
Penalty
Summary
The facility failed to provide adequate bathing and hygiene care for two residents, resulting in a lack of showers, nail care, and personal hygiene. Resident #7 was observed in bed with greasy, unkempt hair and unshaven. The resident reported not having had a shower in a long time and preferred bed baths due to difficulty sitting up. However, the resident indicated that their hair was not washed during bed baths. The electronic medical record showed only two instances of bathing in the past 30 days, despite the resident's care plan indicating a need for assistance with bathing and grooming. Resident #59 was also observed in bed with long, dirty fingernails and reported dissatisfaction with the care received, specifically mentioning infrequent brief changes and bathing. The resident stated that the shower chair was uncomfortable and had informed staff, but no alternatives were offered. The resident's electronic medical record documented only two instances of bathing in the past 30 days, with no recorded refusals of care, despite the resident's complaints about the shower chair. Additionally, Resident #59's call light was found on the floor, out of reach, and the resident reported that staff were slow to respond and complained when the call light was used. The facility's policy requires call lights to be within reach and functioning, but this was not adhered to in this case. Interviews with staff confirmed that refusals of care should be documented, but this was not consistently done for Resident #59.
Failure to Complete Nursing Assessments Leads to Delayed Care
Penalty
Summary
The facility failed to complete nursing assessments for two residents, resulting in delays in treatment for bowel management and a skin rash. Resident #231 developed a rash on her coccyx and back, which she attributed to the briefs used for incontinence care. Despite the rash causing significant discomfort, it was not documented in her medical records until several days after it began. The facility's policy required body audits and documentation of skin conditions, but these were not followed, leading to a delay in addressing the rash. Resident #71 experienced a lack of communication among staff regarding bowel movements. Despite informing staff of not having a bowel movement for several days, no action was taken until the resident requested assistance again. The resident's medical records showed a history of gastrointestinal issues, but there was no care plan in place for bowel management. The facility's process for monitoring bowel movements was not effectively communicated to the nursing staff, resulting in a delay in addressing the resident's constipation. Interviews with staff revealed a lack of awareness and communication regarding the residents' conditions. The Director of Nursing was unaware of Resident #71's prolonged period without a bowel movement and acknowledged the need for a bowel assessment. The facility lacked a policy for bowel management, contributing to the oversight in care for Resident #71. These deficiencies highlight a failure in the facility's processes for monitoring and documenting resident conditions, leading to delays in necessary care.
Failure in Safe IV Administration and Midline Care
Penalty
Summary
The facility failed to ensure the safe administration and maintenance of a PowerMidline IV catheter for a resident, resulting in improper medication reconstitution, inappropriate flushing technique, and lack of adherence to infection control standards. During an observation, a Licensed Practical Nurse (LPN) was seen administering Cefepime, an antibiotic, without properly reconstituting the medication in a Duplex IV bag. The LPN did not mix the medication with the diluent as required, nor did they check for particulate matter before administration. Additionally, the LPN used outdated IV tubing and did not follow the correct procedure for disinfecting the IV catheter hub, failing to allow the alcohol to dry before connecting the flush. The LPN also did not check for blood return before administering the medication, which is a critical step to confirm the patency of the midline catheter. When questioned, the LPN admitted to not knowing the facility's policy on checking for blood return or the proper flushing technique, which should involve a pulsating motion. The LPN's lack of knowledge extended to the importance of blood return and the potential impact of extremity positioning on blood return, indicating a significant gap in training and adherence to professional standards. The resident involved had a history of acute cystitis, transient ischemic attack, diabetes mellitus, and orthostatic hypotension. They were cognitively intact and required supervision for certain activities of daily living. The resident had recently returned from the hospital with a midline catheter inserted for ongoing antibiotic treatment. Despite the care plan and physician orders outlining the necessary steps for midline care, the facility staff failed to implement these procedures, leading to potential risks for the resident's health.
Failure to Provide Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident, resulting in a lack of timely and ongoing assessment of distress related to adjustment, and timely evaluation for consent to receive behavioral health services. The resident, who was admitted with diagnoses including cerebral infarction, Multiple Sclerosis, and aphasia, was observed to be severely cognitively impaired and required maximum assistance with daily activities. Despite these needs, the resident's care plan lacked specific non-pharmacological interventions and did not address the resident's emotional and psychosocial distress. Observations revealed that the resident frequently cried and expressed a desire to go home, indicating emotional distress. Facility staff were present but did not provide emotional support or engage with the resident during these episodes. The resident's care plan included interventions such as offering reassurance and encouraging verbalization of needs, but these were not effectively implemented. Additionally, the resident had been moved from short-term to long-term care, which contributed to their distress, yet there was no documentation of a mental health provider evaluation or consent for such services. Interviews with facility staff, including the Director of Nursing and Social Work Designee, confirmed the lack of mental health provider involvement and the absence of a consent/declination form for mental health services. The facility's policy required assessment and interventions for behavioral health needs, but these were not adequately addressed for the resident. The initiation of an antidepressant medication was noted, but no further mental health evaluation was pursued, highlighting a significant gap in the resident's care plan and the facility's response to their emotional and psychosocial needs.
Sanitation Deficiencies in Kitchen and Nourishment Rooms
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and nourishment rooms, leading to improper sanitization of kitchenware and soiled floors and equipment. During a tour of the kitchen, used gloves were found on the ground, and a container of oats had an unsecured lid. The floor near the stove and the three-compartment sink was visibly soiled with dirt, debris, and food particles. Additionally, vents were covered with thick dust, and a metal plate behind the juice machine had multiple residue streaks. The three-compartment sink could not be tested for sanitization as the quaternary sanitizer tape had expired, and no additional strips were available. In the dishwashing area, debris had accumulated across the floor, and the walls were speckled with dried substances. Dietary staff failed to test the dishwasher for appropriate sanitization temperatures before use, and the last recorded test was several days prior. The dishwasher had been serviced due to a malfunction, but the dietary aide was unaware of the requirement to test the temperature daily. The nourishment rooms also had issues, with ice machines showing residue buildup and water spigots having brown and yellow residues. Maintenance staff reported frequent clogs in the ice machine drainpipes due to improper disposal of items. The facility's policies on warewashing and kitchen equipment maintenance were not consistently followed. The policies required daily temperature checks of the dishwasher and regular cleaning of floors and equipment, but these tasks were not completed as required. The facility's cleaning logs were not consistently maintained, and the new cleaning log was only recently developed. Maintenance and housekeeping staff were unclear about their responsibilities for cleaning specific areas, leading to unsanitary conditions in the kitchen and nourishment rooms.
Facility Fails to Maintain Clean Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for residents, staff, and the public, as evidenced by observations of unclean conditions in various areas. During a survey, it was noted that the main dining room, main activity room, and several residents' rooms had significant cleanliness issues. These included dust-filled heater covers and ceiling vents, cobwebs and spiders, dirty floors and baseboards, and evidence of ceiling or roof leakage. The observations were made in the presence of facility staff, including the Housekeeping Supervisor, Unit Manager, and Infection Control Nurse, who acknowledged the unclean conditions. Specific rooms were found to have dirty baseboards, cobwebs, and spiders, with some rooms having brown residue on the floors and walls. The main dining room had cobwebs in the ceiling corners, dusty mini-split AC units, and heater fan covers with dusty debris. The main activity room also had cobwebs and a fan cover with a large amount of dust buildup. Additionally, the shower room near one of the rooms had a fan cover with dusty buildup. Maintenance staff confirmed that there had been a roof leak, which had been repaired, but the residue from the leak was still visible. The facility's policy on routine cleaning and disinfection was reviewed, which stated that the facility should ensure a safe, sanitary environment to prevent infections. However, the observations indicated that the policy was not being effectively implemented, as evidenced by the widespread unclean conditions throughout the facility. The staff's acknowledgment of the issues suggests a lack of adherence to the cleaning protocols, contributing to the deficiency.
Failure to Provide Clean Urinals for Resident
Penalty
Summary
The facility failed to ensure dignity and provide a clean urinal for a resident, resulting in the use of an old, discolored, and dirty urinal. On December 23, 2024, a resident requested a new urinal from a staff member, who returned with a graduate container instead, stating there were no urinals available. The resident mentioned that the facility often runs out of urinals and had to dispose of their previous one because it was turning black after about a month of use. An observation of the disposed urinal confirmed it appeared old with dark brown residue and a black bottom. Further investigation revealed that the facility's clean supply rooms, including the main central supply room, had no urinals available for male residents. The Unit Manager acknowledged the lack of urinals and mentioned that they believed some were purchased from an external source. The resident, who had a medical history of Chronic Obstructive Pulmonary Disease (COPD), lung cancer, and muscle weakness, required assistance with activities of daily living and was happy with the new urinal they eventually received.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely pain management for a resident who had undergone hip surgery, resulting in the resident experiencing significant pain. The resident, who was admitted to the facility with a femur fracture and had undergone Open Reduction Internal Fixation surgery, reported not receiving adequate pain medication on the first night of their stay. Despite being in pain and crying throughout the night, the resident did not receive pain medication until the following morning when a manager intervened. The resident's pain level was reported to be at an 11 during the night, and it took several days to bring the pain under control. A review of the resident's medical records revealed that they were admitted to the facility in the evening and were prescribed Hydrocodone-Acetaminophen for pain management. However, there was a significant delay in administering the medication, with the first documented administration occurring nearly 15 hours after admission. Although a Hydrocodone tablet was signed out of the Omnicell system the night of admission, there was no documentation confirming its administration to the resident. The resident's admission assessment indicated a pain level of 6, yet no additional pain medication was provided until the next morning, nearly 8 hours later.
Medication Administration Failure
Penalty
Summary
The facility failed to ensure proper medication administration for a resident, resulting in significant medication errors. During an observation, it was found that a resident had three medication cups and loose pills scattered on the floor. The resident was unable to recall when the pills were spilled or what they were for. Additionally, a medication cup with two pills was found on the over-bed table, which the resident speculated might be steroids or stomach-coating medication. The Unit Manager, upon entering the room, confirmed that the pills should not have been on the floor and proceeded to collect and dispose of them. A review of the resident's electronic medical record indicated an admission with conditions including Crohn's Disease, debility, and sepsis, with the resident having intact cognition and requiring assistance with activities of daily living. The Medication Administration Record showed no missed or refused medications, and the resident had previously indicated they did not wish to self-administer medications. The facility's medication administration policy requires staff to remain with residents until medication administration is complete, which was not adhered to in this instance.
Failure to Prevent and Document Pressure Ulcers
Penalty
Summary
The facility failed to prevent and document the occurrence of skin abrasions and deep tissue injuries for two residents. One resident was observed with an abrasion on the left lateral hip and a deep tissue injury on the right heel. The resident was found asleep with the head of the bed elevated, slumped to the bottom of the bed, and without the prescribed Profa boot, which was found in the closet. The resident's care plan required the Profa boot to be worn at all times, but this was not adhered to. Additionally, the resident was observed with a wet brief and a whole baby carrot in her mouth, indicating a lack of proper monitoring and repositioning. Another resident developed a pressure ulcer on the left heel, which progressed to a Stage III pressure ulcer, and a pressure ulcer on the left foot's fifth toe, which increased in size to a Stage II ulcer. The resident was identified as high risk for developing pressure ulcers due to requiring total assistance with bed mobility and transfers. Despite this, the resident's wounds were not adequately monitored or documented, as evidenced by the progression of the ulcers. The facility's new electronic records system, implemented in August, may have contributed to the lack of proper documentation and monitoring. The facility's 'Skin and Wound Guidelines' outlined the necessary steps for identifying residents at risk for pressure injuries and the interventions required for management. However, these guidelines were not followed, leading to the development and worsening of pressure ulcers in the residents. The failure to adhere to care plans and properly document and monitor skin conditions resulted in skin breakdown, pain, and the potential for infection, compromising the residents' overall health and wellbeing.
Inadequate Incontinence Care and Resident Neglect
Penalty
Summary
The facility failed to provide consistent incontinence care for two residents, leading to complaints and potential health risks. Resident #1, who has severe cognitive impairment and multiple medical conditions, was observed in a state of neglect. The resident was found asleep with a wet brief and an abrasion on the left hip/abdomen area. The resident's oxygen was not properly administered, and the Profa boot, which was supposed to be on, was found in the closet. The resident had not been repositioned for several hours, and the oxygen concentrator was running without being connected to the resident. Resident #4, who is cognitively intact but physically dependent, reported long wait times for incontinence care, particularly during the second shift. The resident expressed embarrassment and frustration due to staff reactions when incontinence incidents occurred. The resident's medical history includes a range of conditions such as anemia, hypertension, and diabetes, which necessitate attentive care. Documentation revealed that both residents received only 1 to 3 incontinence changes daily, which is insufficient given their needs. The observations and interviews indicate a systemic issue with incontinence care in the facility, affecting the dignity and health of the residents. The lack of timely and adequate care increases the risk of skin breakdown and other complications. The facility's failure to adhere to its own incontinence care policy and the residents' care plans contributed to the deficiencies noted by the surveyors.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 185 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Saginaw
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Covenant Skilled Nursing And Rehabilitation At Wel | 2.2 mi | ★★★★★ | 15 | 0 |
| Healthsource Saginaw, Inc | 2.4 mi | ★★★★★ | 3 | 0 |
| Saginaw Senior Care And Rehabilitation Center, Llc | 3.3 mi | ★★★★★ | 8 | 0 |
| Adira Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 13 | 0 |
| Great Lakes Rehabilitation Center | 4.8 mi | ★★★★★ | 24 | 0 |
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