Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health And Rehabilitation Of Canton during CMS and state inspections, most recent first.
A resident with paraplegia, blindness, muscle weakness, and moderately impaired cognition, who was on Eliquis and care planned for a two-person assist with bed mobility and ADLs, was being changed in bed by a single CNA. The CNA rolled the resident to the far side of the bed, removed her hands, and walked around to the other side, during which the resident rolled off the bed. The CNA acknowledged that the Kardex required a two-person assist and that the resident should have been rolled toward, not away. The resident was hospitalized with a closed head injury, abdominal hematoma, and a closed femur fracture, with ED records documenting a rollover fall from bed during clothing change and subsequent treatment including blood transfusion and pain management.
Surveyors found that staff failed to use required PPE and follow hand hygiene while providing incontinence and hygiene care to two residents on EBP, one with a stage III pressure ulcer and one with a PEG tube, despite facility policy requiring gowns and gloves for such residents. A CNA reported being in a hurry and not noticing EBP signage, and an LPN and the DON confirmed that gowns and hand hygiene between residents were expected. Review of the infection control binder showed no documented infection control program for several months and missing elements such as antibiotic stewardship, staff education and competency checks, environmental audits, outbreak preparedness, hand hygiene/PPE/cleaning audits, McGeer Criteria, and outbreak investigations, and the requested infection control policy was not provided by survey exit.
The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its policy and CDC core elements, including monitoring antibiotic use, tracking resistance, and following McGeer’s criteria and diagnostic testing protocols before initiating antibiotics. The written policy required complete antibiotic orders with indication and stop dates and tracking of adherence to clinical documentation and culture practices. However, during a review with the DON and a corporate nurse, surveyors found that documentation for the Antibiotic Stewardship Program was missing for several months, and an internal audit had already identified inadequate documentation, indicating the program was not properly implemented and had the potential to affect all residents.
A resident with progressive MS, neuromuscular bladder dysfunction, and total dependence for ADLs reported that night-shift staff ignored call lights and verbal calls for help, leaving him in a soiled brief for hours and leading him to call 911 multiple times when he could not reach staff by call light or phone. Police and fire reports documented unanswered calls to the facility, staff unaware of the resident’s needs until prompted by first responders, and nurses observed on personal phones before attending to the resident. The resident stated these concerns were ongoing and had been reported to prior administrators and nursing staff, while the current administrator denied knowledge of the complaints, despite a facility policy guaranteeing freedom from abuse and neglect.
A resident who was totally dependent for ADLs and had progressive MS, neuromuscular bladder dysfunction, and moderate cognitive impairment reported lying in a soiled brief for about four hours after requesting help, ultimately calling 911 twice when staff did not respond and the brief was not changed. The resident also described chronic issues with night-shift call lights going unanswered for over two hours, staff sitting in the hall on their phones, missed bed baths, rude agency CNAs, and staff cursing at patients. Only one grievance form was found documenting these concerns, which noted that staff education would occur, but there was no evidence the education was completed. The DON gave inconsistent statements about awareness of the 911 incident and did not respond to follow-up from external authorities, and the facility did not follow its own grievance policy requiring thorough investigation and resolution of alleged neglect.
The facility failed to develop and revise a comprehensive care plan for a resident with progressive MS, anxiety, MDD, neuromuscular bladder dysfunction, and protein-calorie malnutrition who was cognitively impaired and fully dependent for ADLs. The existing behavior/mood care plan listed general interventions such as medication administration, distraction, offering choices, psych consults, and redirection, and also included an unexplained entry stating the resident "Calls police and Fire Department." Despite multiple documented incidents in which the resident called 911 when night staff did not respond to call lights, the care plan did not include specific interventions to prevent recurrence, did not address the resident’s stated concern about not wanting agency staff to provide care, and did not incorporate reported safety measures or the resident’s hospice status, contrary to the facility’s own care plan revision policy.
Surveyors found that two residents with urinary incontinence were not provided appropriate care when a CNA delayed incontinence care despite a strong urine odor and then was observed removing multiple layers of clothing and two incontinence briefs from each resident, with one brief placed inside another. One resident had multiple comorbidities, moderate cognitive impairment, and a care plan requiring assistance with ADLs and toileting. An LPN and the DON stated that staff are not allowed to double brief and are expected to check and change residents per policy, while a resident reported that staff double brief at night, and the written incontinence policy did not address the use of multiple briefs.
A resident with multiple comorbidities, including CHF, COPD, CKD stage 3, heart failure, and difficulty walking, and with a stage III sacral/coccyx pressure ulcer treated with zinc oxide and alginate, was observed during incontinence care wearing two briefs, with one brief placed inside another. The CNA performing care stated this was not considered double briefing because the inner brief was not closed. The resident’s MDS showed moderate cognitive impairment and an ADL care plan calling for assistance with toileting in bed. The wound care nurse stated that residents with this type of wound should not have multiple briefs due to moisture impeding healing, and the DON confirmed staff are not to double brief and are expected to follow policy for checking and changing residents.
A resident with paraplegia, muscle weakness, legal blindness, and moderately impaired cognition, care-planned for a two-person assist with bed mobility and in-bed toileting, fell from bed and sustained serious injuries while a CNA was changing an incontinence brief alone. The CNA reported rolling the resident away from themselves and that the resident then rolled off the bed while the CNA moved to the other side, and acknowledged having provided this care alone multiple times despite the two-person assist requirement. The CNA stated they had not received training on bed mobility at the facility and were not educated after the fall, while leadership later confirmed that the educator/trainer role had not been fully functioning for several months, contrary to facility policy requiring skills evaluations at orientation and at least annually.
The facility exhibited systemic operational failures, including lack of adequate supervision and transfer assistance that led to a resident fall with fracture and hospitalization, and absence of a system to monitor and coordinate agency and nursing staff competency over several months. There was no consistent infection control program, and staff turnover contributed to confusion on the night shift about who was in charge, with staff directed to call the DON for problems. A resident’s neglect complaints about call lights not being answered for more than two hours were reported to the Administrator and DON without evidence of investigation or reporting to the State Agency. Incontinence care practices included double briefing of two residents, causing strong odor and potential loss of dignity. Multiple reports from residents, families, and local fire/police showed that calls to the facility during the night went unanswered, which surveyors confirmed when calls rang and went to voicemail while phones were not audible to staff. Leadership changes followed an incomplete internal audit and insufficient departmental action and documentation.
A resident with significant communication impairment and a history of stroke was reported by family to have an unexplained lip issue and to be upset about it. The social worker documented the family’s concern and a subsequent visit where the resident pointed to their mouth and indicated a desire to see someone, but no skin or oral assessment was documented in the EHR. An LPN stated they observed a small, dried crack on the resident’s bottom lip but did not document the finding or conduct any interviews. The DON later produced a paper investigation file concluding the resident bit down on a toothbrush during oral care, based solely on an unsigned statement from a single agency CNA, with no additional interviews, assessments, or documentation. These actions did not follow the facility’s abuse policy requiring a timely, thorough, and well-documented investigation of alleged injuries of unknown source.
A resident with a history of recurrent UTIs and abdominal pain had multiple NP orders for a UA with C&S, but staff failed to obtain the specimen in a timely manner. After an initial refusal of straight catheterization documented by an LPN, there was no documentation of further attempts to collect urine despite care plan information showing the resident was usually continent and able to use the toilet with assistance. The NP re-ordered the UA twice before an RN ultimately obtained a clean-catch urine sample using a collection hat in the toilet, highlighting a prolonged delay in following the ordered diagnostic testing.
A resident with intact cognition who required assistance with most ADLs reported that a CNA knew the resident was wet but delayed providing incontinence care for about an hour, then yelled at the resident for several minutes while changing them after the resident requested a clean gown and sheet. The CNA stated they did not have time to obtain the requested items and would return later, leaving the resident feeling degraded, humiliated, anxious, and uncomfortable. The CNA did not return with the clean linens for approximately two more hours, during which the resident remained in urine. During interviews, the resident became tearful when recounting the incident, and facility leadership later confirmed that the conduct constituted verbal abuse and neglect under the facility’s abuse policy.
A resident admitted with frostbitten feet and intact cognition was documented on admission as having frostbite to both feet, but staff did not obtain physician orders or document assessment, monitoring, or treatment of the feet or dressings. A family member reported that the resident arrived with bandages on both feet, reminded staff that the bandages had not been changed, and later found the same original hospital bandages still in place with a foul odor before calling emergency services for hospital transfer. Review of records showed no related orders, no detailed nursing assessments of the feet, and no skin care plan interventions for the foot wounds, despite facility policy requiring evaluation and documentation of skin alterations by a licensed nurse.
Failure to Prevent Resident-to-Resident Abuse: Two residents with documented behavior issues became involved in a verbal and physical altercation after a hallway exchange of profanity and confrontation. One resident, with COPD, adjustment disorder, and intact cognition, had care plans noting argumentative and verbally aggressive behavior toward peers, while the other resident had cerebral infarction, vascular dementia, bipolar disorder, and a behavior problem related to yelling at staff and others. The incident escalated when one resident ran toward the other, grabbed and pulled hair, and caused both the resident and an RN to fall to the floor; prior records also showed earlier conflict between the same residents and multiple room/unit moves for the resident with aggressive behaviors.
Failure to timely report resident abuse and resident-to-resident altercations to the State Agency. Two residents had a verbal altercation after one resident swore at the roommate, and another incident involved an argument in which one resident was observed pushing another resident. The NHA confirmed both events were reportable, but one was not brought to leadership until days later and the other was not reported because the event was not communicated to the NHA. The involved residents were cognitively intact per MDS, and one resident had diagnoses including major depression, RA, and hand contractures while the other had ESRD, immunodeficiency, DM2, HF, and dialysis dependence.
Failure to provide bathing and grooming per resident preference was identified for two residents. One resident with cerebral infarction, vascular dementia, and bipolar disorder had inconsistent shower documentation, missing nursing notes for refusals, and family reported regular showers were not being provided. Another resident with left femur fracture, Parkinsonism, sarcoidosis, and CHF was observed with a full beard and stated he had not been shaved since admission; staff confirmed shaving was not provided as expected despite the care plan for daily hygiene and grooming.
A resident with hemiplegia/hemiparesis, vascular dementia, aphasia, and gastrostomy status had repeated falls during care and while near the bed. Surveyors observed the bed in elevated transfer positions rather than low, and the resident’s care plan did not include a 2-person assist for bed mobility until later, despite PT and DON statements that the resident was totally dependent for bed mobility and needed 2 staff for brief changes. The resident sustained head injury and facial laceration during one fall when being rolled onto his side.
The facility failed to keep accurate resident records when an LPN documented a high-calorie supplement as given before it was actually administered to a resident with dysphagia and other neurologic conditions. The facility also documented a hospital transfer as due to a fall even though the resident had been sent to the ER after a resident-to-resident altercation, and it did not include an earlier resident assault in the medical record. The DON confirmed the missing documentation and the inaccurate transfer information.
Failure to initiate CPR for a resident found unresponsive with absent VS. Staff called a code and 911, but CPR was not started because they relied on a DNR order that lacked valid authority documentation. The chart contained conflicting code status entries, and the resident’s paperwork only showed HIPAA/financial POA authority, not medical decision-making authority.
Kitchen Surfaces and Utensils Not Kept Clean: During a kitchen tour, the DM observed a soiled rubber bumper on a reach-in juice cooler, a stained drip tray on the ice dispenser with food debris inside, debris and trash on the floor behind equipment, and four ladles stored bowl side up with dried food residue. The DM stated the ice machine was not clean and that the ladles needed to be cleaned; the NHA later stated the kitchen should be clean and sanitary.
Improper Disposal and Poor Maintenance of Outside Garbage Area: The outside dumpster area was observed with open or obstructed dumpster lids, trash and debris piled behind the dumpsters, a trash can lid wedged underneath a dumpster, a partially closed 55-gallon trash can, and standing water on a trash container lid. The NHA stated staff were expected to keep garbage container lids closed and the area clear, and also stated the facility did not have a policy for maintenance of the outside garbage area.
Kitchen equipment was not maintained in proper working order when surveyors observed a handwashing sink faucet that would not fully shut off, a leaking commercial ice dispenser drain pipe, and a walk-in freezer at 12 F. A cup of ice cream stored in the freezer was soft instead of frozen solid, while the freezer log showed 8 F. The DM said maintenance would be contacted, and the MD said he was unaware of the current leaks and the faucet issue.
The facility did not timely report suspected abuse, neglect, or theft, nor did it report the results of its investigation to the proper authorities as required.
Failure to obtain informed consent for psychotropic meds affected two residents. One resident with dementia, depression, and moderately impaired cognition had trazodone and citalopram ordered, but the record lacked guardian consent even though the resident had guardianship. Another resident with vascular dementia, delusions, and severe cognitive impairment was prescribed Depakote for behaviors, but the psych med consent did not include Depakote and resident representative consent was not obtained until later; staff also reported no psych notes showing the psych NP discussed the medication with the representative.
A resident with severe cognitive impairment and multiple serious diagnoses was sent out for a scheduled cranioplasty, but the record lacked a transfer form, progress note, or physician order documenting the transfer. The UM/LPN could not confirm where the resident went, the mode of transfer, or the resident’s condition on departure, and the DON stated the nurse on shift was responsible for documenting resident transfers and departure details.
PASARR screening was not completed annually for a resident with vascular dementia, delusional disorders, major depressive disorder, psychotic disorder with delusions, and severe cognitive impairment. The record contained an older PASARR, and a current PASARR was only provided after the State Agency inquiry. The SW stated the annual PASARR should have been completed earlier, while the DON said social services was responsible for it and the NHA acknowledged it was not done timely.
A resident with cancer-related pain and a pathological fracture was taken to therapy before receiving scheduled pain medication. She reported severe pain and could only tolerate about 10 minutes of therapy before it was stopped. An LPN, PTA, DON, and DT all confirmed that therapy and nursing did not coordinate pain control before the session, and the therapy note documented that treatment was limited by pain.
Failure to provide meals or snacks for residents attending dialysis. Two residents with ESRD reported they were not given breakfast before or after dialysis and were not sent snacks to take with them. One resident also had severe protein-calorie malnutrition and nutritional risk, while records and care plans for both residents called for food to be provided on dialysis days. Staff stated nursing was responsible for offering a snack or meal, and the facility policy allowed early meal service, a meal/snack sent with the resident, or late meal service after return.
A medication cart on Cherry Hall was found with 12 loose pills scattered in the bottom of a drawer, along with a pack of cigarettes and dust. Nurse M was interviewed about the findings, and Nurse G stated the cart should be cleaned by dayshift and midnight nurses. The DON said nurses and nurse managers were expected to check and clean the medication carts on their units.
A resident with severe cognitive impairment and a history of agitation was found sleeping with her head on a nurses' station desktop, unsupervised and not positioned with dignity. The RN responsible acknowledged this was not appropriate, and the DON confirmed it did not meet facility standards for resident dignity, despite care plan interventions for supervision and visibility.
A resident was found sleeping in a wheelchair with her head on the nurse's station desk while a Nurse Practitioner was present but not attending to her, and no other staff were in the area. This situation failed to uphold the resident's dignity as required by federal regulations.
A resident with a PEG tube and a history of dysphagia was observed self-administering oral medications without staff supervision, contrary to physician orders specifying administration via PEG tube. The LPN confirmed that the resident had not been assessed for self-administration, and the facility's policy requiring direct observation during medication pass was not followed.
A resident with a PEG tube and a history of dysphagia and aspiration was observed self-administering whole pills orally without staff supervision, despite physician orders specifying medication administration via PEG tube. Staff interviews confirmed the resident was at high risk for aspiration, and there was no assessment or care plan allowing self-administration of medications by mouth.
A resident with a PEG tube and history of dysphagia was observed self-administering oral medications without staff supervision, despite the MAR indicating medications were given via PEG tube. An LPN confirmed the medications were given orally and not as documented, and there was no assessment, care plan, or order for self-administration in the resident's record.
The facility failed to provide adequate shower linens, resulting in an unclean environment. Observations showed insufficient linens, with staff using alternatives like pillowcases. Two residents, one with pressure ulcers and another post-joint replacement, were directly affected, having to reuse or purchase personal supplies. The facility's linen guidelines were not followed, and the NHA was unaware of the shortage.
A resident's wireless earbuds were misappropriated by a facility housekeeper. The resident, in short-term rehab care, used an app to locate the missing earbuds on the housekeeper's cart. An investigation, including security footage review, confirmed the misappropriation, leading to the housekeeper's termination.
The facility failed to provide proper transfer assistance for two residents, resulting in falls. One resident with ovarian cancer fell during a transfer due to inadequate use of a mechanical lift, while another resident with brain cancer fell when staff attempted to walk them to the bathroom instead of using a mechanical lift as required by their care plan.
A resident with ovarian cancer and severe malnutrition did not receive the correct dosage of TPN due to a failure in documentation and administration processes. The resident was supposed to receive two bags of TPN daily but was only receiving one, and missed an entire dose on one occasion. The issue was identified by the resident and a family member, and confirmed by the RD and DON, who noted that the TPN order was not documented in the electronic health record or MAR.
A facility failed to change a resident's PICC line tubing daily as ordered by the physician, increasing the risk of infection. The resident, with ovarian cancer and severe malnutrition, required daily tubing changes for safety monitoring. However, documentation showed that the tubing was not changed on two consecutive days, and the DON confirmed the protocol was not followed.
A facility failed to inform a cognitively impaired resident's representative of a change in condition, missing an opportunity for the representative to participate in medical decisions. The resident had severe cognitive impairment and was dependent on all ADLs. Despite worsening of a pressure ulcer and abnormal lab results, the family was not notified. Interviews with staff confirmed the oversight, which violated the facility's policy on Change in Condition Notification.
A resident with severe cognitive impairment and dependency on all ADLs was not identified as having dentures, leading to inadequate oral care. The facility's admission evaluation incorrectly noted the absence of dentures, and no interventions were in place for denture care. Hospital staff later found the resident's dentures packed with dried food and mold, and the resident's mouth was extremely dry and bleeding. Facility staff were unaware of the resident's dentures, and the facility's oral care policy was not followed.
A resident with a history of urinary retention and multiple fractures experienced a delay in the insertion of a Foley catheter, as ordered by a physician. The order was confirmed by an RN nine hours after being created and executed by an LPN 17 hours later, causing the resident discomfort until the catheter was placed. The facility's policy requires timely execution of physician orders, which was not followed in this instance.
The facility failed to provide adequate nursing staff to meet the needs of 72 residents, with only two nurse aides per floor for 32 residents each. Despite the Facility Assessment indicating a need for more aides, staffing was based on census rather than resident acuity. Interviews with staff and residents revealed the impact of insufficient staffing, such as delays in assistance and missed showers.
The facility did not ensure RN coverage for eight consecutive hours daily, as required. From June 1st to June 3rd, the DON provided coverage due to RN call-offs, which was inappropriate since the DON cannot fulfill this role. This deficiency potentially affected all 72 residents by risking inadequate care coordination.
The facility failed to provide accurate and complete information on Advance Medical Directives (AMD) for eight residents, resulting in their medical care preferences not being followed. Residents or their legal guardians were not informed about formulating an AMD, as required by the facility's policy. This deficiency was identified through interviews and record reviews, revealing a lack of documentation and communication regarding AMDs for residents with varying cognitive abilities.
A resident experienced embarrassment and humiliation after being taken to physical therapy in a wet brief, despite informing the PTA. The resident remained in the wet brief for 45 minutes, and upon returning to his room, found the bed unchanged. Staff interviews revealed a lack of timely response and awareness of the incident, which was reported weeks later.
A resident with multiple health conditions did not receive scheduled showers for over two weeks, despite being cognitively intact and requiring assistance with hygiene. The resident's wife intervened after staff failed to address the issue, and documentation was found to be disorganized and incomplete. Staff interviews revealed a lack of awareness and communication regarding the resident's needs, and the DON acknowledged the deficiency.
The facility failed to communicate effectively with hospice staff, resulting in a resident not receiving a needed Alternating Pressure Relief Mattress. Additionally, the facility inaccurately documented weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The hospice staff had difficulty accessing the resident's EHR, and the facility's documentation was incomplete, contributing to these deficiencies.
A resident with cataracts experienced delayed treatment due to the facility's failure to schedule an ophthalmologist appointment, despite multiple requests and a documented order. The resident, who enjoys reading and using an iPad, expressed difficulty seeing. The social worker was unaware of the appointment status, and the nurse practitioner confirmed the appointment should have been made. Facility policies require the social worker to assist in scheduling appointments, which was not followed.
Failure to Provide Two-Person Assist and Safe Bed Mobility During In-Bed Care
Penalty
Summary
The deficiency involves the facility’s failure to follow the care plan and Kardex requirements for a two-person assist and safe bed mobility techniques during in-bed care, resulting in a resident fall with serious injury. The resident had multiple diagnoses including chronic kidney disease, legal blindness, atherosclerotic heart disease, heart failure, spinal stenosis, muscle weakness, DVT, and paraplegia, and was receiving Eliquis. The resident’s BIMS score indicated moderately impaired cognition. The care plan and Kardex specified a two-person assist for ADLs, bed mobility, toileting in bed, and bathing/showering, and identified the resident as at risk for falls due to muscle weakness, paraplegia, encephalopathy, and blindness. Despite these documented needs, the resident was being changed in bed by a single CNA. During the incident, the CNA reported changing the resident’s incontinence brief alone and stated that she had changed this resident alone several times because she was the only aide assigned to that hall at the time, which had a census of 12 residents with one CNA and one nurse. The CNA rolled the resident to the other side of the bed and then took her hands off the resident to walk around to the other side, at which point the resident threw a leg over and rolled off the bed. The CNA acknowledged that the Kardex indicated a two-person assist and that the resident should have been rolled toward her rather than away. The resident was sent to the hospital, where records documented a fall from bed during clothing change, with final diagnoses including acute kidney injury, fall, closed head injury, abdominal hematoma, and a closed fracture of the femur, along with imaging showing a left deep subcutaneous hematoma over the left hip and a distal femoral fracture requiring blood transfusion and pain management.
Failure to Implement Enhanced Barrier Precautions and Maintain a Comprehensive Infection Control Program
Penalty
Summary
Surveyors identified a failure to follow Enhanced Barrier Precautions (EBP) and basic infection prevention practices during direct resident care. On 4/15/2026 at 6:28 AM, CNA B was observed changing the incontinent brief and performing hygiene care for resident R519, who was on EBP for a stage III pressure ulcer to the sacrum/coccyx, without wearing a gown as required by the facility’s EBP policy. CNA B changed gloves after providing hygiene care but did not perform hand hygiene with sanitizer or soap and water before donning new gloves, and then immediately proceeded to provide hygiene care to resident R520. At 6:37 AM, CNA B was observed providing incontinence care to R520, who was on EBP due to having a PEG tube, again without wearing a gown. In an interview at 6:45 AM, CNA B stated they were in a hurry and did not see the EBP signs on the room doors. At 6:47 AM, LPN C acknowledged observing CNA B perform hygiene care on both residents without proper PPE and stated that a gown should have been worn for EBP residents. The DON later confirmed that staff are expected to wear appropriate PPE, including gowns, for residents on EBP and to perform hand hygiene between residents. Review of the facility’s EBP policy, revised 2/6/2026, showed that gowns and gloves were required for residents with wounds and feeding tubes, which applied to R519 and R520. On 4/16/2026 at 9:55 AM, review of the facility’s infection control program with the DON and Corporate Nurse K revealed that there was no documented infection control program in the facility’s infection control binder from 9/1/2025 through 4/1/2026. The DON stated they were not employed at the facility during that time, and Corporate Nurse K reported that an internal audit on 4/6/2026 had identified that, despite having several individuals in the Infection Preventionist (IP) role, they had not carried out core IP responsibilities of identifying, investigating, monitoring, and reporting infections. The infection control binder lacked documentation for multiple required components, including an antibiotic stewardship program, staff education and competency checks, environmental audits, emergency preparedness for outbreaks, audit tools for hand hygiene, PPE, and cleaning, McGeer Criteria for infection surveillance, and outbreak investigations. When the infection control policy was requested from the DON at 10:12 AM on 4/16/2026, it was not provided by the time of survey exit.
Failure to Maintain Continuous Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain a continuous Antibiotic Stewardship Program as required by its own policy and CDC core elements, resulting in a lapse in monitoring and documentation of antibiotic use. The facility’s written policy, dated 02/04/2026, states that staff and medical practitioners are responsible for ensuring antibiotics are requested and provided only when a bacterial infection is identified and for only the necessary duration. The policy outlines goals such as improving appropriate antibiotic utilization, reducing resistance, reducing adverse drug events, reducing unnecessary antibiotics, and improving resident outcomes. It also specifies that the facility will follow CDC core elements, including leadership commitment from the DON, Infection Preventionist, Medical Director, and Consultant Pharmacist, use of McGeer’s criteria to determine infection, completion of diagnostic testing per McGeer’s criteria before starting antibiotics, reporting diagnostic results that do not meet criteria to the practitioner, and ensuring antibiotic orders include name, dose, route, frequency, indication, and stop date. The policy further requires tracking measures such as adherence to clinical evaluation documentation, cultures obtained before starting or changing antibiotics, and completeness of antibiotic orders. During a review of the Antibiotic Stewardship Program with the DON and a corporate nurse, surveyors found missing documentation in the program for the period from September 1, 2025, through April 1, 2026. This gap indicated that the program was not in effect or not properly implemented during that timeframe. When asked about the absence of an Infection Preventionist during that period, the DON stated they were not employed at the facility at that time and could not explain why the antibiotic stewardship program was not in effect. The corporate nurse reported that an audit conducted on April 6, 2026, had already identified inadequate documentation for the Antibiotic Stewardship Program, confirming that the program had not been properly implemented for that period, with the potential to affect all residents in the facility.
Failure to Respond to Dependent Resident’s Calls for Care Leading to 911 Involvement
Penalty
Summary
Surveyors found that the facility failed to protect a resident from neglect when staff did not respond to the resident’s calls for assistance, leading the resident to call 911 multiple times for help with basic care needs. During an early-morning observation, the resident reported that staff sat in the hallway, slept, and talked on their phones at night and did not respond to call lights at the front desk or nursing station. In a subsequent interview, the resident stated that agency staff did not answer call lights, that calls to the nursing station and front desk went unanswered, and that the problem was ongoing and had been reported to two prior administrators and a nurse who were no longer employed. The resident described the care on the midnight shift as bad, with nurses and aides ignoring residents. Police and fire department reports corroborated that the resident called 911 on multiple occasions after being unable to obtain assistance from facility staff. On one night, the resident reported lying in a soiled brief for approximately four hours after requesting help around 8:30 p.m., with no staff response despite use of the call light and verbal calls for help with a roommate. The police report documented that the resident called 911 twice hours apart because staff did not respond, that fire department and dispatch calls to the facility went unanswered, and that upon arrival staff were unaware the resident needed assistance. Fire personnel observed nurses on their personal phones and then saw staff change the resident’s soiled brief only after being prompted. Another police case report documented a later service call from the same resident reporting that staff were not answering him. The resident had progressive multiple sclerosis, neuromuscular bladder dysfunction, bladder calculus, recurrent urinary issues, and was totally dependent on staff for all ADLs, with moderate cognitive impairment, and the facility’s abuse policy stated residents have the right to be free from abuse and neglect. The administrator denied knowledge of the resident’s concerns about unresponsive nursing and agency staff.
Failure to Address Resident Grievances and Delayed Response to Care Needs
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and resolve a resident’s grievances regarding delayed responses to call lights and incontinence care, as well as failure to follow its own grievance policy. A resident with progressive multiple sclerosis, neuromuscular bladder dysfunction, protein-calorie malnutrition, anxiety disorder, major depressive disorder, and moderate cognitive impairment (BIMS 10/15) was totally dependent on staff for all ADLs. The resident reported that on one evening they lay in a soiled brief for approximately four hours after requesting assistance around 8:30 P.M., with no staff response. At 10:55 P.M. the resident called 911 for assistance, resulting in a response from the police and fire departments, but the resident’s brief was still not changed and only a blanket was provided. The fire department left at 11:38 P.M., and the resident called 911 again at 12:12 A.M. to report the same unresolved situation. The resident also stated that staff sit in a chair in the hallway at night, sleep, and talk on their phones, and that staff do not respond to calls to the desk or nursing station. The resident reported having raised concerns about delayed or absent call light responses with two previous administrators and another former employee, though they could not recall exact dates. Review of concern forms from November 2025 to the present produced only one documented grievance from this resident dated 1/16/2026, listing multiple issues: waiting over two hours for call lights to be answered on the midnight shift, nurses and CNAs being on their phones while performing care, agency CNAs being rude, going two weeks without a bed bath on Thursdays when a specific CNA was assigned, and staff cursing at patients when upset. The documented resolution stated that education would take place on the specific concerns and that the resident’s concerns were valid, but the administrator later reported there was no evidence that the planned staff education occurred. The facility’s written grievance policy designates the administrator as grievance officer responsible for receiving, tracking, and investigating concerns, maintaining confidentiality, and issuing written grievance decisions, and requires that alleged violations of neglect be reported and investigated; however, the report from local police/fire regarding the 3/15/26 incident noted that the former DON initially claimed to be unaware of the incident, later stated she had been told while half asleep, and then did not respond to follow-up calls or emails, indicating the grievance process was not carried through to conclusion as required by policy.
Failure to Revise Comprehensive Care Plan for Resident With Repeated 911 Calls
Penalty
Summary
Surveyors found that the facility failed to develop and revise a comprehensive care plan for a resident with progressive multiple sclerosis, bladder calculus, anxiety disorder, neuromuscular bladder dysfunction, adjustment disorder, major depressive disorder, adjustment insomnia, and protein calorie malnutrition. The resident was moderately cognitively impaired per the MDS and totally dependent on staff for all ADLs. A care plan initiated on 8/4/2025 addressed risk for changes in behavior and mood related to anxiety and major depressive disorder, with a goal that the resident would accept care and medications as prescribed. Interventions listed included administering medications per physician orders, an entry stating “Calls police and Fire Department,” distraction techniques, offering choices, psychiatric consults as ordered, and redirection as needed. Record review showed that the resident had a history of calling the police and fire department when the midnight shift did not respond to call lights, with three such calls reported, the last on 3/30/26. Despite this pattern, the care plan did not include specific interventions to prevent recurrence of these calls, nor did it contain revisions reflecting that the resident was receiving hospice services. Nursing notes by the DON documented that, when interviewed about one of the incidents, the resident’s only concern was not wanting agency staff to provide care, and safety measures were reported to be in place; however, there was no corresponding care plan or interventions addressing these safety measures. During interview, the social worker could not explain why “calling the police/fire department” appeared as an intervention, and facility leadership provided no additional information. The facility’s own policy required ongoing assessment and care plan revision when residents’ conditions or outcomes changed, but this was not reflected in the resident’s care plan.
Improper Urinary Incontinence Care and Double Briefing of Residents
Penalty
Summary
Surveyors identified a failure to provide appropriate urinary incontinence care when a strong smell of urine and a sticky floor were noted in a shared room occupied by two residents. An LPN acknowledged noticing the odor and sticky floor. A CNA brought incontinence supplies into the room, left them, and did not return to begin incontinence care for one resident until approximately 45 minutes later. During care, the resident was found wearing two incontinence briefs: a white brief over a green brief. The CNA stated this was not considered double briefing because the inner brief was not closed. This resident had a history of acute respiratory failure with hypercapnia, chronic kidney disease stage 3, adjustment disorder with mixed anxiety and depressed mood, heart failure, difficulty in walking, and an MDS showing moderate cognitive impairment, with a care plan indicating an ADL self-care deficit and a goal to receive needed assistance with ADLs, including toileting with 1–2 person assist in bed. The same CNA then provided incontinence care to the roommate and was observed removing multiple layers of clothing and two white incontinence briefs, one inside the other. The LPN stated that staff are not allowed to double brief residents, and the DON later confirmed that staff should not double brief and were expected to check and change residents according to policy. One resident reported that staff double brief residents at night. Review of the incontinence care policy showed it did not address the use of multiple briefs. These observations and interviews showed that two residents were being managed with multiple incontinence briefs at the same time, contrary to staff statements that double briefing was not allowed and without clear guidance in the written policy.
Improper Incontinence Management for Resident With Stage III Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and incontinence management for a resident with a stage III pressure injury. During early morning observations, a CNA entered the resident’s room with incontinence supplies, left them, and later returned to perform incontinence care. When incontinence care was provided, the resident was found wearing two incontinence briefs: a white brief with a green brief placed inside. The CNA stated this was not considered double briefing because the inner brief was not closed. The resident’s care plan indicated an ADL self-care deficit related to muscle weakness, impaired physical mobility, COPD, CHF, and low back pain, with a goal to receive necessary assistance for ADLs and an intervention specifying 1–2 person assist for toileting in bed. The wound care nurse reported that the resident had a stage III pressure ulcer located on the sacral/coccyx area, with treatment ordered as zinc oxide with alginate. The wound care nurse stated that residents with this type of wound should not have multiple incontinence briefs applied because additional moisture can impede healing. The resident’s MDS showed moderate cognitive impairment with a BIMS score of 11 out of 15 and diagnoses including acute respiratory failure with hypercapnia, chronic kidney disease stage 3, adjustment disorder with mixed anxiety and depressed mood, heart failure, and difficulty in walking. The DON confirmed that staff should not double brief residents and that staff were expected to check and change residents according to facility policy.
Failure to Ensure CNA Competency and Adherence to Two-Person Assist Leading to Resident Fall With Injury
Penalty
Summary
The facility failed to ensure that CNAs had appropriate training, demonstrated skills, and confirmed competency to safely provide care, which resulted in a fall with injury for one resident. The resident was admitted with diagnoses including legal blindness, atherosclerotic heart disease, spinal stenosis, muscle weakness, and paraplegia, and had a BIMS score indicating moderately impaired cognition. The resident’s Kardex specified a two-person assist for bed mobility and toileting in bed. On the date of the incident, an LPN documented that staff notified the nurse of a fall during a brief change and that, upon entering the room, the nurse observed the resident on the floor lying on the right side. The resident was subsequently hospitalized with a closed head injury, abdominal hematoma, and a closed femur fracture. During an interview, the CNA who provided care at the time of the fall stated that they were changing the resident’s brief alone, despite the Kardex indicating a two-person assist. The CNA reported rolling the resident to the far side of the bed, away from themselves, and that the resident then threw a leg over and rolled off the bed while the CNA walked to the other side. The CNA acknowledged having changed this resident alone several times and stated they were the only aide on that hall. The CNA also stated they had not received training at the facility on bed mobility, did not know if there was a trainer at the facility, and received no education or feedback after the fall. The DON later stated that the resident should have been rolled toward the CNA and that the Staff Educator/Trainer position had not been fully functioning for several months, despite a facility policy requiring skills evaluations at orientation, annually, and as needed, with records maintained by Human Resources.
Systemic Operational Failures Affecting Quality of Care and Life
Penalty
Summary
The facility failed to administer operations in a way that ensured effective and efficient use of resources to maintain residents’ highest practicable physical, mental, and psychosocial well-being. During an abbreviated survey conducted in the early morning hours, surveyors identified multiple deficiencies, including failure to provide adequate supervision, transfer assistance, and interventions to prevent a resident fall that resulted in a fracture and hospitalization. From September 2025 through April 2026, there was no system or designated individual to consistently monitor, assess, and coordinate the competency and skill level of agency staff and nursing personnel. There was also no consistent infection control program during this same period, resulting in missed opportunities to prevent the spread of infections. Staff turnover and poor resource utilization were evident on the midnight shift when staff could not identify which nurse was in charge and repeatedly identified each other, and first-floor nursing staff reported they had been instructed to call the current DON if any problem arose. An allegation of neglect was reported to the Grievance Officer/Administrator by a resident on 1/16/2026, and two additional incidents for the same resident were reported to the DON on 3/19/2026 after the resident called local fire/police stating nursing staff failed to respond to the call light for more than two hours. There was no evidence these allegations were investigated or reported to the State Agency, despite a 1:1 meeting with the Grievance Officer who documented resolution. Incontinence care practices were inconsistent with best practices, including double briefing of two residents, which produced an unpleasant odor in the second-floor halls and posed a potential loss of dignity. Multiple incidents were reported by residents, local fire/police, and family members that calls to the facility during the midnight shift went unanswered; this was verified when surveyors made calls on and off-site that rang and went to voicemail without staff answering, and a call placed while at the first-floor nursing station was not audible. The Maintenance Director verified the phones were on but not audible to staff. A corporate nurse reported an internal audit on 4/6/2026 could not be completed and resulted in termination of department leadership due to insufficient action and documentation. During an interview with corporate and facility leadership, the current Administrator and DON stated the previous Administrator and DON had been terminated and that they were unable to address the concerns presented by the State Agency, and no additional information was provided by the time surveyors exited the facility.
Failure to Thoroughly Investigate Alleged Lip Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of an injury of unknown origin to a resident’s lip. The resident had a history of stroke with right-sided hemiparesis and aphasia and was documented on the MDS with a BIMS score of 0/15, indicating they were rarely understood or unable to complete the mental status interview. A family member contacted the social worker to report concerns about the resident’s care over a weekend and specifically that the resident had something on their lip and was upset about it. During this call, the Nursing Home Administrator, who is also the abuse coordinator, became aware of the concern. Subsequently, the social worker documented a wellness visit with the resident, noting that when asked about how they were doing following the incident, the resident repeatedly pointed to their mouth and nodded yes that they wanted to see someone regarding the incident. However, there was no documented skin assessment or oral assessment in the electronic health record related to the lip injury, and no additional progress notes describing the condition of the resident’s mouth, lips, or oral cavity. The social worker stated that they did not assess the inside of the resident’s mouth, indicating that such an assessment would be for nursing to perform. The nurse unit manager LPN reported that they had looked at the resident’s mouth and observed a small, dried crack on the bottom lip that appeared chapped, but confirmed there was no progress note or documentation of this assessment and that no interviews or investigation were conducted by them. The DON later stated that an investigation had been completed and kept in a paper file, concluding that the resident bit down on a toothbrush during oral care, causing a small crack or split on the bottom lip that looked like chapped lips rather than an injury. The DON reported interviewing only one CNA, an agency staff member, whose unsigned witness statement described the lip slit occurring during oral care; no other staff or resident interviews, additional assessments, or documentation were completed. This limited and poorly documented response did not meet the facility’s own abuse policy requirements for a timely, thorough, and objective investigation of alleged injuries of unknown source, including comprehensive interviews, observations, record review, and complete documentation.
Failure to Obtain Ordered Urinalysis in a Timely Manner
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and NP orders for a urinalysis (UA) with culture and sensitivity (C&S) for a resident with a history of recurrent UTIs and complaints of abdominal pain. The resident was admitted with multiple diagnoses including a history of UTI. On 2/5/26, the NP ordered a UA with C&S. On 2/6/26, an LPN documented that the resident refused straight catheterization and that a urine sample could not be obtained. There was no documentation of any further attempts to obtain the ordered UA and C&S at that time, despite the resident’s care plan indicating they were usually continent of urine and able to use the toilet with 1–2 person assist, and a care plan for dehydration related to UTI that included obtaining labs as ordered and reporting abnormal results. Nineteen days later, on 2/24/26, the NP re-ordered the UA and C&S, but there was still no documentation that a urine sample was collected. On 3/1/26, the NP again re-ordered the UA and C&S, and on that same day an RN documented that a UA was collected and sent to the lab using a clean-catch method with a collection hat placed in the toilet. Interviews with nursing staff confirmed that attempts had been made to obtain urine via straight catheterization, that the resident declined this method, and that there were progress notes indicating the resident could urinate in a toilet with assistance. The unit manager could not explain why a clean-catch method was not used earlier, and the Nursing Home Administrator acknowledged that the urine sample was not collected in a timely manner.
Failure to Protect Resident From Verbal Abuse and Neglect During Incontinence Care
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse and neglect by a CNA. The cognitively intact resident, who had a BIMS score of 15/15 and required assistance with most ADLs, reported that on the day of the incident the CNA entered the room, placed a brief in the room, and was aware the resident was wet and needed assistance but did not provide care for approximately one hour. When the CNA returned, the resident requested a clean gown and flat sheet due to being wet with urine. The resident stated the CNA began yelling, saying the resident should have requested those items earlier, that she did not have time to obtain them, and that she would change the resident quickly and return later with the requested items. The resident reported the CNA yelled for about five minutes while providing care, which caused the resident to cry and feel degraded, humiliated, anxious, and uncomfortable. The resident further reported that the CNA did not return with the requested clean gown and flat sheet for approximately two hours, during which time the resident remained anxious and uncomfortable while sitting in urine. During follow-up interviews, the resident became tearful when recounting the incident and expressed sadness about being treated in that manner and wishing to be able to care for herself. Record review confirmed the resident’s need for assistance with daily hygiene and grooming. Facility leadership, including the DON and Nursing Home Administrator, reported that an investigation was conducted and that abuse was substantiated, and both acknowledged that yelling at residents constitutes verbal abuse and that making the resident wait so long for needed incontinence care and linens constituted neglect. The facility’s abuse policy states residents have the right to be free from abuse, neglect, exploitation, mistreatment, and misappropriation of resident property.
Failure to Assess and Document Care for Resident With Frostbitten Feet
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals by not adequately assessing, monitoring, or documenting the condition of a resident’s frost-bitten feet. The resident was admitted with diagnoses including pain in both feet and frostbite of the feet, and the admission evaluation documented frostbite to both feet under the integumentary section. The resident’s BIMS score indicated intact cognition. A family member reported that the resident was admitted with bandages on both feet and that during a visit the day after admission, nursing staff were reminded that the bandages had not been changed. On the following morning, the family member again found both feet still wrapped in the original hospital bandages, which had a bad stench, and after staff did not respond in a timely manner, emergency services were called and the resident was transported to the hospital. Record review showed there were no physician orders to assess, monitor, or provide care for the resident’s bilateral feet, and no documentation in progress notes from admission through the date of transfer describing the feet, assessing them, or monitoring them. Medication and treatment administration records contained no related physician orders, and skilled nursing notes either omitted any assessment of the feet or only noted that dressings were present, without further description. The resident’s skin care plan contained no interventions for monitoring, assessment, or treatment of the feet. The DON stated that the resident had no dressings applied at admission, that the feet should have been assessed and monitored regardless of any bandage, and later acknowledged that nursing staff should have thoroughly examined and documented the bandages and notified the physician so that treatment orders could be obtained. Facility policy required that skin alterations be evaluated and documented by a licensed nurse using the admission or readmission evaluation.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure resident-to-resident verbal and physical abuse did not occur between two residents, identified in the report as R104 and R105. On 10/11/25, the residents were involved in a physical altercation on the Cherry Hill unit after an exchange of profanity and verbal confrontation in the hallway. Witness statements and incident documentation described R104 using profanity toward R105, R105 responding verbally, and then R105 standing up, running toward R104, and grabbing and forcefully pulling R104’s hair, which caused both R104 and a nurse to fall to the floor. The record showed that R105 had diagnoses including COPD and adjustment disorder with mixed anxiety and depressed mood, and an MDS assessment documented intact cognition. R105’s care plan identified that the resident could be argumentative and verbally aggressive and had altered behavior characterized by ineffective coping and verbal aggression toward other residents. Progress notes also documented prior incidents involving yelling, profanity, threats toward a roommate, and room changes related to conflict with another resident. Room assignment records showed that R105 had been moved between units multiple times, including being moved back to the Cherry Hill South unit before the 10/11/25 altercation. R104’s record showed diagnoses including cerebral infarction, vascular dementia, and bipolar disorder, and an MDS assessment documented intact cognition. R104’s care plan identified a behavior problem related to yelling at staff and others. Incident documentation for 9/14/25 described an argument between R104 and R105 in which staff observed R105 pushing R104, and R104 stated she had been hit and pushed by another resident. The 10/11/25 and 10/12/25 incident notes documented that the hallway altercation escalated into physical assault when R105 grabbed R104’s hair and slammed her to the floor. During interview, the NHA acknowledged the altercation could have been prevented had R105 remained on the first-floor MedBridge unit rather than being moved back to the second-floor Cherry Hill South unit.
Failure to Timely Report Resident Abuse and Resident-to-Resident Altercations
Penalty
Summary
The facility failed to timely report suspected abuse and resident-to-resident altercations to the State Agency for four residents involved in two separate incidents. In one event, R102 and R103 were involved in a verbal altercation after R103 was heard swearing at R102; the incident occurred on 10/2/2025 but was not brought to the Administrator/Abuse Coordinator’s attention until 10/6/2025. The investigation confirmed the incident between the two residents, and the record noted that R103 was temporarily moved to another room. R102 was admitted with diagnoses including major depression, adjustment disorder with mixed anxiety and depressed mood, rheumatoid arthritis, and bilateral hand contractures, and the quarterly MDS dated 10/29/2025 showed R102 was cognitively intact with a BIMS score of 15/15. R103 was admitted with diagnoses including end stage renal disease, immunodeficiency, type 2 diabetes mellitus, heart failure, and dependence on renal dialysis, and the quarterly MDS showed R103 was cognitively intact with a BIMS score of 15/15. In a second incident, R104 and R105 were involved in an argument and shouting match during which staff observed R105 pushing R104, and R104 stated she had been hit and pushed by another resident. The NHA confirmed this 9/14/2025 incident was reportable to the State Agency but was not reported because the event was not communicated to her. R104’s record documented diagnoses including cerebral infarction, vascular dementia, and bipolar disorder, and a MDS assessment documented intact cognition. R105’s record documented diagnoses including COPD and adjustment disorder with mixed anxiety and depressed mood, and a MDS assessment documented intact cognition. The facility policy required allegations involving abuse to be reported immediately to the Administrator and to the State Survey Agency within the required timeframes, but the facility did not follow that process for these incidents.
Failure to Provide Bathing and Grooming per Resident Preference
Penalty
Summary
The facility failed to ensure showers and grooming were provided according to resident preference and care plan for two residents. One resident with diagnoses including cerebral infarction, vascular dementia, and bipolar disorder had a care plan directing staff to assist with bathing/showering as preferred, but CNA documentation showed inconsistent bath records, including entries marked not applicable and only two shower refusal sheets located. Family reported the resident had not been getting regular showers, and nursing documentation did not show the shower refusals were reported or recorded in the medical record. The DON stated showers and refusals should be documented and that if it is not documented, it looks like it was not done. Another resident, admitted with diagnoses including left femur fracture, sarcoidosis of the lung, Parkinsonism, and CHF, had a care plan calling for assistance with daily hygiene and grooming. The resident was observed with a full, untrimmed beard and stated he had not been shaved since coming to the facility. CNA documentation showed bathing care, but staff interviews indicated the resident was not shaved as expected; one CNA said the resident was showered but not offered shaving, and an LPN stated there was no reason the resident should not have been shaved. The resident later stated he wanted to be shaved on days he gets cleaned up, and staff observed that he had not been shaved as expected.
Failure to Keep Bed Low and Provide Timely Fall Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls in a timely manner for one resident. The resident had diagnoses including hemiplegia/hemiparesis following cerebral infarction, vascular dementia, aphasia, and gastrostomy status. The clinical record also documented intact cognition on the Minimum Data Set assessment. The resident’s care plan included keeping the bed in a low position when in bed, bolsters to define the mattress edge, and later a two-person assist for changes and transfers. Incident reports showed multiple falls while staff were providing care or while the resident was in the room near the bed. On one occasion, while staff were doing care and the resident was placed in side-lying position, the resident suddenly moved and rolled out of bed. On another occasion, the resident was found on the floor near the bed after calling for help. On a later occasion, while being rolled onto his side during a brief change, the resident fell out of bed, struck the closet, and sustained a visible bump on the forehead and a small laceration above the eyebrow. Progress notes documented that after these events the interdisciplinary team reviewed and updated the care plan with additional interventions. Survey observations showed the resident in bed with the mattress top approximately 24 inches from the floor, and later approximately 20 inches from the floor, while staff were observed placing the resident in bed with the bed elevated. During interview, the PT stated the resident was totally dependent for bed mobility and needed two people for assistance, including brief changes. The DON stated the observed bed positions were transfer positions rather than low positions and acknowledged that the two-person assist for bed mobility was not initiated until later, adding that if the resident had been a two-person assist upon admission, the falls may have been prevented.
Inaccurate MAR and transfer documentation; incomplete medical record after resident altercations
Penalty
Summary
The facility failed to ensure accurate documentation of nutritional supplement administration for one resident with hemiplegia/hemiparesis following cerebral infarction, vascular dementia, aphasia, and gastrostomy status. The resident’s diet included a regular diet with soft bite-size pieces and a house supplement with meals, and the physician ordered one can of high-calorie, fiber-fortified liquid supplement if the resident consumed less than 50% of the meal. On review of the November 2025 MAR, the supplement was documented as given at noon even though the resident was still eating lunch and the supplement had not been administered. The LPN acknowledged the entry was premature and that the supplement had not been given when it was charted as administered. The facility also failed to accurately document a hospital transfer for another resident following a resident-to-resident altercation. The resident had diagnoses including cerebral infarction, vascular dementia, and bipolar disorder, and the record included an incident in which another resident verbally and physically assaulted the resident by grabbing her hair and slamming her to the floor. Nursing documentation stated the resident was transferred to the ER for evaluation per family request, but the eINTERACT Transfer Form listed a fall as the reason for transfer. The LPN/UM stated the form was intended to provide accurate information to the hospital and confirmed the resident was transferred after a resident-to-resident altercation, not a fall. In addition, the facility did not maintain a complete medical record for the same resident regarding an earlier resident-to-resident incident. An incident report documented that another resident was pushing and arguing with the resident, and the resident stated she had been hit and pushed. The incident report itself stated it was privileged and confidential and not part of the medical record, and the DON confirmed during interview that the 9/14/25 incident was not documented in the medical record. The facility policy required documentation in the medical record to be factual, objective, resident centered, accurate, relevant, complete, and completed at the time of service or by the end of the shift.
Failure to Initiate CPR Due to Invalid DNR Documentation
Penalty
Summary
The facility failed to initiate CPR for one resident who was found unresponsive with absent vital signs. The resident had been admitted with diagnoses including failure to thrive, paroxysmal A-fib with recurrent falls, ischemic cardiomyopathy with reduced ejection fraction, hypertension, hyperlipidemia, and pulmonary hypertension. The resident was also documented as incompetent and severely cognitively impaired. When the resident was found without a pulse or respirations, staff called a code and called 911, but CPR was not started because staff relied on a DNR order that had been entered without valid documentation showing authority to make life-sustaining decisions. Record review showed the resident’s family member had been involved in discussions about code status, but the paperwork in the chart only identified the family member as a HIPAA representative and financial POA, not as someone authorized to consent to or withdraw medical treatment. Social work notes documented that the current paperwork did not state authority for medical decisions and that legal guardianship might be needed if the paperwork did not allow authorization for care. Despite this, a note later stated that the DPOA was now activated, although the social worker later acknowledged there was no additional DPOA paperwork in the system authorizing life-sustaining decisions. The chart also showed conflicting code status documentation. A DNR form was uploaded after the resident had already become unresponsive, and two code status orders were entered after the resident’s death, including a DNR order entered by a nurse and a later Full Code order entered by the DON. Staff interviews reflected confusion about whether the resident was DNR or Full Code at the time of the event. The medical director stated that CPR is initiated when a resident is Full Code and that a DNR requires proper documentation, while nursing staff reported uncertainty about the validity of the DNR paperwork and the resident’s code status at the time of the arrest.
Kitchen Surfaces and Utensils Not Kept Clean
Penalty
Summary
Food contact and non-food contact surfaces in the kitchen were not adequately cleaned and sanitized. During the initial tour of the kitchen on 8/11/25 at 8:15 AM with Dietary Manager A, the rubber bumper at the base of the reach-in juice cooler was visibly soiled with dust and food stains, and the front drip tray of the commercial ice dispenser was stained with food debris. Dietary Manager A stated the ice machine was not clean, and food debris identified as collard greens was observed on the inside base of the drip tray and was easily removed by DM A. Additional observations included a full fruit cup, an empty plastic cup, a plastic cup lid, loose paper, and food debris on the floor behind the ice dispenser and reach-in cooler. Four ladles hanging from a rack were stored bowl side up and each was stained with dried food debris; DM A indicated they needed to be cleaned. On 8/14/25 at 12:33 PM, the NHA stated the kitchen should be clean and sanitary, and on 8/18/25 at 12:50 PM the NHA and DON reported there was no additional documentation or information to provide prior to the end of the survey.
Improper Disposal and Poor Maintenance of Outside Garbage Area
Penalty
Summary
The facility failed to properly dispose of rubbish and maintain cleanliness of the outside garbage area. On 8/13/25 at 11:16 AM, the outside dumpster area was observed with the Dietary Manager present. Three dumpsters were in the area, and the half lid on dumpster one was flipped open. Dumpster two was pushed against dumpster three, which prevented dumpster three’s lid from closing. Trash and debris of various types and mounds of decaying leaves were piled behind the dumpsters, a lid from a 55-gallon trash can was wedged underneath dumpster three, and the lid of a 55-gallon trash can was not fully closed. A pool of standing water was also observed on the lid of a large gray square plastic trash container positioned on a dolly, with a small cream-colored trash can placed on top of it. On 8/14/25, the NHA stated staff were to make sure the lids to the garbage containers were closed and nothing was on the ground around the garbage cans. The NHA also stated the facility did not have a policy for maintenance of the outside grounds specifically the outside garbage area. The report cited the 2013 FDA Food Code, including requirements that refuse be stored so it is inaccessible to insects and rodents and that premises be free of litter.
Kitchen Equipment Not Maintained in Proper Working Order
Penalty
Summary
The facility failed to keep essential kitchen equipment in proper working order when surveyors observed that the handwashing sink faucet did not shut off completely, water was dripping from the commercial ice dispenser drainage pipe, and the walk-in freezer temperature was 12 F. During the same observation, a four-ounce cup of ice cream stored in the freezer was soft and not frozen solid, even though the freezer temperature log for that morning recorded 8 F. The Dietary Manager stated maintenance would be contacted, and the Maintenance Director later said he was unaware of any current leaks in the kitchen and did not know the handwashing sink faucet did not fully shut off or that the pipe behind the ice machine was leaking. The Nursing Home Administrator stated she expected the kitchen to be fully functioning.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on a review of facility practices and documentation, which showed that when an incident of suspected abuse, neglect, or theft occurred, the required notifications and reporting to authorities were not completed within the mandated timeframe. The report does not provide specific details about the individuals involved or the nature of the incident, but it clearly states that the reporting and communication requirements were not met.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for psychotropic medication use for two residents. One resident was admitted with diagnoses including major depressive disorder and neurocognitive disorder with Lewy bodies, had moderately impaired cognition on BIMS testing, and had guardianship appointed. Trazodone and citalopram were ordered, and the record showed a psychotropic medication consent form stating the resident was educated and consented, but there was no record of consent from the guardian. The Social Worker stated that the psychotropic medication consent signed by the guardian was not obtained and should have been. A second resident had diagnoses including vascular dementia, delusional disorders, major depressive disorder, and psychotic disorder with delusions, with severe cognitive impairment documented on MDS. Depakote was ordered for mood/behavior management, but the psych medication consent form did not include Depakote. The record showed the resident was prescribed Depakote sprinkles for mood disorder, and the Social Worker stated the resident representative consent for Depakote was not obtained until later. The Social Worker also reported there were no psych notes showing the psychiatric practitioner discussed Depakote with the resident representative, and the NHA stated it was the Social Worker's responsibility to ensure psychotropic medication consent was signed.
Missing Transfer Documentation for Resident Sent for Procedure
Penalty
Summary
The facility failed to ensure appropriate transfer documentation was in place for one resident, R6, during a hospital transfer. R6 had diagnoses including hemiplegia and hemiparesis following cerebral infarction, surgical aftercare following surgery on the nervous system, heart failure, aphasia following cerebral infarction, and adult failure to thrive. A Minimum Data Set assessment documented severe cognitive impairment. The resident’s record showed an initial admission date of 6/18/25, readmission on an unspecified date, and discharge from the facility on 8/5/25. During interview and record review, the Unit Manager/LPN stated R6 was not in the facility because he went out for a procedure on 8/5/25, and a physician note dated 8/4/25 documented that R6 was scheduled for a cranioplasty on 8/5/25. The UM/LPN reviewed the clinical record and confirmed there was no transfer form, progress note, or physician’s order regarding R6’s transfer from the facility, and could not provide information on where R6 was transferred, the mode of transfer, or his health status upon leaving. The DON stated the nurse on shift was supposed to document when a resident transfers and that this documentation was important for effective communication, including the resident’s departure time and condition upon leaving. The facility policy titled Transfers and Discharges stated that the hospital transfer form assessment should be completed in the electronic health record and that assessment findings and other relevant information regarding the transfer should be documented in the medical record.
PASARR Screening Not Completed Annually
Penalty
Summary
The facility failed to ensure a PASARR Level I was completed for one resident, R4, out of two residents reviewed for PASARR screening. R4’s clinical record showed an original admission date of 10/18/23 and a readmission date of 4/23/24. R4’s diagnoses included vascular dementia, delusional disorders, major depressive disorder, and psychotic disorder with delusions, and a MDS assessment documented severe cognitive impairment. The PASARR document in the record was dated 7/19/24 and stated that the recipient may be admitted to or remain in the nursing facility and receive mental health services, and that further PASARR Level II evaluation was not required unless a significant change was reported by the facility. During the survey, the facility was asked to provide a current PASARR for R4 and later produced one with a date/time stamp of 8/12/25 at 2:23 PM. The SW stated the facility contacted the corporate social worker regarding R4’s PASARR because of the State Agency inquiry, and said the PASARR was used to screen out mental illness, determine whether specialized services were needed, and determine whether nursing home placement was appropriate. The SW also stated the PASARR should have been completed annually and that R4’s annual PASARR should have been completed by 7/19/25. The DON stated social services was responsible for completing the PASARR, and the NHA stated R4’s annual PASARR should have been done timely.
Delayed Pain Medication Before Therapy
Penalty
Summary
The facility failed to ensure timely pain management for a resident with intact cognition who was admitted with diagnoses including lung cancer, intrahepatic bile duct cancer, a pathological fracture, anxiety disorder, and neoplasm-related pain. The resident’s care plan identified her as at risk for pain and directed staff to administer pain medication as ordered and assess for verbal and non-verbal signs of pain. Her medication regimen included Lidocaine patch, Lyrica, and PRN hydromorphone for pain. On the morning of the event, a physical therapist took the resident to therapy before she received her pain medication, and the resident reported she was in severe pain and was only able to participate for about 10 minutes before therapy was stopped because of pain and discomfort. Staff interviews confirmed the breakdown in coordination between nursing and therapy. An LPN stated the therapist took the resident to therapy before pain medication could be given, and the DON stated it was not okay for therapy to occur before the resident received her pain medications. The Director of Therapy stated therapists should ask residents about pain and whether they have had their pain medicine, and if pain is not controlled, they should check with the nurse. The PTA who worked with the resident stated she started therapy in the morning, returned the resident to her room after about 15 minutes because she was in pain, and later completed therapy in the afternoon. Review of the therapy note documented that treatment was limited by pain, and the DON stated therapy should have assessed the resident for pain before taking her to therapy.
Failure to Provide Meals or Snacks for Residents Attending Dialysis
Penalty
Summary
The facility failed to provide morning meals or snacks for two residents who attended dialysis. One resident with end stage renal disease and dependence on renal dialysis said she was not given breakfast before or after dialysis and was not given a snack to take with her; her spouse said he usually brings food because the facility does not provide anything in the morning. Her record showed a physician order for dialysis on Monday, Wednesday, and Friday with a 5:45 AM pickup time and an instruction to ensure packed food if needed, and her care plan included sending a meal/snack with her to dialysis. A second resident with end stage renal disease, severe protein-calorie malnutrition, and dependence on renal dialysis stated that she was not getting breakfast before or after dialysis and was not sent a snack, and said she was tired and hungry and should not have to wait for lunch. Her record showed a Monday, Wednesday, Friday dialysis schedule with a 5:00 AM pickup time and a care plan focused on nutritional risk with tasks to offer food and beverage selections. Staff interviews indicated nursing aides and nurses were responsible for providing a snack for residents going to dialysis, that premade sandwiches were available in the kitchen, and that the expectation was to offer a snack or meal before dialysis or upon return. The facility policy stated that meals on dialysis days may include early meal service, a meal or snack sent with the resident, or late meal service after return.
Medication Cart Not Kept Clean and Free of Loose Pills
Penalty
Summary
The facility failed to ensure proper cleaning and disposal of loose medications in one medication cart, the Cherry Hall cart, out of three medication carts observed for medication storage and cleanliness. During observation and interview, 12 loose pills were found scattered on the bottom of the second drawer of the cart, with the pills varying in shape, color, and size. The same drawer also contained a pack of cigarettes and dust. Nurse M was interviewed about the findings, and Nurse G stated that the cart should be cleaned by dayshift and midnight nurses. The DON stated that nurses and nurse managers were expected to check and clean the medication carts on their units. The facility policy reviewed stated that medication and treatment carts will be kept clean of dirt, spillage, grime, and other foreign materials, and that medications, treatments, biologicals, and supplies will be maintained per manufacturer guidelines.
Resident Dignity Not Maintained During Supervision Lapse
Penalty
Summary
A resident with severe cognitive impairment, altered mental status, and a history of restlessness and agitation was observed sleeping at the nurses' station with her head resting directly on the desktop. The registered nurse responsible for her care acknowledged that this positioning was not optimal and did not maintain the resident's dignity, stating that the resident should have been returned to her room to sleep in her bed. The nurse was not in a position to directly supervise the resident at the time she was observed, and another nurse practitioner present stated she was not responsible for the resident but had been helping to keep her calm. The resident's care plan included interventions such as encouraging her to be in common areas when awake, increasing the frequency of checks, and ensuring she was up in a wheelchair in visible fields when rambling. Despite these interventions, the resident was left unsupervised and allowed to sleep in a public area in a manner that did not promote dignity or respect, as required by facility policy. The Director of Nursing confirmed that this did not meet the facility's standards for maintaining resident dignity and that alternative arrangements were available for such situations.
Resident Dignity Not Maintained at Nurse's Station
Penalty
Summary
A deficiency was identified when a resident was observed sleeping at the Beck nurse's station, seated in a wheelchair with her head resting directly on the desk. At the time of observation, a Nurse Practitioner was present in the nurse's station but was seated in a different area, facing away from the resident and actively typing on a computer. No other staff members were present in the area during this time. The incident was noted during a review focused on respect, dignity, and the right of residents to retain and use personal possessions, as outlined in §483.10(e). The facility failed to maintain the dignity of the resident by allowing her to sleep in a public and potentially undignified manner at the nurse's station without staff engagement or intervention.
Failure to Supervise Medication Administration and Follow Physician Orders
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed self-administering oral medications without staff supervision. The resident, who has a PEG tube, was seen walking out of his room holding a medication cup with approximately four pills, dropping one on the floor, picking it up, and returning it to the cup before ingesting the remaining pills. The resident was not supervised during this process, despite facility policy requiring direct observation during medication administration. The resident's electronic health record did not contain an assessment for self-administration of medications, a care plan for self-administration, or a physician's order permitting self-administration. Further review of the physician's orders indicated that all prescribed medications were to be administered via the PEG tube, not orally. The LPN involved acknowledged that supervision should have occurred and that the resident had not been formally assessed for self-administration. The DON confirmed that the resident was not assessed for self-medication and should have been supervised. Facility policy also specifies that medications must remain under the direct observation of the person administering them during medication pass, which was not followed in this instance.
Failure to Administer Medications via PEG Tube and Lack of Supervision
Penalty
Summary
A deficiency occurred when a resident with a PEG tube and a history of dysphagia, cerebral ischemia, and recurrent aspiration was observed self-administering whole pills orally without staff supervision. The resident was seen walking out of his room holding a medication cup with several whole pills, dropping one on the floor, picking it up, and then returning to his room to swallow the pills. The resident's medical record indicated that all prescribed medications were ordered to be administered via PEG tube, and there was no assessment, care plan, or physician order permitting self-administration of medications by mouth. Interviews with staff, including an LPN and the SLP, confirmed that the resident was at high risk for aspiration and that medications should have been given via PEG tube as ordered. The SLP noted that the resident coughed when attempting to swallow pills and was at risk for silent aspiration. The facility's policy required verification of physician orders and monitoring for aspiration during tube feeding, but these procedures were not followed in this instance, resulting in the resident receiving medications by an incorrect route and without adequate supervision.
Failure to Accurately Document and Supervise Medication Administration
Penalty
Summary
A resident with a history of cerebral ischemia, dysphagia following cerebral infarction, and gastrostomy status was observed independently taking oral medications from a medication cup without staff supervision. The resident, who had a PEG tube in place, dropped a pill on the floor, picked it up, and returned it to the cup before ingesting the remaining pills. The resident stated he was taking his pills, and there was no staff present to supervise the administration. Interview with an LPN revealed that the resident was given several medications in pill form to take orally, and the LPN acknowledged not supervising the resident during administration. Review of the resident's electronic health record showed no assessment, care plan, or order for self-administration of medications. Additionally, the Medication Administration Record (MAR) inaccurately documented that the medications were administered via PEG tube, contrary to the actual oral administration observed. The Director of Nursing confirmed the inaccuracy in the MAR and stated that documentation should reflect the actual treatment provided.
Linen Shortage Leads to Unclean Environment
Penalty
Summary
The facility failed to provide adequate shower linens, such as towels and washcloths, for its residents, resulting in an unclean and uncomfortable environment. Observations and interviews revealed that the facility had insufficient linens, with some units having zero towels and washcloths available. Staff members reported having to use alternative items like pillowcases and cut-up gowns to clean residents due to the shortage. The Housekeeping Director acknowledged the lack of linens, attributing it to staff shortages and ongoing laundry processes, while the Nursing Home Administrator (NHA) was unaware of the linen issues and claimed that staff did not communicate their needs effectively. Two residents, identified as R112 and R113, were directly affected by the linen shortage. R112, who had pressure ulcers and other medical conditions, reported purchasing personal supplies due to the facility's inadequacy. R113, who had undergone joint replacement and experienced difficulty walking, stated they were given only one washcloth, which they had to reuse for several days. Both residents' care plans indicated the need for assistance with daily hygiene, which was compromised by the lack of available linens. The facility's Linen Supply Guidelines required regular replenishment of linens, but these guidelines were not followed, leading to the deficiency. The NHA could not explain the shortage despite the inventory process and suggested that CNAs were discarding and cutting up linens. The facility's policy on maintaining a homelike environment emphasized the importance of clean and sanitary conditions, which were not met due to the linen shortage.
Misappropriation of Resident's Property by Facility Employee
Penalty
Summary
The facility failed to protect a resident's personal property from theft by an employee, resulting in the misappropriation of the resident's wireless earbuds. The incident involved a resident who was in the facility for short-term rehabilitation care and was alert and oriented. The resident reported to the Director of Nursing (DON) that their Apple AirPods were missing after they left their room for activities. Upon returning, the resident used an app to locate the earbuds, which were found on a housekeeper's cleaning cart. The resident informed the housekeeper, who then returned the earbuds and was instructed to report the incident to a supervisor. The facility conducted an investigation, which included reviewing security camera footage. The footage showed the housekeeper entering the resident's room and placing something at the bottom of the cleaning cart. The housekeeper, who had been employed at the facility for a short period, was interviewed and subsequently suspended pending the investigation. The investigation substantiated the allegation of misappropriation, leading to the termination of the housekeeper. The facility's policy on abuse, updated in May 2023, states that residents have the right to be free from misappropriation of property.
Failure to Ensure Proper Transfer Assistance
Penalty
Summary
The facility failed to ensure proper transfer assistance for two residents, leading to accidents. Resident R102, who had diagnoses including ovarian cancer and severe protein-calorie malnutrition, experienced a fall during a transfer back to bed. The care plan for R102 required one-person assistance with a two-wheeled walker and gait belt. However, during the incident, R102's knees buckled, and she fell to the floor. The CNA and RN involved in the transfer did not use a mechanical lift, as required by the facility's policy, and instead manually lifted R102, which was not in accordance with the guidelines. Resident R103, diagnosed with brain cancer and a history of repeated falls, also experienced a fall due to inadequate assistance. R103's care plan required a full mechanical lift for transfers, but staff attempted to walk R103 to the bathroom, resulting in a fall. The DON confirmed that R103 should have been transferred with two-person assistance and a mechanical lift. The facility's policy on fall management was not followed, as the staff did not use the mechanical lift for either resident, leading to the deficiencies noted in the report.
Failure to Administer Correct TPN Dosage
Penalty
Summary
The facility failed to ensure the correct administration of Total Parenteral Nutrition (TPN) for a resident diagnosed with ovarian cancer and severe protein-calorie malnutrition. The resident, who had intact cognition, was supposed to receive two bags of TPN daily to meet her nutritional needs but was only receiving one bag per day and missed an entire dose on one occasion. This discrepancy was identified when the resident and a family member reported the issue, indicating that the TPN had not been administered correctly since a specific date. The Registered Dietitian (RD) and the Director of Nursing (DON) confirmed that the TPN order was not documented in the electronic health record or the Medication Administration Record (MAR). The DON revealed that the TPN administration was never transcribed onto the MAR, and the nursing staff failed to document the administration in the progress notes. Additionally, the facility staff were administering TPN bags containing lipids but not the clear TPN bags, resulting in the resident not receiving the prescribed amount of TPN.
Failure to Change PICC Line Tubing as Ordered
Penalty
Summary
The facility failed to consistently change the PICC line tubing according to the physician's order for a resident who was receiving parenteral nutrition, which increases the risk of infection. The resident, who was admitted with diagnoses including ovarian cancer and severe protein-calorie malnutrition, had a care plan indicating the need to change the IV tubing daily as per physician orders. However, a review of the resident's Treatment Administration Record revealed that the nursing staff did not document the tubing change on two consecutive days. The Director of Nursing confirmed that the protocol to change the tubing daily was not followed, and no additional documentation was provided to support that the tubing had been changed on those days.
Failure to Notify Resident's Representative of Change in Condition
Penalty
Summary
The facility failed to inform a cognitively impaired resident's representative of a change in condition, which resulted in a missed opportunity for the representative to participate in medical decisions. The resident, identified as R902, was admitted with diagnoses including dementia, pressure ulcers, and chronic kidney disease. The Minimum Data Set indicated severe cognitive impairment, and the resident was dependent on all Activities of Daily Living. A Skin and Wound Evaluation revealed that the resident's pressure ulcer had worsened to a Stage III, but documentation only noted that the patient was notified, not the resident's representative. Further review of the resident's records showed abnormal lab results and the initiation of IV fluids, yet there was no indication that the family was informed of these changes. Interviews with facility staff, including an LPN, an RN, and the Director of Nursing, confirmed that the resident's family should have been notified of the worsening condition and interventions. The facility's policy on Change in Condition Notification mandates that the resident's designated representative be informed of changes in medical or mental condition, which was not adhered to in this case.
Failure to Provide Adequate Oral Care for Resident with Dentures
Penalty
Summary
The facility failed to identify and provide adequate oral care for a resident with dentures, leading to a deficiency in the care of Activities of Daily Living (ADLs). The resident, who was admitted with diagnoses of dementia, pressure ulcers, and chronic kidney disease, was documented as being dependent on all ADLs and had severe cognitive impairment. Despite this, the facility's admission evaluation incorrectly noted that the resident did not have dentures, and there were no interventions in the care plan or Kardex to address denture care. The deficiency was discovered when a hospital employee observed the resident's dentures packed with dried food and mold. Hospital records indicated the resident's mouth was extremely dry, crusting, and bleeding, with mold appearing plaque buildup on the tongue, hard palate, and dentures. Interviews with facility staff revealed a lack of awareness regarding the resident's dentures, and the Director of Nursing stated that oral care should be provided on every shift for dependent residents. The facility's policy required oral care to be provided with morning and nighttime care and as needed, which was not adhered to in this case.
Delayed Execution of Physician's Order for Urinary Catheter
Penalty
Summary
The facility failed to follow a physician's order in a timely manner for a resident who required an indwelling urinary catheter. The resident, who had a history of urinary retention and other urological issues, was admitted with multiple fractures and required maximum assistance for mobility and toileting. On a specific date, the physician ordered the insertion of a Foley catheter due to the resident's inability to urinate independently. However, the order was not confirmed until approximately nine hours later by an RN, and the catheter was not inserted until about 17 hours after the order was created. Interviews with the nursing staff revealed that the order was passed from one shift to the next without being executed promptly. The LPN who eventually inserted the catheter noted that the resident expressed relief and had a significant urine output immediately after the procedure. Both the Medical Director and the Director of Nursing acknowledged that the standard practice is to carry out physician orders as soon as possible, and the delay in this case was unexplained. The facility's policy on physician orders emphasizes the importance of timely execution according to professional standards.
Insufficient Staffing Levels in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all 72 residents, as observed during a survey. On the second floor, there were only two nurses and two nurse aides for 32 residents, while the first floor had two nurse aides for 32 residents. Interviews with staff, including a Unit Manager and an LPN, revealed that the usual staffing level was two nurse aides per floor, which was insufficient given the number of residents requiring two-person assistance for care needs. The Facility Assessment indicated that there should be one aide per eight residents, suggesting a need for more aides than were present. The Nursing Home Administrator and Director of Nursing confirmed that staffing was based on census rather than resident acuity, which led to inadequate staffing levels. The Director of Nursing acknowledged that the staffing was not sufficient according to acuity, and the Staffing Coordinator mentioned that more aides could be scheduled with approval. Interviews with CNAs and residents highlighted the impact of insufficient staffing, such as delays in assistance and missed showers. The facility's policy stated that staffing should be based on residents' care plans, but this was not reflected in practice.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN), excluding the Director of Nursing (DON), was on duty for eight consecutive hours a day, seven days a week. This deficiency was identified through interviews and record reviews, revealing that there was no RN coverage from June 1st through June 3rd. During this period, the DON had to step in to provide coverage due to call-offs, which was later identified as inappropriate since the DON cannot fulfill the role of an RN for this requirement. This lack of RN coverage had the potential to affect all 72 residents in the facility by possibly leading to inadequate coordination of emergent or routine care.
Failure to Provide Information on Advance Medical Directives
Penalty
Summary
The facility failed to provide accurate and complete information regarding Advance Medical Directives (AMD) for eight residents, resulting in their preferences for medical care not being followed. The report highlights that residents or their legal guardians were not fully informed about how to formulate an AMD, which is a legal document that allows individuals to specify their end-of-life care decisions in advance. This deficiency was identified through interviews and record reviews, revealing that the facility did not ensure residents or their legal representatives were aware of their rights to request, refuse, or discontinue treatment. For instance, one resident, who had a legal guardian, was marked as a full code in the Electronic Health Record (EHR) without any documentation indicating that information about AMDs was provided to either the resident or the guardian. Another resident, admitted with a Do Not Resuscitate (DNR) order from the hospital, was also marked as a full code without any documentation of discussions or information provided to the family regarding AMDs. The facility's policy required that information about AMDs be provided upon admission, but this was not consistently followed. Several residents with varying cognitive abilities, ranging from intact cognition to severe impairment, were found to have no documentation of AMD discussions or forms in their records. Interviews with social workers and reviews of clinical records confirmed the lack of documentation and communication regarding AMDs. The facility's policy stated that information should be provided to residents or their legal representatives, but this was not adequately implemented, leading to the deficiency.
Resident Dignity Compromised Due to Inadequate Care
Penalty
Summary
The facility failed to maintain the dignity of a resident, identified as R21, who was taken to physical therapy while wearing a wet brief. R21 reported the incident occurred on 6/21/24, when he informed the Physical Therapy Assistant (PTA) G of his condition, but no assistance was provided to change his brief. Instead, PTA G requested two nurse aides to change the linen on R21's bed before he returned to his room. However, upon returning to his room, R21 found the bed still had the same soiled linen, and he was left in a wet brief for approximately 45 minutes, leading to feelings of embarrassment and humiliation. R21 expressed his distress during an interview, stating that he felt disrespected and humiliated by the experience. Interviews with staff revealed discrepancies in the handling of the incident. PTA G denied being informed by R21 about the wet brief but confirmed requesting the linen change. CNA B confirmed that R21 was wet upon returning from therapy and required assistance. The Unit Manager (UMH) and Director of Nursing (DON) were unaware of the incident until weeks later, with a Concern Form being submitted to the Administrator and Physical Therapy Manager on 7/7/24. The facility's policy on dignity emphasizes care that promotes residents' well-being and self-esteem, which was not upheld in this instance.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to provide scheduled showers for a resident, identified as R21, who was admitted with multiple health conditions including heart failure, chronic kidney disease, and diabetes mellitus. Despite being cognitively intact with a BIMS score of 14 out of 15, R21 required assistance with transferring and hygiene. The resident reported not receiving a shower for two and a half weeks post-admission, leading to frustration and prompting his wife to intervene by giving him a shower herself. The resident had communicated his concerns to a corporate liaison, but the promised shower was not provided, and he continued to receive only bed baths. The investigation revealed that the Nurse Aide's Task Assignment for R21 did not include shower days, and the Shower Logbook was disorganized, with missing documentation for scheduled showers. Interviews with staff, including a CNA and the Unit Manager, indicated a lack of awareness and communication regarding the resident's unmet needs. The Director of Nursing acknowledged the incomplete and disorganized state of the shower documentation and confirmed that all residents should receive two showers a week, which was not adhered to in R21's case. The deficiency was further highlighted by the absence of a documented Concern Form related to the missed showers, despite the resident's wife reporting the issue to the Unit Manager.
Deficiencies in Hospice Communication and Weight Documentation
Penalty
Summary
The facility failed to effectively communicate and collaborate care with hospice staff for a resident receiving hospice services, resulting in the resident not receiving an Alternating Pressure Relief Mattress (APM). The resident's family member reported that the APM, intended for comfort care, had not been received despite being ordered by hospice a month prior. Observations confirmed that the resident was using a regular bariatric mattress, while the APM was found outside the resident's room. The facility's records showed a lack of documentation from hospice regarding the APM order, and a care conference did not include hospice participation or documentation of the APM order. The Director of Nursing (DON) revealed that hospice staff documented communications in a physical binder at the nurse's station, which was found to be blank. The Maintenance Director confirmed the APM was delivered but was the wrong size for the resident's bed, and there was no communication with hospice to rectify the issue. The hospice nurse was unaware of the mattress size issue and cited difficulties in communication due to lack of access to the resident's Electronic Health Record (EHR). Additionally, the facility failed to accurately obtain and document weights for two residents, leading to a significant discrepancy in recorded weight loss for one resident. The resident's records showed an implausible weight loss of 127.4 pounds in one month, which was not supported by the resident's condition or dietary intake. Interviews with the resident, Registered Dietician, and Physician confirmed the weight loss was not possible and attributed the error to inaccurate weight measurements. Another resident's weight was also inaccurately recorded due to improper positioning during weighing, which was corrected upon re-evaluation.
Failure to Schedule Ophthalmologist Appointment for Resident
Penalty
Summary
The facility failed to schedule an ophthalmologist appointment for a resident, identified as R12, who was reviewed for vision services. This resulted in a delay in treatment for R12's cataracts. On July 9, 2024, R12 was observed in bed with several reading materials and an iPad, expressing difficulty in seeing due to cataracts and stating that multiple requests for an eye doctor appointment had not been fulfilled. R12's Electronic Health Record indicated a history of stroke and chronic obstructive pulmonary disease, with intact cognition as per the Minimum Data Set. A progress note from June 5, 2024, documented R12's complaint about worsening cataracts, and an order for an ophthalmology appointment was made on June 9, 2024, with the ophthalmologist's contact information provided. Despite these steps, there was no documentation of an appointment being made. On July 10, 2024, the social worker, SW K, was unaware of any appointment being scheduled and acknowledged the lack of follow-up after reviewing R12's records. Nurse Practitioner Z confirmed that the appointment should have been made, as the necessary information was included in the order. The facility's policy on Hearing and Vision Services and Consultations outlines the responsibility of the social worker to assist in making appointments and arranging transportation, which was not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Canton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Medilodge Of Haggerty Road | 1.4 mi | ★★★★★ | 0 | 0 |
| Medilodge Of Plymouth | 2.3 mi | ★★★★★ | 0 | 0 |
| Four Seasons Nursing Center Of Westland | 2.7 mi | ★★★★★ | 13 | 0 |
| Regency At Westland | 2.7 mi | ★★★★★ | 10 | 0 |
| Cherry Hill For Nursing And Rehabilitation | 2.8 mi | ★★★★★ | 13 | 0 |
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