Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Optalis Health & Rehabilitation Of Whitehall during CMS and state inspections, most recent first.
A cognitively impaired male resident with dementia, delusions, hallucinations, and aggressive behaviors repeatedly entered other residents’ rooms, stood in doorways, and made threatening statements, causing fear and anxiety for multiple cognitively intact residents. An LPN documented that he went into a resident’s room and stood over her, and another resident was crying and scared after hearing him talk about shooting people and guns. The DON and NHA acknowledged the events were not fully documented with incident reports, and residents and family members reported ongoing fear and repeated room intrusions.
Failure to monitor CHF, allergies, and ordered ACE wraps: A resident with CHF had significant weight gain, missed ordered diuretics, worsening respiratory status, and a documented morphine allergy warning before morphine was administered. Another resident with heart failure and edema did not have ordered ACE wraps applied or monitored as directed, and the resident reported the wraps were not being done when out of bed.
Failure to prevent further pressure ulcer development: A resident with neuropathy, COPD, malnutrition, and existing stage IV pressure injuries developed three additional facility-acquired wounds. Staff repeatedly observed the resident positioned with the foot and toes on the bed sheet, without a heel boot, and the resident reported inconsistent turning and repositioning. The wound clinic NP documented minimal healing and deterioration, while the care plan was not updated for new wounds, treatment was delayed for one wound, and the DON reported no incident reports, no physician notification, and no interdisciplinary collaboration regarding the worsening skin breakdown.
Insufficient nursing staffing led to missed and delayed resident care, with staff reporting too few nurses and CNAs to cover a high-acuity census, especially overnight and on weekends. A resident with behavioral issues required constant monitoring because he entered other residents’ rooms and frightened them, while another resident with edema did not receive ordered ACE wraps and monitoring because the nurse did not have time. A dependent resident who required 2 staff for showers reported going weeks without a shower, and staff said the workload left only one aide on the floor during bathing and mealtime.
The DON was observed passing meds at a med cart after a nurse called in, and she stated she sometimes works the floor about once a week to cover staffing shortages. She reported she was not aware of the rule that the DON may serve as charge nurse only when the average daily occupancy is 60 or fewer residents, while the facility census was 87. The staffing policy also stated that the DON may serve as charge nurse only when the average daily occupancy is 60 or fewer residents.
Compliance and Ethics Program Not Effectively Implemented: The NHA was not aware she was the designated Compliance Liaison and did not recall training on the facility’s Ethics and Compliance program. She was unfamiliar with the procedures, was not aware of any reported violations, and had not been involved in written standards, staff education, internal monitoring, enforcement of disciplinary guidelines, or communication with staff regarding the compliance hotline and reporting process.
Incomplete and late charting affected wound care and resident incidents. A resident with multiple pressure injuries and a trauma wound had delayed treatment documentation, missing care plan updates, and later-added notes and incident reports that were not in the chart when first reviewed. In a separate event, a confused male resident repeatedly entered other residents’ rooms and made threatening statements, but the incidents were not documented timely; the DON and NHA later created progress notes and incident reports that appeared backdated rather than clearly identified as late entries.
General cleanliness and repair deficiencies were observed in common areas and shower rooms. A wall-mounted mini-split near the nurses’ station had grey and green crusted material on the interior and face of the unit, and multiple shower rooms had broken, chipped, or missing tile coving at the wall and floor juncture, with sections of wall exposed in the 400 hall shower room and similar damage confirmed in the 300, 200, and 100 hall shower rooms.
A resident with CHF, anxiety, and insomnia was not allowed to follow her preferred bedtime schedule. She reported that a CNA wanted her in bed at 7 PM for staff convenience and told her she would have to wait for 3rd shift when she refused. The resident also reported delayed evening meds, and the MAR confirmed her PM medication was given at about 1:30 AM during a staffing shortage.
Failure to Reevaluate PRN Psychotropic Use: A resident with CHF, DM2, anxiety, and morbid obesity received PRN clonazepam repeatedly over several months, but the facility could not produce the required q14-day physician evaluation before the PRN psychotropic was continued. The DON acknowledged the requirement and said she had spoken with the provider, while later NP and MD notes stated the medication could continue because benefits were greater than risks, with no additional evaluation shown.
Failure to report alleged abuse and resident-to-resident incidents: A male resident with dementia, delusions, and hallucinations repeatedly entered other residents’ rooms, stood in doorways, and made threatening statements about guns and shooting people. A cognitively intact resident reported fear and anxiety after he entered her room multiple times, and another resident stated he was scared to have the male resident in his room. The DON/NHA acknowledged no incident reports were completed for the events and stated the situation may have been reportable as an allegation of abuse.
Failure to update care plans for skin, wound, and behavior changes. A resident with chronic skin itching had ongoing scabs and a rash on the upper arm, but the care plan and orders did not reflect the current condition. Another resident with COPD and pressure injuries developed new facility-acquired wounds, yet the care plan still listed older wounds and had not been revised for the new trauma and sacral wounds. A third resident with dementia and delusions had repeated wandering, exit-seeking, and unsteady behavior, but the behavior and elopement care plans were not updated to match the documented changes.
Medication administration was not provided according to ordered times and parameters for several residents. Evening meds for multiple residents were given hours late, and an RN and UM reported staffing shortages contributed to the delays and that no provider approval was obtained for the late doses. In another case, a resident with DM received Lispro insulin even when blood sugars were below the ordered hold parameter, and the DON was unaware of the repeated omissions from the order.
Failure to Provide Scheduled Showers: A resident with contractures, morbid obesity, and paraplegia required extensive 2-staff assistance for ADLs and was care planned for showers twice weekly, but reported missing showers and sometimes going weeks without one. CNAs said bathing her requires 2 staff, which leaves limited coverage on the unit, and documentation did not clearly show when she last received a shower.
Failure to supervise a resident with severe cognitive impairment and high fall risk led to unsafe ambulation and multiple injuries. Staff observed the resident on a locked unit without consistent oversight, with a missing or inappropriate walker/wheelchair setup, and at times walking without a gait belt or walker. The resident was noted to have skin tears, bruising, and a facial abrasion from an unknown source, while documentation described poor safety awareness, impulsivity, and a history of falls and bumping into objects.
The facility did not consistently follow physician orders for medication administration and monitoring. Several residents did not have required pre-administration assessments, such as blood pressure and heart rate, documented before receiving medications like metoprolol and digoxin. In addition, daily weights were not consistently obtained or reported for a resident with CHF, and prescribed doses of prednisone were missed for another resident without proper documentation.
Two residents experienced delays and lack of resolution after voicing grievances about care and communication, including improper catheter care and insufficient notice of medical appointments. Staff did not consistently document or follow up on these concerns, and residents who could not write were not always assisted in filing grievances, resulting in a failure to address issues as required by facility policy.
Two residents experienced unsafe transfers with a new electronic lift due to lack of staff training, unclear care instructions, and failure to follow manufacturer safety guidelines. One resident hit his head on the lift bar, and staff did not check sling placement or properly position the lift during another transfer. Staff were unaware of required safety steps, and no training had been provided on the new equipment.
A resident with a history of recurrent UTIs and an indwelling urinary catheter did not receive proper infection control measures, including consistent use of PPE by staff and correct handling of the catheter drainage bag. Staff placed the catheter bag above bladder level, causing urine backflow, and failed to follow recommended cleaning procedures. The facility's policy lacked guidance on these critical infection prevention steps, and the resident reported lapses in care and hygiene practices.
The facility did not maintain adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, resulting in insufficient oversight and care.
Three residents received medications outside of prescribed parameters or without proper assessment, including one who was given an incorrect insulin dose and required emergency monitoring. Insulin and antihypertensive medications were administered without documented rationale or provider orders when parameters were not met, and relevant orders were missing from nurse binders.
A resident with a fractured shoulder, dementia, and lack of coordination did not receive the required 1:1 meal assistance as outlined in her care plan and Kardex. Observations showed her meal trays were left out of reach or without help, and documentation did not accurately reflect her needs or intake.
A resident with multiple sclerosis and limited mobility developed a pressure ulcer that was not promptly reported to the provider or DPOA, and required treatments were not consistently completed or documented. The resident was observed in the same position for extended periods despite care plan interventions, and there was a lack of timely communication and documentation regarding the wound and its management.
The facility did not consistently follow physician-ordered wound care protocols or provide adequate interventions to prevent skin breakdown for multiple residents with wounds or at risk for pressure injuries. Treatments such as barrier creams, wound cleansers, and dressings were missed on several occasions, and there was no documentation explaining the omissions.
A resident with complex medical needs did not receive care and services according to provider orders and her preferences. The facility failed to provide a gluten-free diet, did not administer wound care as ordered, neglected to obtain daily weights or follow-up labs, and did not notify the provider of significant weight loss. Additionally, there was a discrepancy in the resident's code status documentation, with staff unaware of the correct DNR status.
The facility failed to maintain cleanliness and proper maintenance of food service equipment, affecting 68 residents. Observations included mold and debris in the Walk-In Cooler, undated hot dogs, residue on kitchen equipment, and ice build-up in the Walk-In Freezer. These issues indicate non-compliance with FDA Food Code requirements, increasing the risk of cross-contamination.
The facility failed to implement an effective infection control program, lacking surveillance and documentation of infections among residents and staff. The abrupt departure of the PDON/ICP left the program without oversight, and no records were available for the months of October to December 2024. Employee absences due to illness were not documented or followed up on, indicating non-compliance with infection control policies.
The facility failed to meet the needs of four residents, including a male with Alzheimer's and a female with vascular dementia, by not ensuring call lights were accessible and not responding promptly to requests for assistance. Residents were left without access to necessary items like blankets and fluids, and staff did not adequately address their expressed needs.
A CNA in a LTC facility was found to have verbally abused multiple residents, using derogatory language and profanity. Witnesses confirmed the CNA's inappropriate behavior, which violated the facility's abuse policies. Despite some residents not recalling the incidents, the facility's investigation substantiated the claims, leading to the CNA's termination.
The facility failed to report suspected abuse in a timely manner, involving verbal and mental abuse by staff towards three residents. The facility's policy required immediate reporting to the Administrator, but delays occurred, with the State Survey Agency being informed a day later. A CNA involved in reporting the incident lacked documentation of education or discipline for the delay.
The facility failed to adhere to professional standards in medication administration, resulting in errors for several residents. Controlled medications were not properly documented, and medications were administered without following physician-ordered parameters. Additionally, a resident received an incorrect dose of an antipsychotic medication due to transcription errors.
The facility failed to provide timely and appropriate care to three residents, resulting in untreated conditions and delayed treatments. A resident experienced significant swelling in the feet that was not documented or assessed, another had a missed order to change tube feed guidelines, and a third experienced a delay in treating a urinary tract infection. These deficiencies were attributed to administrative changes, staff turnover, and delays in lab results.
A facility failed to prevent the misappropriation of controlled substances for three residents. A CNA observed an RN pocketing a narcotic pill meant for a resident, who confirmed not receiving it. The incident was not immediately reported to the State Agency, and the RN continued working before being removed. An audit revealed two more missing narcotics belonging to other residents, found in a bathroom. The facility remained non-compliant with narcotic documentation and storage standards.
The facility failed to use wheelchair footrests for two residents, one with paralysis and another with dementia, leading to potential hazards. A CNA propelled a resident without footrests, and another resident, at high fall risk, self-propelled into obstacles, causing entanglement with another wheelchair.
A facility failed to ensure pharmacy recommendations were documented and communicated to the physician for a resident with multiple diagnoses, including diabetes and hypertension. The pharmacist noted irregularities in the medication regimen review, but the report was missing from the resident's medical record, and the physician was not informed. The Nursing Home Administrator confirmed the absence of documentation during the survey.
The facility failed to implement an effective antibiotic stewardship program, leading to inappropriate antibiotic use for two residents. One resident received Ciprofloxacin without proper documentation or clinical criteria, while another was given an ineffective antibiotic before switching to an appropriate one. The program lacked proper oversight and documentation, resulting in deficiencies in monitoring and tracking antibiotic use.
The facility failed to provide pneumococcal immunizations per CDC recommendations and resident consent for three residents. A resident with pneumonia and two others with pertinent health conditions had no documentation of receiving or being offered the vaccine. The Infection Control Program, managed by two different PDON/ICPs, did not ensure proper immunization practices, as confirmed by the Regional Director of Clinical.
Surveyors found multiple medication carts left unlocked and unattended, with loose pills present and several opened medications, such as insulin pens and eye drops, lacking required date labels. Staff confirmed that carts should be locked and medications properly labeled, in accordance with facility policy and industry standards.
The facility failed to properly assess, monitor, and document pressure injuries for several residents, leading to inadequate care. One resident had a Stage II pressure injury and a deep tissue injury that were not properly documented or treated, with delays in notifying the physician. Another resident experienced delays in treatment and inconsistent evaluations of a pressure injury, with conflicting documentation. Additionally, a resident with quadriplegia had multiple concurrent treatment orders for a sacral wound, leading to missed treatments. The facility also failed to consistently obtain weights for a resident with CHF, as required.
Failure to Protect Residents from Repeated Intrusions and Threatening Behavior
Penalty
Summary
The facility failed to protect multiple residents from mental abuse and verbal abuse by a cognitively impaired male resident, R52, whose repeated wandering into other residents’ rooms and threatening, agitated behavior caused fear and distress. R52 had diagnoses including Wernicke’s encephalopathy, dementia, delusional disorders, and hallucinations. His record documented repeated episodes of wandering into other residents’ rooms, entering female residents’ rooms, standing in doorways, and becoming verbally and physically aggressive when redirected. On 2/7/26, he was documented as going into R58’s room and standing over her while she lay in bed, and he also made comments to staff and his roommate R60 about shooting people, guns, and “one bullet.” He was sent to the ED after swinging a wheelchair foot pedal at a CNA and making threatening statements. Several cognitively intact residents reported that R52 repeatedly entered or attempted to enter their rooms and that staff often had to redirect him. R58, who was cognitively intact and had diagnoses including heart failure, acute respiratory failure, anxiety disorder, and major depressive disorder, reported that R52 repeatedly stood in her doorway, opened her door, entered her room, and stood near her bed, which made her anxious, fearful, and nauseated. Her psychology notes documented increased depressive and anxiety symptoms, fear, and avoidance behaviors related to R52. Her family member also reported that R52 repeatedly appeared in her doorway and entered her room, and that R58 feared him. Other residents, including R6, R7, R9, R15, R27, R34, R35, and R26, reported similar incidents of R52 entering rooms, standing in doorways, staring, and needing repeated redirection. The record showed that the facility did not document incident reports for the 2/7/26 events involving R52, R58, and R60, and there was no further documentation in R58’s record beyond psychology notes. The administrator stated she had not seen the behavior note before review and acknowledged that it may have been abuse and reportable. The DON stated she was unaware of the behavior note until it was discussed in the IDT meeting and confirmed no incident reports were completed. Facility policy required immediate reporting of abuse allegations and protection of other residents through measures such as room changes, increased supervision, or transfer if indicated, but the record showed repeated incidents continued after R52 returned from the hospital and residents continued to report fear and repeated intrusions.
Failure to Monitor CHF, Allergies, and Ordered ACE Wraps
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for a resident with CHF, diabetes, and vascular dementia, and this failure contributed to the resident’s death in the facility. The resident’s weight increased over time, with dietary notes documenting significant weight gain and repeated weight warnings, but weights were obtained only about weekly and no goal weight was established. The record also showed no daily weights after a chest x-ray on 1/6/26 and after orders for increased Lasix on 1/6/26. Nursing documentation did not show consistent CHF assessments such as edema measurements, fluid or sodium intake monitoring, or a baseline goal weight without extra fluid retention. After a chest x-ray showed cardiomegaly, right pleural effusion, and findings consistent with CHF, the practitioner ordered increased Lasix and potassium. Nursing notes documented shortness of breath, low oxygen saturation, lethargy, and worsening condition, but the record did not show a full nursing assessment, clear follow-up documentation, or documentation explaining missed doses of ordered Lasix and Aldactone. The MAR showed the resident did not receive all ordered doses of Lasix and missed doses of Aldactone on several days, and there was no documentation showing why the medications were not given or whether the practitioner was notified. The care plan addressed altered cardiovascular status and daily weights, but it did not include concise CHF-focused goals or interventions such as fluid overload management, positioning, sodium or fluid restriction, or resident education. The facility also failed to address the resident’s documented morphine allergy before administering morphine sulfate oral solution. The EMR generated allergy warnings and drug interaction alerts when morphine was ordered, but there was no documentation that the practitioner was aware of the allergy at the time the medication was ordered or given. Morphine was administered despite the allergy warning, and later documentation stated the allergy was not a true allergy but an intolerance, with nausea and vomiting listed in hospital documentation. The resident was later found without breaths or pulse after receiving PRN medication. For another resident with spinal stenosis, heart failure, and diabetes, the facility failed to implement and monitor an order to wrap both lower extremities with ACE wraps twice daily for edema, applying them in the morning and removing them at night. The MAR did not document ACE wrap application, and there was no documentation showing that tightness of the bilateral lower extremities was monitored. The resident reported that the legs were supposed to be wrapped before getting out of bed because fluid pooled in the legs, that the wraps had not been applied since getting up, and that she had already told staff about the issue. The DON was informed that the resident had not been wrapped since being out of bed and acknowledged the timing of the order would not be ideal because the legs were dependent during the day.
Failure to Prevent Further Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent further pressure ulcer development for one resident who had multiple existing wounds and developed three additional facility-acquired pressure injuries. The resident was admitted with diagnoses including neuropathy, COPD, stage IV sacral pressure ulcer, and malnutrition, and was documented as cognitively intact with a BIMS score of 15. The resident was also documented as completely immobile and unable to make even slight changes in body or extremity position without assistance. Observation and record review showed the resident was repeatedly positioned with the right foot and toes touching the bed sheet, the bedspread folded on top of the foot, and no heel boot in place. On multiple observations across several days, the resident remained in similar positions for extended periods, and the resident stated staff had not turned and repositioned him since the prior night or since supper the day before. A CNA reported the resident had not received care or been repositioned since her arrival at 6:00 AM and stated she was unsure of other interventions in place to prevent skin breakdown. The CNA also reported that night shift and day shift did not communicate when residents were last repositioned. The resident’s wound records showed a chronic stage 4 right gluteal fold pressure ulcer, a stage 4 right dorsal second toe pressure ulcer, a full-thickness right anterior thigh trauma wound, and a new stage 3 sacral pressure injury. The wound clinic NP documented minimal healing or deterioration over an 8-week period, with limited or no treatment changes for some wounds. Treatment for the right thigh wound was ordered a week after it was evaluated, and treatment for the new sacral wound was delayed after the first documented treatment was declined. The care plan included pressure redistribution, position changes, off-loading, heel boots, and keeping blanket pressure off the toe, but the last intervention was dated 12/24/2025. The DON stated wound #3 and wound #4 were not addressed in the care plan, incident reports were not available for wounds #2, #3, or #4, there were no notifications to the primary physician about wound deterioration, and there was no interdisciplinary collaboration to discuss the resident’s pressure wounds. The facility policy required an individualized comprehensive care plan addressing the resident’s risk factors and interventions for prevention and treatment.
Insufficient Nursing Staffing and Incomplete Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. During an early entry survey conducted because of staffing concerns, staff and leadership repeatedly stated that the building did not have enough nurses and aides to cover the resident load, especially overnight and on weekends. RN A reported that on one shift there were only two nurses and four aides in the building, and later stated that six staff for a high-acuity building was not enough. CNA B, CNA C, CNA D, and the DON all described ongoing staffing shortages, with aides working extra hours, missing breaks, and being unable to find help when residents needed assistance. The staffing concerns were tied to resident care needs and behaviors. CNA B reported that R52 wandered into other residents’ rooms, hovered over residents while they slept, and frightened residents such as R58 and R60. CNA C reported that R52 had made gun and shooting comments and was found standing naked over a sleeping resident. Staff stated they needed to closely watch him to protect other residents, but also said there were not enough aides to do so. The acuity lists for the 300 and 400 halls showed that 31 of 54 residents required extensive staff assistance, including residents who needed sit-to-stand or Hoyer transfers and residents who needed help eating. The staffing shortage also affected direct care for individual residents. R40, who had diagnoses including spinal stenosis, heart failure, and diabetes, had an order to have ACE wraps applied to both lower extremities in the morning and removed at night, with monitoring for tightness twice daily. The MAR and EMR did not show the wraps were applied or that tightness was monitored, and the floor nurse stated she did not have time to wrap R40’s legs. R45, who had contractures, morbid obesity, and paraplegia, was care planned for showers on Mondays and Fridays and required two staff for bathing, but she reported her last shower had been 2 1/2 weeks earlier and said she sometimes only got a shower about once a month. Staff stated that providing her shower would leave only one aide on the floor, and the DON acknowledged that the facility did not have a shower aide and that staffing was based on census rather than acuity.
DON Worked on the Floor During Staffing Shortage
Penalty
Summary
The facility failed to prevent the Director of Nursing (DON) from working as a nurse on the floor, despite the reported staffing rule that the DON may serve as charge nurse only when the average daily occupancy is 60 or fewer residents. During observation and interview, the DON was seen at a medication cart passing medications and stated that a nurse had called in and she was covering until relief arrived. The DON also stated that she works on the floor about once a week to cover staffing shortages, that she was not aware of the regulation limiting the DON from serving as charge nurse when the average census is 60 or greater, and that the facility census for the survey was 87. The DON further reported staffing concerns had been raised with Corporate Administrators, who focused on census rather than resident acuity, and that she also served as the Infection Control Nurse. Review of the facility staffing policy stated that the DON may serve as charge nurse only when the average daily occupancy is 60 or fewer residents.
Compliance and Ethics Program Not Effectively Implemented
Penalty
Summary
The facility failed to implement policies and procedures to ensure an effective Compliance and Ethics program. During an interview, the Regional Nurse stated that the parent organization had a corporate director of compliance and that staff could report suspected violations to a hotline. The Nursing Home Administrator stated she did not recall having training on the facility Ethics and Compliance program, thought online training was scheduled yearly, and believed postings for the hotline were in common areas. She identified possible reportable issues as HIPAA/privacy concerns, resident care concerns, and staffing concerns, but said she was not aware of any reported violations and had not responded to any alleged violations. The Nursing Home Administrator was not aware of who the facility Compliance liaison was and was not familiar with the procedures, stating she would review the policy and find out. A policy provided to surveyors was dated 11/01/2019, while a later policy dated 12/09/2024 stated the facility had a Corporate Compliance and Ethics Program, designated a compliance contact, and described reporting methods, audits, and the administrator’s responsibility for maintaining compliance documentation. In an email after the interview, the Nursing Home Administrator confirmed she was the Compliance Liaison, but prior to that she had not been aware she was designated in that role and therefore was not involved with written standards, training, internal monitoring, enforcement of disciplinary guidelines, communication with staff, or participation in a compliance committee.
Incomplete and Late Documentation of Wounds and Resident Incidents
Penalty
Summary
The facility failed to document in the medical record in a complete, accurate, and timely fashion for 4 residents out of 19 sampled residents. The deficiency involved delayed, missing, and backdated documentation related to wound care, resident behaviors, and resident-to-resident incidents. Surveyors reviewed records, progress notes, treatment records, care plans, and interviewed the DON and NHA, and found that several entries were not present in the chart when first reviewed, while later-added notes appeared as late entries without clear identification as such. For one resident with neuropathy, COPD, malnutrition, and pressure injuries, the record showed multiple wounds assessed by a visiting wound clinic NP, including a chronic stage 4 right gluteal fold ulcer, a stage 4 right dorsal second toe ulcer, a full-thickness right anterior thigh trauma wound with purulent drainage, and a new sacral stage 3 pressure injury. The record reflected delays in treatment initiation for the thigh wound and sacral wound, incomplete documentation of wound-related interventions, and lack of documentation showing rotation of the catheter stat lock. The DON stated the new wounds should have been addressed in the care plan and that staff should have been communicating about turning and repositioning, but the record did not show this. Later, the DON produced incident reports and progress notes that had not been present in the clinical record when first reviewed, including notes dated weeks earlier that described IDT review and care plan updates that were not reflected in the care plan or Kardex. During an investigation involving three other residents, the facility also failed to document resident-to-resident incidents in a timely and accurate manner. One cognitively intact resident reported fear and anxiety after a confused male resident repeatedly entered her room and stood over her bed, but there was no documentation of the incident in her electronic record aside from psychology notes. Another cognitively intact resident and a severely cognitively impaired resident were both involved in the same event, during which the male resident made threatening comments about guns and shooting people, swung a wheelchair foot pedal at staff, entered other residents’ rooms, and caused fear in the roommates. The NHA and DON stated they were unaware of the behavior note until it was later read in an IDT meeting, and they reported no incident reports had been completed. After being made aware of the concerns, the DON created late progress notes and incident reports dated as if they had been entered at the time of the events, but the survey found these were created later and not clearly identified as late entries.
General cleanliness and repair deficiencies in common areas and shower rooms
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the building. On 03/03/2026 at 9:13 AM, a wall-mounted mini-split unit near the nurses’ station on 200 hall was observed with grey and green crusted material on both the interior and face of the unit. During the tour, the Maintenance Director confirmed the crusted material and stated the mini-splits were not in use during the winter and were scheduled to be professionally cleaned before being started for the year. Multiple shower rooms also had damaged tile coving and missing tile at the wall and floor juncture. In the 400 hall shower room, tile coving was broken and chipped, with sections of wall averaging six inches where tiles were missing across from the shower table washing area and adjacent to the shower area; the Maintenance Director stated the coving was scheduled for removal and replacement within the next month and that bathing equipment was causing damage when it ran into the tile. Similar broken, chipped, or missing tile coving was observed in the 300 hall, 200 hall, and 100 hall shower rooms, and the Maintenance Director confirmed the conditions in each room.
Resident’s Right to Set Own Schedule Not Honored
Penalty
Summary
The facility failed to honor R24’s right to set her own schedule and maintain a dignified existence. R24 was admitted with diagnoses including congestive heart failure, adjustment disorder with anxiety, and insomnia. During an interview, R24 reported that the facility was short staffed and that a second shift CNA wanted her to go to bed at 7:00 PM for staff convenience. She stated that when she refused, she was told she would have to wait for third shift because staff could not accommodate her preference to stay up a few more hours. R24 also reported that on a weekend she did not receive her evening medications until 1:30 AM. Review of the February 2026 MAR confirmed that on 2/28/2026 her evening medication was administered at 1:26 AM. An agency RN later confirmed she administered the medication at almost 1:30 AM after arriving to relieve the UM during a staffing shortage, and stated that R24 was not in bed when she brought the medication.
Failure to Reevaluate PRN Psychotropic Use
Penalty
Summary
The facility failed to evaluate one resident, R6, every 14 days before a PRN benzodiazepine was renewed. R6 was admitted with diagnoses including chronic congestive heart failure, type II diabetes mellitus, anxiety, and morbid obesity. A physician order dated 12/16/25 included clonazepam 0.5 mg by mouth every 12 hours as needed for anxiety for 90 days. The MAR showed clonazepam was administered 8 times from 12/16/25 to 12/31/25, 15 times in January 2026, 12 times in February 2026, and 4 times in March 2026. During interview and record review on 3/4/2026, the DON stated she was aware the medication required a physician evaluation every 14 days before it could be continued and said she had spoken with the provider about the evaluation. However, she could not produce an evaluation every 14 days for R6's clonazepam use. A progress note with an effective date of 2/3/26 and a created date of 3/4/2026 documented that NP Q believed clonazepam could continue because benefits were greater than risks at that time, and a physician progress note dated 3/3/26 also stated clonazepam 0.5 mg every 12 hours as needed would be continued because benefits were greater than risks at that time. No further evaluation related to the continued PRN clonazepam use was revealed or provided.
Failure to Report Alleged Abuse and Resident-to-Resident Incidents
Penalty
Summary
The facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act. The deficiency involved a male resident with diagnoses including Wernicke's encephalopathy, dementia, delusional disorders, and hallucinations, who had repeated episodes of wandering into other residents’ rooms, making threatening statements, and becoming physically aggressive with staff. The record showed multiple incidents in which he entered other residents’ rooms, stood over a cognitively intact female resident while she was in bed, and continued to wander into rooms on the hallways beside her room. A cognitively intact female resident reported that the male resident stood in her doorway, stared into her room, opened her door, and entered her room on multiple occasions. She stated that she felt anxious, very leery, and unsafe, and that she had reported her concerns to the administrator. Her family member also reported that the male resident repeatedly appeared in her doorway and entered her room, and that staff had to be called for assistance. Another resident with severe cognitive impairment was documented as crying and stating that he was scared to have the male resident in his room, and later stated that the male resident talked about dying and suicide. The male resident’s behavior notes documented that he used a wheelchair foot pedal as a potential weapon, made comments about shooting people and guns, wandered into other residents’ rooms, and became physically violent when redirected. He was transferred to the emergency department on more than one occasion for aggressive behavior and psychiatric evaluation. The nursing home administrator stated that she had not seen one of the behavior notes before the survey and that no incident reports had been completed from the occurrence involving the residents. She further stated that after reviewing the note, it may be possible abuse and reportable as an allegation of abuse to the state agency. The facility policy stated that allegations involving abuse, neglect, exploitation, mistreatment, injuries of unknown source, misappropriation of resident property, and crimes are to be reported immediately to the Administrator and to the State Survey Agency and other officials as applicable.
Failure to Update Care Plans for Skin, Wound, and Behavior Changes
Penalty
Summary
The facility failed to implement and update individualized care plans for three residents whose conditions had changed. For Resident #6, who had diagnoses including chronic congestive heart failure, type II diabetes mellitus, anxiety, and morbid obesity, the record showed ongoing skin concerns. On observation, the resident stated her skin was always itchy and had multiple small scabs up the left upper arm. The current skin care plan referenced concerns about scabies and precautions pending a dermatologist appointment, and the orders included petroleum jelly to the arms, torso, and back and hydrocortisone cream to the buttocks, but the current orders did not include a treatment for the rash on the left upper arm. The DON stated the resident had seen the dermatologist and that the care plan should be updated to reflect the resident’s status. For Resident #7, who had diagnoses including neuropathy, COPD, and a stage IV sacral pressure ulcer, the wound clinic documented new facility-acquired wounds. A right anterior thigh full-thickness trauma wound was assessed with purulent drainage, and a new sacral stage 3 wound was later documented with serosanguineous drainage. The resident’s pressure injury care plan still addressed a right ischium pressure ulcer and a left second toe wound, with interventions for pressure redistribution, off-loading, heel protection, and monitoring for changes, but the last intervention had been initiated months earlier. The DON stated the thigh trauma wound and sacral stage 3 wound had not been addressed in the resident’s plan of care and should have been included with new pressure injuries and interventions. For Resident #52, who had diagnoses including Wernicke’s encephalopathy, dementia, delusional disorders, and hallucinations, progress notes documented repeated wandering, resistance to redirection, attempts to exit the facility, entering other residents’ rooms, muttering to self, nonsensical speech, and an unsteady gait. A one-to-one was initiated after one episode of restless wandering and attempts to leave, but the care plans for behavior/mood and exit seeking/elopement risk were last updated on the same date they were initiated and did not reflect the later documented behaviors. The LPN unit manager stated there had been no time to update care plans because of working the floor, and the regional nurse stated the expectation was for care planning interventions and wound or condition changes to be updated the next business day.
Medication administration not given at ordered times and insulin not held per parameters
Penalty
Summary
The facility failed to ensure medications were administered according to professional standards of quality for multiple residents. For R24, who had diagnoses including congestive heart failure, adjustment disorder with anxiety, and insomnia, an evening medication scheduled for 7:00 PM on 2/27/2026 was not administered until 1:26 AM on 2/28/2026. R38, who had diagnoses including sepsis, acute respiratory failure with hypoxia, high blood pressure, and heart failure, also had an evening medication scheduled for 7:00 PM on 2/27/2026 that was not given until 12:32 AM on 2/28/2026. R93, with diagnoses including burns involving 10-19% of body surface, severe protein malnutrition, obstructive sleep apnea, and insomnia, did not receive an evening medication scheduled for 7:00 PM on 2/27/2026 until 1:16 AM on 2/28/2026. R94, who had Type 2 diabetes, high blood pressure, depression, and anxiety, did not receive a medication scheduled for 8:00 PM on 2/27/2026 until 12:24 AM on 2/28/2026, and did not receive Insulin Glargine scheduled for 7:00 PM on 2/27/2026 until 12:24 AM on 1/28/2026. For R3, who had bipolar disorder, Type II diabetes mellitus, and depression, the physician's order for Lispro Insulin 10 units with meals, hold if blood sugar was less than 120, was not followed on multiple occasions. The MAR showed the insulin was administered even when blood sugars were below the ordered threshold, including readings of 112, 107, 95, 68, 113, and 108 on several dates. The DON stated she was unaware of the insulin not being held as ordered, and the facility could not produce documentation showing the insulin had been held or otherwise addressed in the record.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to provide showers for 1 resident reviewed for bathing care. The resident had diagnoses of contractures, morbid obesity, and paraplegia, and was observed lying in bed and unable to provide care for herself. She reported needing extensive assistance from 2 staff for many ADLs because of her contractures and stated she had concerns about not enough staff being available to provide showers twice a week. She reported her last shower was 2 1/2 weeks earlier and that she had to push to get that shower so her hair could be washed; she also stated she gets a shower maybe once a month. The care plan indicated the resident was to receive showers on Mondays and Fridays and was totally dependent on 2 staff for showers. During interview, the resident stated she did not receive her shower on Monday. CNAs reported the resident requires 2 staff for bathing, which would leave only one CNA on the floor to answer call lights, and that the resident prefers morning showers before breakfast, which they said is hard to provide. Bathing/shower task documentation showed she was bathed, but it was not clear when she received a shower. The DON reviewed the EMR and verified the shower schedule, but it was not clearly documented when the resident last received a shower.
Failure to Supervise a High-Fall-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls and injuries for one resident with Wernicke's encephalopathy, dementia, delusional disorder, hallucinations, and a documented decline in cognition from a BIMS score of 15 to 3. The resident was identified as a high fall risk with poor safety awareness, impulsivity, and a history of bumping into walls and other items in the facility. The care plan included interventions such as keeping a walker and wheelchair near the resident, using a gait belt during ambulation as tolerated, and maintaining the bed in a low position. Survey observations showed the locked unit hallway was without staff, with low lighting and no visible supervision in the area where the resident was located. A CNA stated she was the only staff member working the hallway while the nurse and another aide were outside the locked unit doors, and she was observed sitting away from the hallway and call lights. The resident’s walker was not consistently present, and a wheelchair stored outside his room belonged to another resident and appeared too small for his height. During observation, the resident was seen ambulating without a gait belt or walker, and at times he left the walker and walked away unassisted. A hospitality aide followed him without notifying other staff or obtaining assistance, and the DON confirmed hospitality aides cannot walk residents with gait belts. The resident was also observed with multiple injuries, including skin tears and bruising on his arms and a superficial abrasion with petechiae on his left cheek. Nursing documentation noted the resident had a skin tear with total flap loss on the right elbow and a prior closed skin tear with continued discoloration on the left elbow. Staff documented that the resident had no safety awareness, a history of falls, and had been witnessed putting himself on the floor and getting himself off the floor without assistance. The physician note also documented a laceration to the left cheek from an unknown source and right-sided weakness, while the IDT note stated the resident required directing and cueing due to poor safety awareness, no spatial awareness, and impulsivity.
Failure to Follow Physician Orders for Medication Administration and Monitoring
Penalty
Summary
The facility failed to ensure that weights were obtained and medications were administered in accordance with physician orders for five residents reviewed for nursing services. For one resident with adrenocortical insufficiency, two doses of prescribed prednisone were not administered as ordered, and there was no documentation of a rationale or provider order for withholding the medication. The DON confirmed the missed doses and lack of documentation. For three residents with congestive heart failure and hypertension, medications such as metoprolol and digoxin were administered without obtaining required pre-administration assessments, including blood pressure and heart rate, as specified in the physician orders. Documentation showed that these assessments were either not performed or not recorded prior to medication administration, and there was no documentation explaining the rationale for administering the medications without the required assessments. Additionally, for one resident with congestive heart failure, daily weights were not consistently obtained as ordered, and significant weight gains that should have triggered provider notification were not acted upon or documented. The DON confirmed that weights were not consistently documented or reported as required by the provider orders.
Failure to Timely Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to resolve grievances in a timely manner for two residents who voiced concerns about their care and communication. One resident, a female with paraplegia, diabetes, and a urinary catheter, reported ongoing issues with staff not using proper personal protective equipment (PPE) during catheter care, improper cleaning of her catheter, and staff refusing to assist her when she experienced pain and issues with her catheter. She stated that she reported these concerns to the Director of Nursing (DON), who documented the issue on a sticky note but did not follow up or provide her with a copy of her grievance. The resident was unable to write due to hand contractures and required staff assistance to document her concerns, which was not consistently provided. Interviews with CNAs confirmed ongoing concerns about infection control and lack of response from the Registered Nurse Unit Manager (RNUM), but no additional grievance forms were found to address these issues. Another resident, a male with a history of stroke and spinal cord disease, expressed frustration with the lack of communication regarding his outside medical appointments. He reported that he was not informed of appointments in advance and was unaware of the facility's grievance process. The resident stated that staff did not offer to help him complete a concern form, despite his difficulty writing. During an interview, the facility's Social Worker acknowledged the concern but did not offer to complete a grievance form, instead stating she would relay the issue to the scheduler. The Appointment Scheduler confirmed attempts to arrange the resident's orthopedic appointment but was unaware of the resident's desire for earlier notification. The Nursing Home Administrator was not aware of the resident's concerns until informed during the survey and noted that staff education on the grievance process was ongoing. The facility's policy required that grievances be documented and responded to promptly, with actions taken to prevent potential violations of residents' rights. However, the investigation found that grievances were not consistently documented, residents were not always assisted in filing grievances when unable to do so themselves, and timely follow-up and resolution were lacking. The absence of proper documentation and response to residents' concerns, particularly regarding infection control and communication about medical appointments, constituted a failure to honor residents' rights to voice grievances without discrimination or reprisal.
Failure to Ensure Safe Transfer Practices with Electronic Lift
Penalty
Summary
The facility failed to ensure safe transfer practices with an electronic lift for two residents who required assistance. One resident expressed discomfort with the new electronic lift, stating it did not fit properly and that he hit his head on the bar during a transfer. The resident's care guide specified the use of a toileting sling and hoyer lift with two staff for transfers, along with cervical precautions, but did not indicate which brand or size of sling should be used. Staff interviews revealed a lack of clarity regarding sling assessments and appropriate equipment selection for the resident, and there was no documentation that the incident of the resident hitting his head had been reported or addressed. During direct observation, staff were seen transferring another resident with the new lift without following manufacturer safety instructions. The bed was in the highest position, and the resident's buttocks did not clear the mattress before being moved. Staff did not check that all sling loops were properly attached before moving the resident, and the lift's legs were not in the fully open position as required for stability. Both staff members involved in the transfer were unaware of the need to check loop placement, ensure the resident cleared the surface before moving, or that the lift legs should be fully open for safety. Further review showed that staff had not received training on the new lift since its purchase, and there was no evidence that management had addressed residents' concerns or reported incidents related to the lift. The instruction manual for the lift provided clear safety requirements that were not followed during observed transfers. The lack of training, unclear care instructions, and failure to follow manufacturer guidelines contributed to unsafe transfer practices and accident hazards for residents requiring lift assistance.
Failure to Implement Proper Infection Control for Catheterized Resident
Penalty
Summary
A deficiency was identified when a resident with a history of recurrent urinary tract infections (UTIs), paraplegia, and an indwelling urinary catheter did not receive proper infection prevention and control measures. The resident's care plan required enhanced barrier precautions, including the use of gowns and gloves during direct care, and specified that the urinary catheter drainage bag should be kept below bladder level to prevent backflow. However, observations revealed that staff did not consistently use personal protective equipment (PPE) such as gloves and gowns when providing care, as reported by the resident herself. The resident expressed concern that this lack of PPE use was contributing to her recurrent UTIs. During direct care, certified nurse aides (CNAs) were observed removing the Foley catheter bag from its privacy bag and placing it on the bed above the resident's bladder level. This action caused urine from the external measuring device to flow back up the catheter tube into the resident's bladder. The CNAs admitted they were unfamiliar with the external measuring device and had not received training on its proper use or the importance of bag placement. Additionally, a soaker pad was found to be wet with urine, and the CNAs stated that the resident did not normally have catheter leakage. A review of the facility's catheter draining bag emptying policy revealed it lacked instructions on keeping the Foley bag below bladder level and on cleaning the emptying device tip with alcohol after use, both of which were included in the hospital's discharge instructions for the resident. The resident also reported that staff did not use alcohol swabs or paper towels when emptying the catheter bag, and that she was not checked or repositioned during the night as required by her care plan.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified based on observations and findings that indicated staffing levels were insufficient to address resident care requirements, and there were shifts without a licensed nurse present to oversee care.
Failure to Follow Professional Standards in Medication Administration
Penalty
Summary
The facility failed to follow professional standards of quality in medication administration for three residents. One resident with diabetes mellitus was given an incorrect dose of insulin after a nurse read the wrong record, resulting in the resident being sent to the emergency room for monitoring due to the risk of hypoglycemia. Another resident with type 2 diabetes mellitus received insulin doses outside of the prescribed blood sugar parameters on multiple occasions, with no documentation of the rationale for administering the medication outside of those parameters or any provider order authorizing such administration. Additionally, this resident was not included on the list of orders with parameters for holding medications in the nurse binder. A third resident with hypertension received Losartan despite blood pressure readings that were outside the parameters set by the provider's order, or without a blood pressure assessment prior to administration. There was no documentation explaining the rationale for administering Losartan outside of the prescribed parameters or any provider order to do so. This resident was also not included on the list of orders with parameters for holding medications in the nurse binder. These findings were based on interviews, record reviews, and review of medication administration records.
Failure to Provide Required Meal Assistance
Penalty
Summary
The facility failed to provide necessary meal assistance to a resident who required 1:1 help with eating due to a fractured right shoulder, dementia, and lack of coordination. On two separate mornings, the resident was observed with her meal tray left out of reach or placed in front of her without assistance, despite care plan and Kardex instructions specifying the need for 1:1 assistance. Documentation inconsistencies were also noted, with staff recording the resident as 'not available' for one meal and indicating partial intake for another, even though the resident reported difficulty eating without help.
Failure to Prevent and Manage Pressure Ulcer and Notify Provider and DPOA
Penalty
Summary
The facility failed to provide care in accordance with professional standards and its own policies to prevent the development and worsening of a pressure injury for a resident with multiple sclerosis and limited mobility. The resident was observed in bed for extended periods, with her position unchanged for several hours, and her heels resting directly on the bed surface despite care plan interventions requiring heel elevation and frequent repositioning. Staff interviews confirmed that the resident was to be repositioned at least every two hours, but observations showed this was not consistently implemented. Documentation review revealed that the resident developed two open sores in the coccyx area, which were not promptly reported to the provider or the resident's DPOA. There was a significant delay in notifying the provider (12 days after initial identification) and the DPOA (18 days after identification) of the pressure injury. Additionally, there was no documentation of new care plan interventions or treatment orders at the time the wounds were first identified, and the DPOA was not informed of subsequent treatment changes in a timely manner. Treatment records showed that ordered wound care was not consistently completed on several dates, and there was a lack of documentation regarding the implementation of new treatments. The facility's own policy required prompt notification of the provider and responsible party, timely implementation of treatments, and regular documentation and monitoring, all of which were not followed in this case. Family interviews further indicated a lack of communication regarding the resident's condition and care, with the DPOA unaware of the wound's status and treatment changes.
Failure to Follow Physician-Ordered Wound Care and Prevent Pressure Injuries
Penalty
Summary
The facility failed to follow physician-ordered wound care and did not provide adequate care to prevent the development of skin breakdown or pressure injuries for six residents reviewed for skin integrity issues. Multiple residents had specific wound care orders, such as the application of zinc oxide, barrier creams, hydrogel, collagen powder, and other treatments at prescribed times and frequencies. However, treatment administration records revealed that these wound care interventions were frequently missed or not completed as ordered. In several cases, there was no documentation in the electronic medical record to account for the missed treatments. Residents affected included individuals with existing wounds or at high risk for skin breakdown, such as those with excoriation, pressure injuries, abrasions, and impaired skin. The missed treatments occurred across various shifts and dates, with some residents not receiving wound care at all during certain scheduled times. The lack of adherence to prescribed wound care regimens and the absence of documentation for missed treatments contributed to the deficiency identified during the survey.
Failure to Follow Provider Orders and Resident Preferences Results in Poor Care
Penalty
Summary
The facility failed to provide care and services in accordance with provider orders, resident preferences, and goals for one resident with multiple complex medical conditions, including congestive heart failure, irritable bowel syndrome, dysphagia, and gluten intolerance. Upon admission, the resident had clear hospital discharge instructions for wound care, a gluten-free diet, daily weights, and follow-up laboratory testing due to a history of hypokalemia and ongoing diuretic therapy. However, the facility did not transcribe or implement these orders accurately. The resident did not receive zinc oxide as ordered for skin excoriation, and the application was not performed three times daily as required. The gluten-free diet was not ordered or provided upon admission, resulting in the resident receiving meals containing gluten, which led to excessive diarrhea and further skin breakdown. Additionally, the facility failed to order or complete the recommended follow-up laboratory tests to monitor electrolyte levels, despite the resident's risk factors and recent history of hypokalemia. Daily weights were not obtained as ordered, and significant weight loss of approximately 23 pounds over six days was not identified or reported to the provider. Documentation in the medical record was incomplete, and there was no evidence that the physician was notified of these significant changes in the resident's condition. There was also a failure to ensure accurate documentation and communication regarding the resident's code status. Although a Do Not Resuscitate (DNR) order was signed and available in the electronic medical record, the active order in the system remained as Full Code, and facility staff were unaware of the discrepancy. These failures resulted in the resident not receiving care and services as ordered and as needed for her medical conditions.
Deficiencies in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper maintenance of food service equipment, as well as to date mark potentially hazardous food items, which could affect 68 residents. During an initial tour of the kitchen, several issues were observed, including mold, mildew, grime, and debris on the shelving and fan compressor grate inside the Walk-In Cooler. Additionally, an undated container of hot dogs was found stored on the shelving. In the cook line area, the can opener blade and holster had food residue and debris, and the commercial blender lid had a yellow/white build-up with black speckles resembling mold or mildew. Further observations revealed ice build-up on the shelving and opened/sealed boxes of food in the Walk-In Freezer, located directly beneath the compressor unit. The Reach-In Cooler units throughout the kitchen were also found to have food residue and debris on the shelving, bottoms, doors, and door openings. These findings indicate a failure to adhere to the 2017 FDA Food Code requirements for equipment cleanliness, food-contact surfaces, and proper food storage, increasing the likelihood of cross-contamination and bacterial harborage.
Inadequate Infection Control Program Implementation
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by the lack of surveillance, tracking, and monitoring of infections among residents and staff. During the survey, it was discovered that the facility did not maintain any line lists or documentation of confirmed or suspected infections for the months of October to December 2024. This deficiency was further compounded by the abrupt departure of the Previous Director of Nursing/Infection Control Preventionist (PDON/ICP) S, who had been responsible for the program for the past six weeks. The Regional Director of Clinical (RDC) X confirmed that both PDON/ICP S and the previous PDON/ICP T were responsible for the oversight and maintenance of the Infection Control Program, yet no records were available to demonstrate compliance with the facility's infection control policies. The facility's policy on Infection Prevention and Control-Surveillance, dated July 11, 2018, outlines the requirement for ongoing monitoring and documentation of infections among residents, employees, volunteers, and visitors. However, the review of the 300/400 Unit Scheduling Book revealed employee absences due to illness, with no documentation of the unit they worked in, the residents they interacted with, or any follow-up actions taken to prevent the spread of infection. This lack of documentation and follow-up indicates a failure to adhere to the facility's stated goals of decreasing infection risk and maintaining compliance with state and federal regulations.
Failure to Accommodate Resident Needs
Penalty
Summary
The facility failed to accommodate the needs and preferences of four residents, as observed during a survey. Resident #45, a male with Alzheimer's, lack of coordination, muscle wasting, and a below-the-knee amputation, was repeatedly observed with his call light out of reach, preventing him from requesting assistance. On multiple occasions, he was unable to reach his blanket and expressed feeling cold, yet staff did not adequately address his needs. Similarly, Resident #67, a female with vascular dementia and other conditions, was left shivering in her wheelchair after staff delayed assisting her with dressing, despite her call light being activated. Resident #62, a female with dementia and other health issues, was observed without access to fluids while sitting at the nurses' station and self-propelling in her wheelchair throughout the facility. She expressed thirst, yet no fluids were provided within her reach. Additionally, Resident #7, a male with chronic kidney disease and other serious health conditions, had his call light activated for over an hour without response, leaving him without fresh water. These observations indicate a failure to ensure call lights were accessible and to respond promptly to residents' needs, as outlined in the facility's policy.
Verbal and Mental Abuse by Staff in LTC Facility
Penalty
Summary
The facility failed to protect residents from verbal and mental abuse by staff, specifically involving a Certified Nursing Assistant (CNA) identified as CNA B. The incidents involved five residents, with specific allegations of verbal abuse and derogatory language directed at residents. The facility's investigation revealed that CNA B used inappropriate language, including profanity, in the presence of residents, creating an uncomfortable environment. Witnesses, including other CNAs and staff, corroborated these allegations, noting that CNA B often used profanity and derogatory terms in resident care areas. One resident, identified as R12, was reportedly called 'fat and disgusting' by CNA B, although the resident, who was hard of hearing, did not recall the incident. Another resident, R35, was allegedly called an 'a**hole' by CNA B, and although the resident did not remember the specific incident, they confirmed hearing profanity from CNA B. Additionally, R53 was reportedly subjected to derogatory comments about their hygiene, although the resident did not recall these comments. The facility's investigation substantiated these claims based on witness statements, despite some residents not recalling the incidents. The facility's policies on abuse and neglect clearly define verbal and mental abuse, including the use of disparaging language. Despite these policies, the investigation concluded that CNA B's behavior violated these standards, leading to a hostile environment for both residents and staff. The facility's administration was initially unaware of the extent of the issue until it was reported and investigated, resulting in the termination of CNA B's employment due to the substantiated allegations of abuse.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to develop and implement policies and procedures for timely reporting of suspected abuse, neglect, or theft, as required by section 1150B of the Act. This deficiency involved three residents who were subjected to verbal and/or mental abuse by staff members. The facility's Abuse and Neglect Policy and Procedure, dated 3/24/23, outlined that all allegations and suspicions of abuse must be reported immediately to the Administrator or the Administrator's Designee. However, the facility did not adhere to this policy, resulting in a delay in reporting the incidents to the State Survey Agency. The incident involved a Certified Nursing Assistant (CNA) who failed to report allegations of abuse immediately. On 11/11/24, CNA B was reported to have used inappropriate language towards two residents, calling one an "*sshole" and being rude and disrespectful to another. The report was not made to the Interim Nursing Home Administrator until the following day, and the State Survey Agency was not informed until later that day. The personnel file of CNA C, who reported the incident, lacked documentation of any education or discipline regarding the failure to report the allegations timely, although a Teachable Moment form indicated she was educated on the need to report such allegations immediately.
Medication Administration Errors and Documentation Issues
Penalty
Summary
The facility failed to administer controlled medications following professional standards of practice, resulting in several medication administration errors. For Resident #5, the administration of HYDROcodone-Acetaminophen was not properly documented, with one dose being illegible and not recorded in the Medication Administration Record. Similarly, Resident #46's records showed discrepancies between the Control Substance Record and the Medication Administration Record, indicating that not all doses were administered as documented. Resident #7 also experienced a similar issue, where the Control Substance Record showed fewer doses of oxyCODONE administered than what was documented in the Medication Administration Record. The facility also failed to ensure medications were administered following physician-ordered parameters. Resident #2 was given Midodrine without proper blood pressure assessments, contrary to the physician's orders to hold the medication if blood pressure was over 120. This resulted in the administration of Midodrine when the resident's blood pressure was above the specified threshold. Additionally, Resident #24 received insulin despite having blood sugar levels below the threshold specified in the physician's orders, indicating a failure to adhere to the prescribed parameters for insulin administration. Furthermore, the facility inaccurately transcribed and ordered a newly admitted resident's antipsychotic medication. Resident #68 was prescribed 100 mg of quetiapine at bedtime, but the facility administered 200 mg, resulting in the resident receiving twice the ordered dose. This error persisted from the time of admission, as reflected in the Electronic Medication Administration Records, and was confirmed by the facility's administrator upon review.
Failure to Provide Timely and Appropriate Care
Penalty
Summary
The facility failed to provide quality care to three residents, resulting in untreated conditions and delayed treatments. Resident #14 experienced significant swelling in the feet, which was not documented, monitored, or assessed despite a noticeable weight increase and previous diagnoses of lymphedema and chronic kidney disease. The care plan required daily skin observations and reporting of changes, but the edema was not reassessed or addressed in subsequent physician assessments. Resident #3 had a missed order to change tube feed guidelines, which was recommended by a registered dietitian due to frequent clogging issues. Despite the recommendation to adjust the feeding rate and flush volume, no follow-up or changes were made to the tube feed orders for nearly a month. The oversight was attributed to administrative changes and staff turnover, leading to the recommendation falling through the cracks. Resident #19 experienced a delay in treating a urinary tract infection. The resident reported symptoms consistent with a UTI, but there was a significant delay between the onset of symptoms and the administration of antibiotics. The facility awaited culture results before starting treatment, and the resident was eventually hospitalized due to the UTI and lethargy. The delay was partly attributed to the time taken for lab results to be returned.
Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for three residents. An incident occurred where a certified nurse aide observed a registered nurse placing a narcotic pill prescribed to a resident into her pocket. The resident confirmed that he had not received his pain medication. The incident was reported to the interim nursing home administrator, who did not immediately report it to the State Agency or suspend the registered nurse. The registered nurse continued to work an additional shift before being removed from the floor the following morning. An audit of the medication cart used by the registered nurse revealed two additional narcotics were unaccounted for, which belonged to two other residents. These missing narcotics were later found in a medication cup in a bathroom. The facility's policy on abuse and neglect emphasizes providing care in an environment free from misappropriation of property. However, the facility failed to demonstrate substantial compliance with narcotic documentation and storage, remaining out of compliance with professional standards for controlled drug administration and documentation.
Failure to Use Wheelchair Footrests Leads to Hazards
Penalty
Summary
The facility failed to ensure the use of footrests on wheelchairs for two residents, leading to potential accident hazards. Resident #44, a female with left-sided paralysis following a stroke and abnormal posture, was observed being propelled by a Certified Nurse Aide (CNA) down a hallway without footrests on her wheelchair. This lack of footrests could contribute to instability and potential injury during transport. Resident #62, a female with dementia, rheumatoid arthritis, and a high risk for falls, was also observed without footrests on her wheelchair. She was pushed by a CNA and later self-propelled down a hallway, encountering obstacles such as meal service carts. This led to a situation where she leaned forward to move a cart, and subsequently, her wheelchair became entangled with another resident's wheelchair, causing frustration and requiring staff intervention to resolve the situation.
Failure to Document and Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were received and reviewed by the physician for a resident, leading to a deficiency in the medication regimen review process. The facility's Medication Regimen Review (MRR) Policy and Procedure requires that any irregularities identified by the pharmacist be reported to the attending physician, medical director, and Director of Nursing Services within seven working days. However, for one resident, the pharmacist noted irregularities on the Medication Regimen Review form but did not specify what they were, and the corresponding report was not found in the resident's electronic medical record. The resident in question had multiple diagnoses, including diabetes, hypertension, hyperlipidemia, and paranoid schizophrenia. Despite the pharmacist's indication of irregularities, there was no documentation in the resident's medical record to show that the physician was aware of these recommendations. During interviews, the Nursing Home Administrator acknowledged the absence of the pharmacy report and the lack of evidence that the physician had been informed. The facility was unable to provide any further documentation related to the pharmacy recommendation by the completion of the survey.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic utilization for two residents. The previous Director of Nursing/Infection Control Preventionist (PDON/ICP) abruptly ended her employment, leaving the program without proper oversight. The Regional Director of Clinical (RDC) confirmed that the PDON/ICP was responsible for monitoring antibiotic use and ensuring clinical criteria were met, but this was not effectively carried out. For Resident #5, there was no documentation of clinical criteria for the use of Ciprofloxacin, no culture and sensitivity report reviewed, and no provider rationale for the continued use of the antibiotic. This lack of documentation and oversight led to the inappropriate administration of antibiotics without proper justification or evidence of necessity. Resident #45 was initially prescribed Macrobid for a UTI, but a culture and sensitivity report later indicated resistance to this antibiotic. Despite this, Macrobid was administered twice before switching to Ciprofloxacin, which was deemed appropriate by the culture report. The facility's Infection Control Program documentation lacked surveillance and tracking of infections and antibiotic use, further highlighting the deficiency in the antibiotic stewardship program.
Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to provide pneumococcal immunizations according to CDC recommendations and resident consent for three residents. Resident #18, a female with a history of pneumonia, had no documentation of receiving or being offered the pneumonia vaccine since her admission. Similarly, Resident #4, who was readmitted with pneumonia, lacked documentation of vaccine administration or discussion with her guardian. Resident #56, with lung and heart disease, also had no record of receiving the vaccine or having it discussed with him or his guardian. These deficiencies were identified during a review of the residents' electronic medical records. The facility's Infection Control Program, which was overseen by two different Directors of Nursing/Infection Control Preventionists (PDON/ICP) over a short period, failed to ensure that the necessary immunizations were offered and documented. The Regional Director of Clinical confirmed the absence of historical data for the pneumococcal immunizations for these residents and acknowledged the need to obtain consent and offer the immunizations. The facility's policy on Infection Prevention and Control, dated 2018, emphasized the importance of offering immunizations to decrease the incidence of preventable infectious diseases, but this was not adhered to in these cases.
Unsecured Medication Carts and Improper Medication Labeling
Penalty
Summary
Surveyors observed multiple instances where medication carts were left unlocked and unattended by licensed nursing staff. Specifically, one medication cart was found unlocked and unattended, containing five loose pills in a drawer, and several medications, including Lantus insulin pens and brimonidone eye drops, were not labeled with the date they were opened. Another medication cart was found with eight loose pills in a drawer. Additionally, both medication carts on a particular hall were observed sitting side by side, unlocked and unattended, while a registered nurse was away from the carts. Interviews with staff confirmed that medication carts should be locked at all times when not attended by a nurse, and that loose pills should not be present in the carts. Review of facility policy and industry standards indicated that all drugs and biologicals must be stored in locked compartments and that opened medications should be dated according to manufacturer guidelines. The failure to secure medication carts and properly label opened medications was directly observed and acknowledged by staff.
Deficiencies in Pressure Injury and Wound Care Management
Penalty
Summary
The facility failed to adequately assess, monitor, and document pressure injuries and wounds for several residents, leading to deficiencies in care. For one resident, there was a lack of proper assessment and documentation of pressure injuries, including a Stage II pressure injury to the buttocks and a deep tissue injury to the left foot. The resident was observed multiple times without necessary protective equipment, such as offloading boots and cushions, and there was a delay in notifying the physician and obtaining treatment orders for new injuries. Additionally, the resident's care plan was not updated with meaningful interventions following the identification of pressure injuries. Another resident experienced a delay in the treatment of a pressure injury, with inconsistent evaluations and contradictory documentation regarding the condition of the injury. The facility staff failed to implement hospice-provided wound care orders, and there was a lack of documentation regarding the notification of the physician and guardian about the pressure injury. The resident's care plan was not updated promptly, and there were discrepancies in the assessment of the pressure injury, with conflicting reports about its severity and condition. The facility also failed to ensure that another resident received appropriate wound care as per physician orders. There were multiple concurrent treatment orders for the resident's sacral wound, leading to confusion and missed treatments. The facility did not document any attempts to clarify these orders, resulting in inadequate wound care. Additionally, the facility did not consistently obtain and document weights for a resident with congestive heart failure, as required by the treatment plan. The Director of Nursing acknowledged the lack of oversight and monitoring of pressure injuries and wounds, indicating systemic issues in the facility's wound management program.
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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 Whitehall
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Nursing And Rehabilitation Community | 9.8 mi | ★★★★★ | 12 | 0 |
| Harbor Terrace Senior Living | 12.3 mi | ★★★★★ | 10 | 0 |
| Optalis Health & Rehabilitation Of Muskegon | 13.3 mi | ★★★★★ | 40 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 13.6 mi | ★★★★★ | 2 | 0 |
| Roosevelt Park Nursing And Rehabilitation Communit | 14 mi | ★★★★★ | 3 | 0 |
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