Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Roosevelt Park Nursing And Rehabilitation Communit during CMS and state inspections, most recent first.
Surveyors identified multiple safety failures, including excessively hot water at several resident hand sinks and in a shower room, a missing cold-water handle, and a non-functioning shower call light. Residents reported that the water became very hot and required careful checking before use. An unsecured oxygen tank was found standing at the foot of a bed in a resident room. In addition, a bariatric shower chair of unknown weight capacity collapsed under a morbidly obese resident during a lift transfer, after which staff and the Director of Maintenance acknowledged that there was no preventive maintenance program for shower chairs, no visible manufacturer information or weight limits on the chairs, and confusion among staff about how to determine appropriate weight capacities.
A dependent resident with hemiplegia, severe cognitive impairment, incontinence, and visual deficits was repeatedly observed lying in bed with contracted hands and unused hand splints, no oral care supplies in the room, and persistent white discharge from one eye despite a care plan requiring daily eye/face washing, toothettes BID, and bilateral palm protectors. The resident’s brief was found saturated even though a CNA stated checks and changes were to occur every 2 hours and claimed to have recently changed the brief. The CNA also reported not providing oral care that day and noted the eye discharge had been present for weeks, while staff accounts of how often the resident was assisted out of bed conflicted with the care plan’s direction to encourage daily use of a Broda chair. The resident’s toenails were very long and curled around the toes, further demonstrating missed hygiene and ADL care responsibilities.
Multiple instances of misappropriation of controlled substances occurred, including altered documentation, unaccounted-for doses, and administration of medications outside of prescribed times. An LPN was identified as altering narcotic counts and dispensing medications without proper documentation, affecting several residents. Additional deficiencies included dispensing medications without active orders and lack of required signatures for wastage, with staff failing to follow established procedures for controlled substance management.
A long-term care facility failed to prevent the misappropriation and diversion of narcotic medications for several residents. A nurse was found with unauthorized medications off-site, and discrepancies in medication counts were discovered after another nurse left abruptly. Ongoing issues with controlled medication administration were also identified, with the facility lacking a formal audit system to ensure proper medication handling.
The facility failed to document allegations of abuse made by two residents, resulting in incomplete medical records. One resident, with severe cognitive impairment, reported being pushed by a CNA, while another, moderately cognitively intact, reported being hit. Both cases lacked documentation of physical or psychosocial assessments related to the allegations, and staff interviews revealed an expectation for such documentation, which was not met.
The facility failed to maintain sanitary conditions in the kitchen, with dirty freezer seals and inconsistent refrigeration temperatures. A Raetone unit had a loose door seal and was low on Freon, affecting food safety. Additionally, ready-to-eat foods were improperly date-marked, and thawing procedures were not followed, violating FDA Food Code standards.
The facility failed to implement an effective infection prevention and control program, with inadequate tracking of infections and a lack of investigation during a COVID-19 outbreak. Additionally, the facility did not have an active plan for reducing the risk of Legionella in the plumbing system, with no evidence of regular flushing or testing.
The facility failed to maintain cleanliness and repair, with deteriorating cabinets, unsealed holes, debris in storage areas, and disrepair in the roof and soffit. A family member reported unclean conditions in a resident's room, including an unclean bedside commode and soiled bedding. These issues indicate a lack of consistent maintenance and cleanliness, potentially affecting resident satisfaction.
The facility failed to accommodate the needs and preferences of three residents, including not assisting a resident with mobility issues out of bed, and not responding to call lights in a timely manner. Residents reported long wait times for assistance, particularly during evening shifts, and issues with the distribution of snacks and water. These deficiencies were consistently highlighted in Resident Council Meetings over several months.
The facility was found to have fall hazards due to unsecured rubber mats in a hallway and high hot water temperatures in the central spa and dining room sinks. The clean utility/pantry room was also left unlocked with an unsecured aerosol spray can, posing additional risks. Staff were observed navigating around the hazards without addressing them.
The facility failed to follow proper tube feeding protocols for two residents. One resident's feeding equipment was not properly dated or stored, and the setup lacked necessary labeling. Another resident's head of bed was not elevated to the required degree during feeding, and the feeding setup was also improperly labeled.
The facility failed to properly store and label medications in a medication cart and storage room. An LPN was found with a cart containing improperly labeled and undated medications, and a spray bottle with an unidentified liquid. Additionally, a medication storage room had a refrigerator at an incorrect temperature and contained expired medications. A resident was found with unused eye drops left by facility nurses, which she did not administer herself.
The facility failed to provide adequate food options and meal variety for two residents, leading to dissatisfaction and unmet dietary needs. Despite having a system for residents to choose between a main entree and an alternate menu, the process was inconsistently implemented, with some menu items unavailable and repetitive meal options offered. Residents expressed frustration with the lack of variety and the requirement to request alternatives before a specific time.
A facility failed to accurately document the activated medical and financial DPOA for a resident, resulting in the potential for inappropriate delegation of rights. The resident's family members were designated as DPOA, but discrepancies in documentation led to the wrong individual being notified of health status changes. The facility's process for documenting DPOA information was not followed, contributing to the deficiency.
The facility did not provide required Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents discharged from a Medicare-covered Part A stay with benefit days remaining. The Nursing Home Administrator and Social Worker confirmed the absence of these notices, which are mandated by facility policy to inform beneficiaries of their rights and potential liabilities.
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. A resident was prescribed ciprofloxacin without a culture and sensitivity report, another was initially given an ineffective antibiotic for a UTI, and a third resident also lacked culture documentation. The DON confirmed lapses in reviewing reports and monitoring the antibiotic stewardship program.
The facility failed to ensure a qualified Infection Preventionist (IP) was working at least part-time, as the IP was also a full-time floor nurse, limiting their ability to focus on infection control duties. The Director of Nursing (DON), who lacked specialized training, covered IPCP duties when the IP was unavailable. This led to inadequate infection surveillance, including a missed COVID-19 outbreak investigation and incomplete Resident Infection Control Logs. The facility's policy required the IP to be employed at least part-time, but the facility assessment did not specify the necessary time for IPCP duties.
Unsafe Water Temperatures, Unsecured Oxygen, and Inadequate Shower Chair Safety
Penalty
Summary
The deficiency involves the facility’s failure to maintain safe water temperatures and functional safety equipment in resident bathrooms and a shower room, as well as failure to secure oxygen equipment and ensure safe, appropriate use and maintenance of shower chairs. During an environmental tour, surveyors measured excessively hot water at multiple resident hand sinks and in a shower room, with temperatures ranging from 120.7°F to 130.3°F at hand sinks and 127.1°F at a shower. Residents reported that the water became very hot and that they had to check the temperature before using it. In the [NAME] Shower Room, the cold-water knob/handle was missing from the bathroom hand sink, and the call light switch on the shower wall was not functioning, as confirmed by the Director of Maintenance (DOM) K. In the boiler room, the temperature valve on the large holding tank read 134°F and the mixing valve read 130°F, which did not match the 120°F temperature DOM K stated he had previously recorded as the outgoing water temperature. The deficiency also includes failure to secure oxygen equipment. During an observation in one resident’s room, an unsecured oxygen tank was found standing alone at the foot of the bed under the window. The Regional Nurse Consultant acknowledged that the oxygen tank should have been secured. This unsecured tank represented an accident hazard in the resident’s immediate environment and reflected a lack of appropriate supervision and environmental safety controls. Another component of the deficiency concerns the facility’s failure to ensure that shower equipment was appropriate for a resident’s weight and maintained in safe condition. Resident R2, a cognitively intact individual with reduced mobility, generalized muscle weakness, morbid obesity, and dependence on staff for bathing and transfers, weighed over 400 pounds at the time of the incident. While being lowered into a bariatric shower chair in the shower room using a mechanical lift, the chair’s leg broke and the chair collapsed, causing the resident to fall to the floor and hit his head. The resident described the chair as made of flimsy, thin PVC piping, appearing small for his size, and reported that it splintered into many pieces. DOM K stated he did not perform preventive maintenance checks on shower chairs, did not know the brand or weight rating of the broken chair, and that the maximum weight limits were not printed on the chairs. Staff interviews revealed confusion and lack of clear knowledge about the weight limits of shower chairs, with some staff believing chairs were color coded by weight capacity but being unable to identify actual limits or find manufacturer information on the chairs themselves. These combined findings show that the facility did not prevent accidents or maintain an environment free from accident hazards in multiple areas: excessively hot water in resident rooms and a shower room, missing sink hardware and a non-functioning shower call light, an unsecured oxygen tank in a resident room, and the use of a shower chair of unknown and unverified weight capacity that collapsed under a bariatric resident during a transfer.
Failure to Provide Daily ADL, Hygiene, and Positioning Care for a Dependent Resident
Penalty
Summary
Failure to provide daily care and assistance with ADLs occurred for a dependent resident with hemiplegia, vascular dementia, severe cognitive impairment, and visual deficits. Surveyors observed the resident repeatedly lying in bed over two consecutive days, with contracted hands and hand splints not applied as care-planned, instead left on a table or bedside. The resident’s care plan documented urinary incontinence with a check-and-change schedule, bilateral palm protectors to be applied in the morning and removed in the evening, daily washing of eyes and face, and use of toothettes twice daily for oral care, as well as staff assistance and encouragement to get the resident up in a Broda chair daily. Despite this, observations showed the resident remained in bed throughout multiple time points, with no oral swabs or toothettes visible in the room, and with a noticeable white discharge in the left eye on several occasions. Interviews further supported that required daily care was not consistently provided. The resident’s guardian reported concerns about lack of oral care, the resident staying in bed all day, and not attending preferred religious activities. A CNA stated the resident was to be checked and changed every two hours but, when asked to check the resident’s brief, found it saturated, despite having claimed to have changed it earlier via entry through the adjoining bathroom. The CNA acknowledged not providing oral care that day and confirmed there were no oral glycerin swabs readily accessible in the room. The CNA also confirmed the eye discharge had been present for a couple of weeks and that the resident typically only got out of bed on two days per week, which conflicted with the RN’s statement that the resident was scheduled to be out of bed three days per week and with the care plan’s approach to encourage daily out-of-bed activity. The resident’s toenails were observed to be very long and wrapped around the tips of the toes, and the eye discharge remained evident during multiple observations, indicating lapses in basic hygiene and ADL care as outlined in the care plan.
Failure to Prevent and Monitor Misappropriation of Controlled Substances
Penalty
Summary
The facility failed to prevent the misappropriation of controlled substances for multiple residents, as evidenced by altered documentation and unaccounted-for doses of narcotic medications. For one resident, the Controlled Substances Proof of Use sheet showed repeated alterations in the quantity remaining, with bold overwriting of numbers to obscure previous entries. This resulted in discrepancies where more tablets were dispensed than ordered, and the documentation was manipulated to hide the actual count. Staff interviews confirmed that an agency LPN was responsible for altering the narcotic count and that these changes were not immediately detected during shift exchanges, as the counts were verbally confirmed rather than visually verified against the medication sleeves and documentation. Another resident's records revealed that an additional dose of a controlled medication was dispensed outside of the prescribed times, with no corresponding entry in the electronic medication administration record (eMAR) or the resident's electronic medical record. The missing documentation and the lack of a scheduled administration at that time indicated that the medication was unaccounted for. Further audits of medication carts did not reveal additional discrepancies, but the incident was substantiated as misappropriation based on the available evidence. Staff statements indicated that the LPN involved had a history of similar issues at other facilities. Additional deficiencies were identified for other residents, including the dispensing of controlled substances without active orders, administration of medications outside of prescribed times, and lack of required documentation for medication administration and wastage. In several cases, doses were dispensed and not recorded in the eMAR, and there was no second nurse signature to verify wastage of unused medication. Interviews with nursing staff and review of facility policies confirmed that these actions did not follow professional standards or facility procedures for controlled substance management, leading to unaccounted-for medications and the potential for ongoing diversion.
Medication Misappropriation and Diversion in LTC Facility
Penalty
Summary
The facility failed to prevent the misappropriation and diversion of narcotic medications for several residents, leading to a deficiency in safeguarding resident property. In one incident, a registered nurse (RN E) was found in possession of medications belonging to a resident (R8) during a police traffic stop. The medications included 17 vials of Promethazine and a hydrocodone capsule, which were not authorized for removal from the facility. The facility confirmed the misappropriation of these medications, as they were found off-site and in the possession of RN E without proper authorization. In another incident, discrepancies in the medication count were discovered after RN D abruptly left the facility without completing the required medication count. This resulted in missing doses of Norco for two residents (R7 and R3) and Tramadol for another resident (R4). The facility's investigation was inconclusive due to RN D's refusal to cooperate, including failing to submit to a drug test and provide a statement. Despite the evidence of missing medications and RN D's abrupt departure, the facility was unable to definitively conclude that RN D diverted the medications. Additionally, ongoing discrepancies in controlled medication administration were identified for three residents (R3, R4, and R5), with missing documentation for the administration of medications such as Lorazepam, Tramadol, and Oxycodone-Acetaminophen. The facility lacked a formal audit system to ensure proper medication administration and reconciliation, and the Director of Nursing (DON) had not implemented a comprehensive review process to address these discrepancies. The facility's failure to monitor and investigate these issues adequately contributed to the deficiency in protecting residents' medications from misappropriation and diversion.
Deficiency in Documentation of Resident Allegations
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, resulting in the potential for providers not having an accurate and complete picture of the residents' stay. For one resident, identified as R2, the facility's records did not document an allegation made by the resident that a CNA had pushed her. Despite the resident's severe cognitive impairment and multiple diagnoses, including delusional disorders and PTSD, there was no documentation of physical or psychosocial assessments related to the allegation. Additionally, the social services notes and assessments conducted did not specify the reasons for the visits or assessments, such as whether they were routine or related to the incident. Similarly, for another resident, identified as R4, the facility's records failed to document an allegation that someone had hit her. R4, who was moderately cognitively intact, also had no documentation of physical or psychosocial assessments related to her allegation. The social services notes and assessments for R4 did not indicate the reasons for the visits or assessments, leaving a gap in the documentation of care provided following the resident's report of abuse. Interviews with facility staff, including the Nursing Home Administrator and the Director of Nursing, revealed that there was an expectation for nurses to document such allegations in the residents' progress notes. However, upon review, no such documentation was found in the electronic medical records of either resident. This lack of documentation was acknowledged by the Director of Nursing, who noted the need for improvement in this area. The absence of documentation related to the allegations was not rectified by the time of the survey's completion, highlighting a deficiency in the facility's record-keeping practices.
Sanitation and Temperature Control Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which could potentially spread foodborne illness to all residents consuming food from the kitchen. During an initial tour, the top portion of the door seals of a two-door Traulson freezer was found with an accumulation of crumbs and dirt debris. This issue persisted during a revisit, indicating a lack of proper cleaning and maintenance. Additionally, the internal thermometer of a Raetone refrigeration unit showed inconsistent temperatures, and a whole tomato inside the unit was found to be at an unsafe temperature. The door seal of the unit was loose, allowing light to be seen from inside, which could compromise the unit's ability to maintain safe temperatures. Further inspection revealed that the Raetone refrigeration unit was low on Freon and had icing on the thermostat, affecting its functionality. Despite these issues, potentially hazardous food was not immediately discarded or moved, as confirmed by the Dietary Supervisor. It was only after a vendor's intervention that the unit was emptied. Additionally, the facility failed to properly date-mark ready-to-eat foods, with several items found open and without discard dates, or held past their discard dates, in the hallway utility pantry. The facility also did not adhere to proper thawing procedures for time/temperature control for safety food. Frozen nutritional drinks were found in a bowl of water in the rinse compartment of a three-compartment sink, and a box of frozen nutritional drinks and ice cream was left in ambient air outside of refrigeration. These actions and inactions demonstrate a failure to comply with the 2017 FDA Food Code, which outlines necessary standards for maintaining food safety and preventing foodborne illnesses.
Inadequate Infection Control and Water Management in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by inadequate tracking and surveillance of infections among residents. Three residents were identified as having been prescribed antibiotics, but their information was not accurately reflected in the Resident Infection Control Log. Additionally, the facility did not conduct a thorough investigation or implement preventative measures during a COVID-19 outbreak, failing to document essential details such as contact tracing, notifications, and interventions. The facility's infection control program was found lacking in several areas, including the absence of a comprehensive outbreak investigation and management plan. The documentation provided did not include critical information such as the notification of the Medical Director, Health Department, staff, residents, and families about the outbreak. Furthermore, there was no evidence of daily active surveillance or implementation of transmission-based precautions to prevent the spread of infection. Additionally, the facility did not have an active plan for reducing the risk of Legionella and other opportunistic pathogens in the plumbing system. The Maintenance Director was unaware of the facility's water management plan, and there was no evidence of regular flushing or testing of the water system. The facility's Water Pathogen Risk Reduction policy was not dated, and there was no indication that a water management team was in place to monitor and address potential risks.
Facility Cleanliness and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain general cleanliness and repair of the premises, leading to potential contamination and decreased resident satisfaction. During a tour of the utility pantry, it was observed that the cabinets were deteriorating due to water damage, and a large hole in the wall behind a stainless-steel panel was not sealed, allowing potential pest entry. In the storage room containing nursing and tube feeding supplies, excess debris and trash were found on the floor, and a light shield was hanging down. Additionally, a light shield cover was missing in the service hall storage room. The back portion of the roof and soffit was in disrepair, providing open access to the attic space. Several wall-mounted air conditioning units in the hallways had an accumulation of black spotted debris. A family member expressed concerns about the cleanliness of a resident's room, reporting that the bedside commode was often not cleaned, resulting in a strong odor of urine and feces. The family member also noted that the resident's bedding was not changed regularly, leaving it visibly soiled and malodorous. Despite voicing these concerns to management, improvements were inconsistent. These observations and interviews highlight the facility's failure to maintain a clean and safe environment for residents, staff, and the public.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of three residents, as well as address several unmet needs reported during Resident Council Meetings. Resident #10, a male with a history of stroke and left-sided weakness, was observed to have remained in bed for extended periods without being assisted out of bed by staff, despite care plan interventions that included encouraging participation in facility life and assisting with activities. Observations over several days showed that Resident #10 was not engaged in any meaningful activities, and staff interviews confirmed that he had not been assisted out of bed due to time constraints. Resident #4, a cognitively intact female, expressed concerns about call light wait times, reporting that it could take up to an hour for her call light to be answered. She also reported that staff did not inform her of extended wait times and often had excuses for not promptly assisting her. On one occasion, she was not assisted to get up or cleaned before breakfast, which was against her usual preference. Resident #18, another cognitively intact female, reported similar issues with call light wait times, particularly during the evening shift, and described the CNAs as having bad attitudes and being unresponsive to residents' needs. The Resident Council Meetings consistently highlighted issues with slow call light response times, particularly during the second and third shifts, and problems with the distribution of evening snacks and water. These concerns were documented over several months, indicating a pattern of unmet needs and preferences among residents. The facility's policy on call light response times, which states that staff should respond within a reasonable period of no longer than 10 minutes, was not adhered to, contributing to the deficiencies observed.
Fall Hazards and High Water Temperatures Identified
Penalty
Summary
The facility failed to maintain an environment free of fall hazards and high hot water temperatures. During an observation, the clean utility/pantry room was found unlocked and accessible to self-mobile residents, containing an unsecured aerosol spray can of disinfectant cleaner. Additionally, two thick black rubber mats were observed folded and placed in the walkway, creating a tripping hazard. These mats were left in the resident hallway, causing staff and residents to navigate around them, with some staff stepping over the mats instead of removing them. This situation persisted for a significant period, with multiple staff members observed passing by without addressing the hazard. Furthermore, during a facility tour, it was discovered that the hot water temperature at the central spa hand sink reached 123.9°F, exceeding safe levels. The Maintenance Director confirmed that the water heater supplying this area was set too high and attempted to adjust the mixing valve to lower the temperature. Similarly, the hot water in the dining room sink was found to reach 126.8°F, with a point of use mixing valve that required adjustment. These findings indicate a failure to adequately monitor and control water temperatures, posing a risk to residents.
Failure to Follow Tube Feeding Protocols
Penalty
Summary
The facility failed to adhere to standards of practice for two residents receiving nutrition and hydration through feeding tubes. Resident #10, a male with a history of stroke and blindness, was observed with a syringe and plastic basin used for tube feeding that were not properly dated and stored. Additionally, the tube feeding setup lacked proper labeling, including the resident's name, date, time, and the ordered rate, as required by the facility's policy. Resident #25, a female with a history of cerebral infarction, was observed multiple times with her head of bed elevated below the recommended 30 degrees while receiving tube feeding. The feeding setup also lacked proper labeling, missing the resident's name and the time the feeding was started. These observations indicate a failure to follow the facility's policy and standard nursing practices for tube feeding management.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to properly store medications in one of two medication carts and one of two medication storage rooms. During an observation, an LPN was found with a medication cart containing several open bottles of artificial tears, some without dates indicating when they were opened, and other medications such as Moisture Eye drops, Fluconazole nasal spray, Azelastine nasal spray, and Dorzolamide eye drops, all lacking proper labeling or opened dates. Additionally, a large spray bottle with an unidentified clear liquid was found in the cart, which the LPN assumed was hand sanitizer. The LPN acknowledged that the medications should have been dated and not used if opened without a date. In another instance, the medication storage room near the front nursing station had a refrigerator storing insulins and other medications at an incorrect temperature of 32 degrees, with the temperature log last completed several days prior. Expired medications, including a liquid multivitamin and Cherry flavored liquid acetaminophen, were also found in the storage room. An LPN admitted to not knowing the correct refrigerator temperature and acknowledged the expired medications. Furthermore, a resident was found with unused/unopened dropperettes of cyclosporine 0.05% (Restasis) on her nightstand, which she reported were left by facility nurses, and she did not administer them herself.
Inadequate Food Options and Meal Variety
Penalty
Summary
The facility failed to provide adequate food options that accommodate resident preferences and dietary needs, as evidenced by the experiences of two residents. Interviews and record reviews revealed that the facility's dietary system was not effectively offering alternative or optional food choices. The Dietary Supervisor indicated that residents could choose between a main entree and an alternate menu, but the process relied on residents communicating their preferences to nursing staff, who would then inform the kitchen. However, the system was not consistently implemented, as some items on the alternative menu were not regularly available, and residents were not always able to receive their preferred meals. Resident #4, a cognitively intact female, expressed dissatisfaction with the quality and variety of the meals, describing them as "lousy and cold." Similarly, Resident #18, also cognitively intact, reported a lack of variety and repetitive meal options, such as being served pork for several consecutive days and receiving hot dogs as the only alternative meal. This resident also faced challenges in obtaining suitable meals for those with chewing or swallowing difficulties. The resident expressed frustration with the requirement to request alternative meals before a specific time and felt that the facility's approach did not adequately cater to individual needs.
Inaccurate DPOA Documentation Leads to Miscommunication
Penalty
Summary
The facility failed to accurately record the activated medical and financial Durable Power of Attorney (DPOA) in the medical record for a resident, leading to the potential for inappropriate delegation of resident rights. The resident, an elderly female, was admitted to the facility with family members designated as her DPOA for medical and financial decisions. However, discrepancies were found in the documentation: one family member was incorrectly listed as the primary contact for both medical and financial decisions, despite not being the legal DPOA. This resulted in the wrong individual being notified of changes in the resident's health status and medication. Interviews and record reviews revealed that the facility's process for documenting DPOA information was not followed correctly. The social worker confirmed that the contact information for each DPOA should be documented in the electronic health record and on the admission record, specifying if there are separate DPOAs for financial and medical decisions. The facility's policy on advance directives requires that a copy of the advance directive be placed in the resident's medical record upon admission, but this was not accurately done in this case, leading to the deficiency.
Failure to Provide Medicare Coverage Notices
Penalty
Summary
The facility failed to provide necessary notifications to residents regarding their Medicare coverage and potential liability for services not covered. Specifically, the facility did not issue Advance Beneficiary Notices (ABN) and Notices of Medicare Non-Coverage (NOMNC) to three residents who were discharged from a Medicare-covered Part A stay with benefit days remaining. During an entrance conference, a request was made for a list of such residents discharged in the past six months. Subsequently, the Nursing Home Administrator and Social Worker confirmed that they did not have the required ABN or NOMNC for the selected residents. The facility's policy mandates the issuance of these notices to inform beneficiaries of their rights and potential liabilities, but this was not adhered to in these cases.
Inappropriate Antibiotic Utilization Due to Lack of Culture and Sensitivity Reports
Penalty
Summary
The facility failed to ensure appropriate antibiotic prescriptions for three residents, leading to inappropriate antibiotic utilization. Resident #142 was prescribed ciprofloxacin without a culture and sensitivity report to confirm its effectiveness against the bacteria. Resident #143 was initially prescribed cephalexin, which was ineffective against the urinary tract infection as indicated by the laboratory report. The resident was later switched to ciprofloxacin after a delay in treatment. Resident #144 was also prescribed ciprofloxacin without any culture and sensitivity documentation to verify its appropriateness. The Director of Nursing (DON) confirmed during interviews that there were lapses in reviewing culture and sensitivity reports upon admission and that the facility's antibiotic stewardship program required closer monitoring. The facility's policy on antibiotic stewardship outlines the roles of the Infection Preventionist and DON in coordinating and supporting antibiotic stewardship activities, including monitoring antibiotic use and ensuring prescriptions are appropriate. However, these protocols were not adequately followed, resulting in the deficiencies noted in the report.
Inadequate Infection Preventionist Role and Time Allocation
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was working at least part-time and was provided sufficient time to perform the Infection Prevention and Control Program (IPCP) duties. The Director of Nursing (DON) was listed as the Infection Control Preventionist in the Facility Assessment, but the actual IP, who was certified in infection prevention and control, was also working full-time as a floor nurse. This dual role limited the IP's ability to focus on infection control duties, as the IP did not have designated time to maintain or monitor the IPCP effectively. Interviews revealed that the IP, who took over the role after the previous IP left, did not have set hours or days for assessing, developing, implementing, monitoring, and managing the IPCP. The DON, who had not completed specialized training in infection prevention and control, was covering the IPCP duties when the IP was unavailable. This lack of dedicated time and specialized training led to inadequate surveillance and tracking of infections, as evidenced by the failure to complete an outbreak investigation for a COVID-19 outbreak and the omission of residents on antibiotics from the Resident Infection Control Log. The facility's policy required the IP to be employed at least part-time, with the amount of time determined by the facility assessment. However, the assessment did not specify the time needed for the IP to complete IPCP duties. The report highlighted deficiencies in antibiotic stewardship, as antibiotics were administered without confirming their effectiveness against identified bacteria. The DON confirmed the need for improved antibiotic stewardship and acknowledged the inadequacies in the IPCP, including the lack of an outbreak investigation and an incomplete Resident Infection Control Log.
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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 Muskegon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health & Rehabilitation Of Muskegon | 0.8 mi | ★★★★★ | 40 | 0 |
| Harbor Terrace Senior Living | 2.4 mi | ★★★★★ | 10 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 3.2 mi | ★★★★★ | 2 | 0 |
| Christian Care Nursing Center | 4.6 mi | ★★★★★ | 5 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 4.9 mi | ★★★★★ | 12 | 0 |
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