Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 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.
RN coverage was not documented on the Daily Staffing sheet for one day reviewed. The NHA stated the PBJ report showed RN coverage and that staffing sheets should reflect any changes, but she could not explain why the sheet was not updated. Requested PBJ, work schedule, and time sheets were not provided before survey exit.
Kitchen sanitation and equipment maintenance deficiencies: The Dietary Manager quit, leaving another staff member in charge while surveyors observed torn cooler door seals, a broken hood light switch, a nonworking hood light, and dirty food service equipment including the can opener and dish machine. Surveyors also found dust, mold, food debris, and garbage buildup on coolers, freezers, floors, and hood filters, and noted the coffee and juice machines lacked backflow prevention and were not connected to a water filter.
A CNA provided incontinence care to a resident requiring EBP without the proper PPE, touched the resident and nearby items with the same gloves, and left the room without hand hygiene. In a separate event, an LPN handled a resident’s tablets with bare hands and did not perform hand hygiene before or after medication administration. Facility leaders confirmed hand hygiene and medication-handling practices were not followed, and infection control audits only documented EBP monitoring.
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 resident with depression, generalized muscle weakness, and intact cognition was supposed to receive showers twice weekly, but she reported going weeks without one and said she had to fight for showers. Resident council minutes, nursing notes, and shower logs showed repeated complaints that showers were not being offered or documented, and staff acknowledged problems with providing and/or recording showers.
Medication Storage, Administration, and Documentation Failures: An LPN left a med cart unsecured with unlocked drawers, unsecured narcotic storage, open stock meds, and unlabeled medications in the cart. For one resident with stroke-related deficits, the MAR documented completion of ordered care despite observations showing missing palm protectors, no eye wash/baby wipes available, and the resident not out of bed as ordered. For three other residents, MAR, controlled substance records, and EMR documentation did not match for Norco, Ativan, and Xanax, including missing documentation, duplicate administration, and no rationale for withheld or closely spaced doses.
Failure to provide activities for a resident with hemiplegia, vascular dementia, and R eye blindness. The resident was repeatedly observed in bed or sleeping, while the guardian reported concern that he was in bed all day and liked gospel singing and church activities. The care plan included interest-based activities such as scripture, music, and 1:1 visits, but the AD said the resident had not been involved in activities in over a year and there was no documentation that his preferred activities were offered. The activity calendar showed Bible Reading and a visiting Pastor, but no singing or musical activities were offered.
A resident receiving hospice services had inconsistent documentation of hospice visits and communication. The resident’s chart showed a hospice order with scheduled nurse and aide visits, but the facility matrix did not trigger hospice services, the EMR lacked consistent visit documentation, and the hospice binder did not reflect weekly visits. An LPN reported hospice staff gave verbal reports and that she documented visits when they occurred, but there was no formal sign-in and no documentation of a reported hospice visit in the progress notes.
Failure to document and maintain resident vaccination status: The facility did not ensure flu, pneumonia, and COVID vaccinations were offered and up to date for 5 residents reviewed. EMR review showed no vaccination information and/or no informed consent forms for the residents, and the RN consultant verified they were not up to date. The facility had held a vaccination clinic, but records remained incomplete, one resident reportedly refused COVID vaccine, and others still needed vaccines or documentation.
Equipment and Water Temperature Maintenance Failures: Surveyors observed multiple maintenance issues affecting kitchen and shower room equipment, including cooler door seals that were torn or not sealing properly, a nonworking hood light with a broken switch, coffee and juice machines without backflow prevention or a water filter, and shower room problems such as a nonworking bathroom light, a missing cold-water knob, a nonworking call light switch, and water temperatures measuring 130.3 F at the sink and 127.1 F at the shower. The boiler room mixing valve and holding tank temperatures were also observed at 130-134 degrees, while the maintenance director stated the last recorded log temperature was 120 degrees.
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.
A resident with Alzheimer’s disease, anxiety disorder, spinal stenosis, COPD, and squamous cell carcinoma expired, but the facility did not complete a Discharge MDS. The MDS Coordinator stated the last MDS completed was the admission MDS, and a Regional Nurse said the coordinator was unsure of the discharge/death MDS process and that the resident had not been discharged in the system.
The facility failed to timely address PASARR Level II requirements for a resident with traumatic brain injury and bipolar disorder. The resident’s record showed a PASARR Level I, but no Level II was documented in the EMR, and SS staff stated a Level II had not been requested or completed. The facility’s CMS-802 Matrix also did not reflect residents requiring PASARR Level II.
Respiratory care was not provided as ordered for two residents. One resident with COPD and other pulmonary diagnoses was receiving oxygen through undated tubing despite an order for weekly tubing changes and dating, and another resident with hemiplegia, vascular dementia, and blindness had a densely dusty oxygen concentrator filter while receiving O2. An LPN later confirmed the filter was dirty.
Failure to follow up on psychosocial distress and suicidal ideation: A cognitively intact resident with multiple chronic conditions expressed interest in counseling, but the care plan lacked psychosocial interventions and the record did not show BCS evaluation or follow-up. Later, after the resident stated she was upset about not being on the list for a mobile service unit and said, "I have to get out of here one way or another," a nurse reported suicidal ideations with a plan, yet the EMR lacked documented follow-up or notification to the MD, family, SS, DON, or NHA.
A facility failed to properly label medications in the West medication cart. An LPN found an albuterol HFA inhaler and a fluticasone nasal spray marked only with room numbers, with no pharmacy labels, resident identifiers, or open/discard dates on the individual products, and she could not tell which resident they belonged to. The facility’s policy provided to surveyors addressed only open and discard dating, not resident-specific labeling.
Incomplete guardianship documentation was found for a resident with severe cognitive impairment and multiple psychiatric diagnoses. The EMR contained expired Letters of Guardianship and no current guardianship paperwork or documentation showing the issue was being addressed. Staff interviews showed the SS was unaware the papers had expired, the NHA said the guardian had stated she would continue, and the RDO said the guardian was sending paperwork, but the current documents were still not scanned into the EMR.
Incomplete and inaccurate daily staffing sheets were posted for several shifts. A review showed one RN listed with no hours worked on one day and no RN coverage documented on two other days, while the NHA stated the PBJ report showed RN coverage and that staffing changes should have been reflected on the sheets. Later Punch Detail reports showed RN hours and coverage that were not originally recorded on the staffing sheets.
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.
RN Coverage Not Documented on Staffing Sheet
Penalty
Summary
The facility failed to ensure RN coverage for at least 8 consecutive hours a day for 1 of 30 days reviewed, specifically on 3/8/26. Review of the Daily Staffing sheets from 3/1/26 through 3/30/26 showed no RN coverage listed for Sunday 3/8/26. During an interview on 04/02/2026 at 10:30 AM, the NHA stated she did not know why the Daily Staffing sheet for that day did not include RN hours and said the facility's PBJ Staffing Data Report showed RN coverage for that day. She also stated that the staffing sheets provided to surveyors were the ones used to start the day and that any changes should have been reflected on them, but she did not know why the sheet for 3/8/26 was not updated. The NHA was asked to provide the PBJ Staffing Data Report, the nursing work schedule with actual hours worked, and the nurses' time sheets for 3/8/26, but by the end of the survey and exit from the facility, no documentation was provided to show RN coverage on that date.
Kitchen sanitation and equipment maintenance deficiencies
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment and kitchen areas during the initial kitchen tour. The Dietary Manager had quit that morning, and the staff member present stated that she was now in charge. The Raetone and True Cooler units had torn and improperly fitting door seals, and the hood system had a light fixture that was not working with a broken toggle switch on the outside of the hood. The can opener blade and housing unit had stuck-on food residue and debris, and the dish machine was dirty with an accumulation of build-up on top. Additional observations showed dust, mold, and food debris on the cooler and freezer units throughout the kitchen, including on the doors, seals, fans, fan grates, shelving, bottoms, sides, handles, and tops. The flooring in the kitchen, hallways, and storage areas had a build-up of dust, dirt, food debris, and general garbage. The hood system filters were dusty and dirty with build-up. The water lines on the coffee and juice machines did not have backflow prevention, and the coffee and juice machines were not connected to a water filter. During the follow-up visit, the Regional Dietitian confirmed the Dietary Manager had quit that morning and stated she would be working on getting things cleaned up, changing menus, making repairs, and finding a replacement for the Dietary Manager.
Infection Control Failures During Resident Care and Medication Administration
Penalty
Summary
The facility failed to follow its infection prevention and control policies for enhanced barrier precautions, hand hygiene, and medication handling during care for two residents. One resident had hemiplegia and hemiparesis, vascular dementia, blindness in the right eye, severe cognitive impairment, tube feedings, and bowel and bladder incontinence, and was identified as requiring enhanced barrier precautions related to the feeding tube. During observed incontinence care, a CNA began care without the appropriate PPE, allowed long hair to hang down and touch the bed and resident, used the same gloves to adjust the oxygen nasal cannula, reposition the pillow and blankets, and handle the bed remote and other nearby items, then removed gloves and carried soiled linen down the hallway without hand hygiene. The CNA stated she was nervous and forgot to put on the appropriate PPE and perform hand hygiene after incontinence care. The DON and Regional Nurse Consultant stated hand hygiene should be performed after incontinence care and when moving from dirty to clean surfaces, and that hand sanitizer is available outside resident rooms for use after removing gloves and leaving the room. The Assistant DON/LPN reported she was responsible for infection control monitoring audits and provided audits from December 2025 through February 2026, but those documents only showed enhanced barrier precautions audits. She stated she completed the audits on one day each month and had no other audits or documented staff education for hand hygiene or other infection control monitoring. For another resident, an LPN was observed pouring medications into her bare hand and handing them to the resident two, three, or four tablets at a time, depending on tablet size. The LPN stated the resident preferred to receive tablets individually rather than all at once in a medication cup, and she was not observed washing or sanitizing her hands before or after administering the medications. The DON stated nurses are not supposed to handle medications with bare hands and should wash their hands between residents during medication administration. An RN also stated nurses should not handle medications with bare hands and that doing so would be an infection control issue.
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 Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor a cognitively intact resident’s desire for showers. The resident had diagnoses including depression and generalized muscle weakness, and her MDS indicated she needed supervision or touching assistance for showers. She stated during interview that she did not get showers often, that she and her resident advocate had been fighting to get showers for a while, and that she sometimes went without showers for weeks. Her face sheet and shower schedule showed she was supposed to receive showers twice weekly on Tuesdays and Thursdays during the AM shift. Record review and interviews showed the resident’s shower documentation was inconsistent and incomplete. Her EMR contained shower review sheets only for a few dates, while the facility later provided additional sheets showing showers on only a small number of dates between 11/01/25 and 03/31/26. Resident Council minutes repeatedly documented complaints that showers were not being done, that the resident was not being asked if she wanted a shower, that showers were still not being given, and that she felt she had to beg for one. A nurse documented that the resident’s daughter reported the resident had not had a shower since the prior Saturday and that staffing shortages were given as the reason. Facility staff also acknowledged there was an issue with providing showers and/or documenting them, and the resident ultimately received only eight showers during the reviewed period despite concerns being raised as early as 11/18/25.
Medication Storage, Administration, and Documentation Failures
Penalty
Summary
The facility failed to ensure licensed nurses followed professional standards of practice related to medication storage, medication administration, medication administration documentation, and treatment documentation for 4 residents. For one resident with diagnoses including hemiplegia and hemiparesis following cerebral infarction, epilepsy, dysphagia, gastrostomy, and contractures, an observation showed the resident did not have bilateral palm protectors in place and had thick drainage on the left eye. A CNA attempted to place a palm protector before cleaning the resident’s hand, found the resident’s fingernails long with sharp edges, and used a rolled washcloth instead when the palm protector could not be placed. The CNA also used washcloths for peri-care because baby wipes were not available in the room and could not locate baby shampoo/body wash. The care plan directed bilateral palm protectors in the morning and evening, hand hygiene before and after use, family preference for baby wipes for peri-care, and use of a Hoyer lift with 2 assist, but the care plan did not address bathing or showering needs and preferences. The resident was not observed out of bed during the survey day, although the MAR documented completion of orders for baby shampoo eye wash, baby wipes for peri-care, being up in the Broda chair every Monday, Wednesday, and Friday, and bilateral palm protectors. Medication storage concerns were observed at the East Hall medication cart. An LPN was seen walking away from the cart while the lock was not engaged, the drawers were unlocked, and the narcotic compartment cover was not locked. Stock medications in the drawer were open to air with lids off, an oval tablet was in an unlabeled plastic medication cup, another cup contained dark round tablets with only the word iron written on it and no resident name or room number, and an unlabeled orange prescription bottle containing multiple tablets was present in the cart. The LPN stated the unlabeled prescription bottle belonged to her and could not explain why the cart keys were left unsecured on top of the cart or why stock medications were uncovered. A regional nurse consultant stated the facility’s standard practice was that personal belongings would not be stored in a medication cart, unlabeled preset medications would not be stored, and the medication cart and controlled substances would be secured at all times. Documentation discrepancies were identified for three residents. For one resident with kidney disease and lymphedema, Norco was documented as administered on the MAR, but there was no corresponding entry on the controlled substances proof of use form or in the EMR. For another resident with dementia and behavioral disturbances, Ativan was dispensed twice on the same day and documented as administered twice, with only 2 hours and 41 minutes between doses, but there was no documentation in the EMR explaining the rationale for giving the doses less than 3 hours apart. For a third resident with heart failure, lymphedema, and anxiety, Xanax was ordered twice daily, but only one dose was documented as dispensed while both morning and evening doses were charted as administered; Norco was also dispensed but not documented as administered on the MAR. There was no EMR documentation explaining why the evening Xanax was withheld or why the Norco dose was not documented. During interview, the regional nurse confirmed the medication errors and documentation discrepancies, and at exit conference confirmed licensed nurses were expected to follow professional standards of nursing practice and the rights of medication administration.
Failure to Provide Resident Activities
Penalty
Summary
The facility failed to provide activities for 1 resident reviewed for activities. The resident had diagnoses including hemiplegia and hemiparesis, vascular dementia, and blindness in the right eye, and was documented as severely cognitively impaired. During multiple observations, the resident was repeatedly found lying in bed or sleeping in bed throughout the day. The resident's guardian reported concern that the resident was in bed all day and not attending activities, and stated the resident liked religious activities such as singing gospel songs and church activities. The guardian also reported there had not been a care conference in at least 6 months. The care plan included approaches such as encouraging the resident to get up in a broda chair daily, inviting the resident to activities suited to his interests, offering 1:1 visits, and providing activities such as reading scripture, singing, listening to music, and looking at photographs. However, the care plan did not reflect the resident being scheduled to get out of bed on Mondays, Wednesdays, and Saturdays, and staff gave inconsistent reports about when he got out of bed. The Activities Director reported the resident had not been involved in facility activities in over a year and stated that although the resident liked to sing, there was no documentation showing activities of his interest were offered. Review of the activity calendar showed Bible Reading and a visiting Pastor, but no singing or musical activities were offered, and refusals to bingo and social hour were documented.
Inconsistent Documentation of Hospice Visits
Penalty
Summary
The facility failed to have regular hospice visits documented and/or communication for one resident receiving hospice services. The resident’s face sheet showed hospice services, and a physician order dated 1/9/26 stated the resident required hospice services with nurse visits on Monday and aide visits on Tuesday and Friday. However, the facility matrix reviewed on 3/30/26 did not trigger the resident for hospice services, and the electronic medical record did not contain consistent documentation showing regular hospice visits. During interview, an LPN stated hospice staff gave verbal reports when they visited but there was no formal sign-in to show they were there, and she said she documented hospice visits in progress notes when they occurred but could not speak for everyone else. A hospice binder contained some handwritten visit documentation, but it did not reflect the resident’s weekly visits, and the last note in the binder was from 3/25/26. The LPN reported the resident received a hospice visit on 3/30/26, but review of progress notes from 1/9/26 through 3/31/26 did not show documentation of that visit.
Failure to Document and Maintain Resident Vaccination Status
Penalty
Summary
The facility failed to ensure flu and pneumonia vaccinations were offered and kept up to date according to CDC guidance for 5 residents reviewed for vaccination status. Review of the EMR for R6, R7, R31, R44, and R45 on 3/31/26 showed no vaccination information documented and/or no informed consent forms completed for any of the 5 residents. During an interview, the Regional Nurse Consultant verified that none of the 5 residents had vaccinations entered into the EMR and stated that all 5 were not up to date on all vaccinations. The Regional Nurse Consultant reported that vaccinations were to be offered upon admission and confirmed that the 5 residents were not new admissions. She stated the influenza vaccine was seasonal and the COVID vaccine was to be offered every 6 months. She also reported the facility had an influenza and COVID vaccination clinic in November or December 2025, but the 5 residents still lacked complete vaccination documentation in the EMR. She further stated that R6 was thought to have received influenza vaccine at dialysis but there was no record of it, R7 refused the COVID vaccine, R31 would have vaccines ordered after antibiotics were finished, and the other residents would get their vaccinations caught up that week.
Equipment and Water Temperature Maintenance Failures
Penalty
Summary
The facility failed to ensure that equipment was maintained in proper working order. During a kitchen tour, surveyors observed that the Raetone 2-door cooler had door seals that were no longer sealing properly and was holding at 44 F, which was above the highest cold holding temperature. The True 2-door cooler also had torn door seals. In the hood system, the light fixture did not work, leaving staff without light while cooking resident food, and the toggle switch used to turn the lights on and off was broken off or removed. Surveyors also observed that the water lines on the coffee and juice machines did not have backflow prevention and that the machines were not connected to a water filter. During an environmental tour, surveyors observed multiple maintenance issues in [NAME] Shower Room and W Shower Room. The bathroom light was not working, the cold-water knob on the sink was missing, and the water temperature from the faucet measured 130.3 F. The shower water temperature measured 127.1 F. The shower room call light switch on the wall was not working, and the Director of Maintenance confirmed it was not activating the call lights outside the shower room doors. In the boiler room, the temperature valve on the large holding tank was 134 degrees and the mixing valve was 130 degrees, while the maintenance director stated he had last checked it on 3/26/26 and the recorded temperature on the log was 120 degrees. The weekly temperature monitoring log showed water temperatures at or under 123 degrees prior to going out to resident rooms.
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 Complete Discharge MDS After Resident Death
Penalty
Summary
The facility failed to submit and ensure an accurate and timely MDS for one resident who was admitted with diagnoses including Alzheimer's disease, anxiety disorder, spinal stenosis, COPD, and squamous cell carcinoma of the scalp and neck. Review of the resident's progress notes showed that the resident expired, but the MDS Coordinator stated during interview that a Discharge MDS had not been completed and that the last MDS on file was the admission MDS. A Regional Nurse later stated that the MDS Coordinator was unsure of the MDS procedure for discharge/death of a resident and acknowledged that the resident had not been discharged in the system.
Failure to Timely Address PASARR Level II for a Resident with Behavioral Diagnoses
Penalty
Summary
The facility failed to address PASARR requirements in a timely manner for one resident, R35, out of 17 residents reviewed. The facility’s Social Services policy stated that Social Services would review each potential resident’s psychosocial and behavioral needs and PASARR information before determining appropriateness of placement, and would ensure the referring party obtained a Level II PASARR screening when indicated. However, the facility’s CMS-802 Matrix for Providers did not reflect residents who required a PASARR Level II. Review of R35’s EMR showed a PASARR Level I was completed on 2/19/26 with diagnoses including traumatic brain injury and bipolar disorder, but the record did not reflect that a Level II PASARR had been completed. The record also showed a prior Level I Change of Condition PASARR completed on 12/27/24, with no Level II documented in 2025. During interview, Social Services staff stated she had just started in January and did not have OBRA access, and acknowledged that a Level II had not been requested or completed for R35. On 4/1/26, the facility provided documentation showing an OBRA Level II Evaluation dated 2/7/25, which stated that if the individual remained in the nursing facility, a Level II Evaluation was needed by 2/6/26; this document was not found in R35’s EMR.
Respiratory Equipment Not Maintained as Ordered
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when oxygen equipment was not maintained as ordered for two residents. R20, who had diagnoses including COPD, peripheral vascular disease, and interstitial pulmonary disease, was observed receiving 4.5 L of oxygen via nasal cannula, and on two separate observations the oxygen tubing was undated even though physician orders required the tubing to be changed weekly and dated. R14, who had hemiplegia and hemiparesis, vascular dementia, and blindness in the right eye, had an order for 2 liters of oxygen via nasal cannula for comfort and oxygen saturations below 88%; during observation, the oxygen concentrator filter in the resident’s room was densely dusty while the resident was receiving oxygen. An LPN later verified the filter looked dirty and cleaned the filter and dusty plastic holder.
Failure to Follow Up on Psychosocial Distress and Suicidal Ideation
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with psychosocial adjustment difficulty after the resident and the resident’s son expressed interest in speaking with a counselor during a care conference. The social worker completed and sent a referral for an evaluation, but the resident’s care plan did not reflect any psychosocial concerns or interventions, and the resident’s electronic record did not show that the resident was evaluated by BCS or that there was documented follow-up after the referral. The resident, who was cognitively intact with a BIMS score of 14 and had diagnoses including chronic diastolic heart failure, macular degeneration, paroxysmal atrial fibrillation, muscle weakness, need for assistance with personal care, and chronic kidney disease, later became upset after being told she was not on the list to see the mobile service unit. A nurse documented that the resident stated, "I have to get out of here one way or another. Not eating or drinking should only take a couple days," and reported suicidal ideations with a plan to social work. The resident’s record did not reflect follow-up documentation regarding the suicidal ideation, and there was no documentation of correspondence or follow-up with the family, physician, social services, DON, or NHA. During interview, the resident stated she felt depressed and like nobody cared, said no staff followed up with her about those feelings, and reported she had not seen a doctor since then.
Medication Labeling Deficiency in West Medication Cart
Penalty
Summary
The facility failed to properly label medications in 1 of 1 medication carts inspected, the West Medication Cart. During an observation with an LPN, an albuterol sulfate HFA box marked with a room number had no pharmacy label or other identifying information on the box or inhaler, and no open/discard date on the inhaler. The LPN stated she did not know who the inhaler belonged to, whether it was for the current resident in that room or a previous resident. A fluticasone propionate 50 mcg nasal spray in the same cart was also marked only with a room number and lacked a pharmacy label, identifying information, and an open/discard date; the LPN again stated she did not know which resident it belonged to. Record review showed the facility’s Storage and Expiration Dating of Medications and Biologicals policy, last revised 6/30/25, addressed only open dates and discard dates for medications and biologicals. The policy did not address labeling medications with resident names or other identifying information. When asked for the facility’s labeling policy, the facility provided only the storage and expiration dating policy, and by the end of the survey did not provide a policy that addressed labeling medications with anything besides open/discard dates.
Incomplete Guardianship Documentation in Resident Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident with significant cognitive and psychiatric diagnoses, including bipolar disorder, mild cognitive impairment, cognitive communication deficit, obsessive-compulsive disorder, depression, and dementia with psychotic disturbance. The resident’s MDS showed a BIMS score of 4, indicating severe cognitive impairment. A review of the EMR showed Letters of Guardianship that had expired, and the record did not contain any current guardianship documentation or any documentation showing that the guardianship issue was scheduled to be addressed after the expiration date. During interviews, the SS stated she was new to the facility and was not aware the guardianship papers had expired. The NHA stated she and the SS had met with the resident’s guardian the prior week and that the guardian said she would continue to be the guardian. The RDO later stated the facility had just contacted the guardian and she was sending the guardianship paperwork. Although current Letters of Guardianship were later submitted to the facility, a subsequent review of the EMR still did not show that the current guardianship documents had been scanned into the resident’s record.
Incomplete and inaccurate daily staffing sheets
Penalty
Summary
The facility failed to post complete and accurate Daily Staffing sheets for 3 of 30 sheets reviewed, including 3/3/26, 3/7/26, and 3/22/26. A review of the Daily Staffing sheets for 3/1/26 through 3/30/26 showed no actual RN hours for 3/3/26 even though one RN was listed, and no RN coverage documented for 3/7/26 and 3/22/26. During interview, the NHA stated she did not know why the staffing sheets for 3/7/26 and 3/22/26 did not include RN hours and said the PBJ Staffing Data Report showed RN coverage for those days. She also stated the staffing sheets are the ones used to start the day and that any staffing changes should be reflected on them. The NHA was notified that the 3/3/26 staffing sheet listed one RN for 3rd shift but no hours worked. When requested, the facility later provided Punch Detail reports showing an RN worked 9.18 hours on 3rd shift on 3/3/26 and that RN coverage existed on 3/7/26 and 3/22/26, which had not been originally recorded on the Daily Staffing sheets.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 163 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 10 | 0 |
| Hillcrest Nursing And Rehabilitation Community | 4.9 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.