Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Orchards At Three Rivers during CMS and state inspections, most recent first.
Infection control was not effectively operationalized, and the facility lacked an active legionella/OPPP water management program. Staff did not consistently follow TBP or EBP: an RN provided wound care without a gown, a housekeeping aide entered a C. difficile contact precaution room multiple times without PPE and without hand hygiene, a social services staff member entered an MRSA contact precaution room without PPE, and a CNA transferred a resident on EBP without gown or gloves. The report also noted staff working while ill and multiple water management and housekeeping issues, including an expired WMP, no water sampling, and stagnant or improperly stored items in utility and shower areas.
Surveyors identified widespread environmental uncleanliness and poor housekeeping practices, including resident rooms with trash, dust, food debris, stained floor mats, and damaged surfaces, as well as shared bathrooms with unflushed urine, brown smears and splatters resembling fecal matter on toilets, walls, and floors, sticky floors, deteriorated grip strips, and buildup around toilet bases. In the memory care unit, hallways, dining areas, and wall-mounted fans had heavy dust and debris accumulations that persisted over multiple days, and spa/shower rooms contained dust, dead bugs, crusted debris on shower chairs, ants, and other visible soil. Some residents with dementia and cognitive communication deficits were observed in these dirty environments, while cognitively intact residents reported dissatisfaction with room cleanliness and infrequent bedding changes. The Ombudsman reported ongoing cleanliness complaints from residents and families, and housekeeping staff stated that only two housekeepers cleaned the entire building daily and that CNAs were expected to clean visible bowel and urine contamination before housekeeping would disinfect, while a CNA reported leaving a resident alone in the bathroom and not returning to assist with cleanup.
Medication administration errors exceeded the allowed rate when an LPN gave wrong dosages and crushed medications that were not to be crushed for two residents. One resident with multiple chronic conditions received incorrect doses of Vitamin D3 and B-12 and had ER meds crushed in pudding, while another resident received Ferrous Sulfate at the wrong dose. Surveyors found 6 of 32 observed administrations were not in accordance with orders and professional standards, for an 18.75% error rate.
The facility failed to designate an Infection Preventionist with adequate time to oversee the infection control program. The IP was also serving as the DON and Unit Manager, could not state how much time was spent on infection control tasks, and was unable to provide verification of staff education, infection control audits, or ongoing surveillance documentation. The IP also reported concerns that staff were not following TBP and EBP, and could not explain key infection reporting and monitoring processes.
A resident with severe cognitive impairment and multiple comorbidities developed a UTI confirmed by abnormal urine labs and culture, leading the physician to order daily IM ceftriaxone. Nursing staff documented administration of the IM antibiotics over several days without adverse reactions, but there was no documentation that the resident’s POA/responsible party was notified of the abnormal lab results, UTI diagnosis, or new antibiotic orders. The POA later learned of the treatment only when the resident mentioned receiving injections, and facility staff acknowledged that resident representatives should be notified of new infections, changes in condition, new orders, and abnormal labs for cognitively impaired residents.
Call Light Not Kept Within Reach: A resident with a hx of falls, TBI, confusion, weakness, and poor judgment was observed in bed with the call light on the floor and out of reach, and it was again found out of reach after an RN completed wound care and left the room. The RN stated she did not know if the resident could use the call light and said he would yell out if he needed staff. The resident later had the touch pad call light in reach while sitting in his chair and used it to request assistance.
Failure to provide written transfer and bed hold notices: A resident with ESRD on dialysis and dementia was transferred to the ED for an acute change in condition on two occasions, but the record contained no Notice of Transfer for either transfer and no Bed Hold information for the later transfer. The MR/S, DON, and NHA all could not locate documentation showing the resident or resident representative received the required forms in writing before transfer.
Improper Crushing of Extended-Release Medications: An LPN crushed and administered multiple medications to a resident with swallowing difficulty, including ER Metoprolol and ER potassium chloride, despite pharmacy guidance that these medications should not be crushed. The resident also received imipramine tablets crushed, and staff could not provide documentation showing physician approval to crush the ER medications before survey exit.
Failure to provide pressure ulcer prevention and monitoring. A resident with a high Braden score developed a left heel pressure injury that progressed from a DTI to a stage 2 wound. Although the care plan included pressure-reducing interventions and wound orders were in place, staff observations showed the resident’s feet resting directly on the bed without a pillow to offload pressure, and the DON confirmed weekly skin assessments had not been documented since early February. The wound specialist had also recommended considering offloading boots, but they had not been obtained.
A resident with dysphagia and a history of pneumonitis from aspiration received continuous enteral nutrition while lying flat in bed, despite an order and care plan requiring HOB elevation to 45 degrees during feeding and afterward. Surveyors observed the tube feed running at 50 mL/hr with the HOB not elevated; an RN later adjusted the bed and confirmed the resident needed elevation to help prevent aspiration, noting aides were not consistently keeping the resident positioned correctly.
A resident with chronic respiratory failure and dyspnea had oxygen ordered at 2 L/min via NC, but staff left the tubing coiled on the wheelchair seat pad instead of storing it in a bag between uses. Staff also increased the concentrator to 4 L/min without a new MD order or documentation, and the DON confirmed the resident’s order remained at 2 L/min.
A facility failed to keep complete and accurate medical records for two residents. One resident’s advance directive showed a wish for CPR, but the active order and care plan listed DNR, creating conflicting code status documentation in the chart. Another resident had no current weekly skin assessment documented and had missing TAR entries for ordered wound care and weight checks, which the DON confirmed should have been documented.
Failure to assess and document COVID-19 vaccination status for a resident with pneumonia and pulmonary HTN. The immunization record showed COVID-19 Dose 2 as pending historical with no administration date, and the IP confirmed the resident’s vaccine history was not reviewed on admission to determine eligibility or whether the vaccine was wanted and offered.
Multiple deficiencies were identified in food safety and sanitation, including improper food labeling and storage, inadequate hand hygiene, inaccessible handwashing sinks, and poor monitoring of refrigerator temperatures. Dietary staff were observed not following required practices such as wearing hair restraints, washing hands between tasks, and ensuring food items were properly cooled, labeled, and stored. Structural and cleanliness issues in kitchen and storage areas further contributed to unsafe food handling conditions.
The facility did not effectively manage its staffing and meal service, leading to insufficient staff coverage, long call light wait times, missed showers, and inadequate assistance for residents. Residents and staff reported poor food quality, small portions, missing dietary supplements, and inconsistencies between posted menus and actual meals. Despite repeated concerns raised to management, no effective corrective actions were implemented.
Multiple residents experienced missed or uncomfortable showers due to persistent hot water shortages, and several reported or were observed living in rooms with peeling paint, debris, and unsanitary conditions. Staff interviews confirmed ongoing hot water issues and inadequate maintenance, while observations revealed additional facility-wide cleanliness and maintenance deficiencies.
Several residents with significant physical and cognitive needs did not receive showers or baths as scheduled according to their care plans, with missed bathing days, lack of hot water, and short-staffing contributing to the deficiency. Residents and families reported dissatisfaction with hygiene care, and facility documentation was inconsistent regarding missed or refused showers.
Multiple residents reported missed showers, long call light wait times, and unmet personal care needs due to insufficient staffing. Staff interviews confirmed frequent unfilled positions, minimal management intervention, and routine omission of essential care tasks when short-staffed. Facility documentation and policies indicated higher staffing expectations than what was provided, resulting in delayed or omitted care.
The facility did not consistently follow the scheduled menu, failed to clearly post the current menu cycle for residents, and did not update the menu when changes occurred. A resident with multiple health conditions reported frequent inconsistencies between the posted menu and meals served, and dietary staff confirmed confusion about the menu cycle and substitutions based on ingredient availability.
Multiple residents and family members reported that meals were often bland, unrecognizable, served in small portions, and delivered at temperatures below recommended levels. Staff interviews and test tray observations confirmed that food was frequently cold, lacked flavor, and that dietary shortages led to substitutions and missing supplements. These deficiencies resulted in widespread dissatisfaction and inconsistent provision of appropriate diets.
A resident with severe cognitive impairment was prescribed and administered multiple psychotropic medications without documented informed consent from the resident's representative. Family members were not notified of medication changes and only learned about the medications after reviewing a list provided by the facility. Facility staff confirmed the absence of signed consent forms for these medications, and verbal consent was only documented after the medications had already been administered.
Two residents did not receive their ordered medications on time due to administrative delays and lack of timely authorization or prescription signatures. One resident with a severe infection missed all doses of a prescribed IV antibiotic, leading to worsening symptoms and hospital transfer, while another resident with a seizure disorder missed multiple doses of an anti-seizure medication because of delays in obtaining a signed prescription.
A resident with cognitive impairment suffered a chest burn after spilling hot coffee, and several other residents were observed with hot beverages without lids, clothing protectors, or current hot-liquid safety assessments. In a separate issue, a resident with dementia and a history of falls had 11 falls, most tied to toileting attempts without staff help, while staff and the DPOA reported inconsistent toileting assistance, a urinal not kept within reach, and limited monitoring of the fall interventions.
Failure to Timely Report Injury of Unknown Origin: A resident with Alzheimer’s disease, cognitive communication deficit, and dependence for transfers developed a forehead hematoma that staff initially assumed was related to an earlier fall. An RN reported the injury to the UM, a CNA observed it worsen during the day, and the DON and NHA later confirmed it was an injury of unknown origin that was not reported to the State Agency within the required 24 hours.
Failure to Thoroughly Investigate Injuries of Unknown Origin: Multiple residents with severe cognitive impairment developed bruises, hematomas, a skin tear, and other injuries of unknown origin, but staff did not fully investigate the events. An RN reported a head hematoma to a UM who assumed it was from an old fall without viewing the injury, several CNAs said they were not interviewed, and the NHA reported limited witness statements, no 3rd shift interviews, and no monitoring of staff interactions after the injuries were found.
Staff Lacked Behavioral Health Competency: The facility failed to ensure 6 reviewed staff members had current behavioral health competencies and the skills needed to care for residents with cognitive impairment and psychological distress. CNAs and an RN reported that some staff did not know how to approach residents in memory care without triggering stress responses, and that personal care was sometimes not completed because residents became too upset. Record review showed several staff had not completed nursing competencies within the last 12 months, including behavioral health competency, while others had competencies older than 12 months.
Failure to Report Injury of Unknown Origin as Potential Abuse: A resident with Alzheimer’s disease, severe cognitive impairment, and dependence for transfers developed a forehead hematoma that an RN reported to the UM as an injury of unknown origin. The UM assumed it was from an earlier fall and did not assess the resident, and the DON and NHA later confirmed the injury was actually new and should have been reported immediately as a potential abuse situation.
Inappropriate First Aid for Burn Injury: A resident with altered mental status, weakness, cognitive communication deficit, and DM2 spilled hot coffee on her chest and sustained a burn with an open area. An LPN removed the gown, poured cold water on the burn, and applied aloe burn gel before contacting the MD; the MD said he was not contacted before the gel was used and would not have recommended it, and the DON stated nurses should not apply treatment without a physician order.
Failure to promptly assess new head trauma: A resident with Alzheimer’s disease, cognitive communication deficit, and a history of falls had a new forehead hematoma noted by an RN, but the UM assumed it was from an older fall and no assessment was completed at that time. The hematoma became more elevated, later was documented by the DON as bruising and a raised area on the head with unknown origin, and the NP reported she was not aware of the injury until 5 days after it was first identified; the resident was later sent to the ER after becoming more difficult to arouse.
A resident with severe cognitive impairment and dementia was prescribed Haldol and Olanzapine without a proper psychiatric diagnosis or adequate documentation. Staff administered these psychotropic medications without consistently attempting non-pharmacological interventions or monitoring for side effects, leading to increased sedation, weight loss, falls, and decreased ability to communicate. The resident's guardian was not properly informed of medication changes, and care plans lacked necessary details, resulting in significant harm including dehydration and hospitalization.
The facility did not complete required annual performance reviews for three CNAs who had been employed for over a year, as confirmed by personnel file reviews and staff interviews. This omission resulted in the potential for unidentified staff performance concerns and unmet training needs, contrary to facility policy.
The facility did not ensure its QAPI program identified and corrected quality deficiencies, particularly in dementia care. A resident with dementia did not receive individualized care despite interventions provided by her DPOA, and staff lacked knowledge on managing her stress responses. The QAPI committee failed to review data or develop action plans for identified concerns, and issues such as psychotropic medication use and staff training were not adequately monitored.
The facility did not ensure that the medical director or a designee attended QAPI committee meetings at least quarterly, as required by policy. Sign-in sheets confirmed no attendance by the medical director or designee over several months, with management turnover and a change in medical directors contributing to the deficiency.
The facility did not maintain an effective staff training program, resulting in missing documentation and lack of required training in areas such as QAPI, infection control, compliance and ethics, communication, and resident rights for multiple employees. The DON and NHA confirmed that training was not tracked and that no performance improvement plan was in place to address these deficiencies.
The facility did not implement or document an effective in-service training program for CNAs, resulting in a lack of evidence for the required 12 hours of annual training. The DON reported the absence of a staff educator and no current training plan, while the NHA confirmed non-compliance with training requirements. Personnel files reviewed did not show completion of mandatory training.
A resident with severe cognitive impairment and high ADL assistance needs was repeatedly observed with a call light placed out of sight and reach, either under the sheet or clipped at the head of the bed. The unit manager confirmed staff intentionally positioned the call light this way, but acknowledged it should have been accessible.
A resident with severe cognitive and visual impairments did not receive individualized, meaningful activities to support leisure needs. Documentation inaccurately reflected participation in activities that the resident was unable to perform, and staff did not consult the resident's DPOA for past interests. Interviews confirmed the resident required one-on-one support and was not engaged in appropriate activities, highlighting a lack of resident-centered programming in the memory care unit.
A resident with severe cognitive impairment and vascular dementia experienced ongoing wandering, frustration, and stress due to the facility's failure to implement individualized dementia care interventions, incorporate input from the resident's DPOA, and provide appropriate activities or staff training. The care plan was incomplete and did not address known triggers or effective calming techniques, and staff reported insufficient training and resources to meet the needs of dementia residents.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately documented as participating in group activities and outings, including after discharge, despite staff and DPOA statements confirming non-participation. The care plan also listed an incorrect nickname, and the activity attendance records contained errors acknowledged by the Activity Director.
A resident requiring dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to meet established standards for such care.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
Staff failed to use a gait belt when assisting a resident with ambulation despite the resident's history of weakness and hip fracture, and another resident with severe cognitive impairment was transported in a wheelchair without footrests in place. Staff interviews confirmed that both actions were contrary to facility policy and training.
A narcotic medication intended for a resident was left unattended in a medication cup on top of a medication cart in a secure unit's common area, with multiple residents and staff present but not monitoring the cart. The medication, identified as Lorazepam, remained out of staff supervision for 37 minutes, contrary to facility policy requiring direct observation or secure storage of controlled substances.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
The facility did not ensure the dietary manager had the necessary skills and presence to manage food and nutrition services, resulting in missed menu items, use of emergency food supplies, and lack of essential dietary products. Staff were unclear about food ordering processes, and both the dietary manager and interim manager were only PRN, leading to inconsistent oversight and potential unmet nutrition and hydration needs for residents.
Dietary staff were unable to follow planned menus due to insufficient food supplies and made unapproved substitutions without notifying the RD or documenting changes. The RD had not been present or informed of substitutions, and required oversight and documentation were lacking, resulting in unmet nutritional needs for residents.
The facility did not ensure that a qualified Infection Preventionist was dedicated at least part-time to infection control duties, as the staff member assigned to this role was also serving as ADON and Unit Manager, with significant additional responsibilities. This resulted in limited time for infection control activities, insufficient staff education on PPE use for Enhanced Barrier Precautions, and audits that did not assess staff compliance, leading to a failure in properly managing the infection prevention and control program.
A resident with severe cognitive impairment and a Foley catheter did not have a care plan addressing enhanced barrier precautions, despite staff and facility expectations that such precautions should be implemented and care planned. The care plan only addressed fall risk and urinary retention, omitting necessary interventions for infection prevention related to the catheter.
A resident with severe cognitive impairment and a history of traumatic brain injury had changes in diet and hydration orders, but the care plan was not updated to reflect these changes. Staff interviews and observations revealed outdated care plan documentation, confusion over responsibility for updates, and discrepancies between current orders, visual cues, and the care plan, resulting in an inaccurate description of the resident's care needs.
Two residents with physical disabilities did not receive scheduled showers for extended periods, with documentation showing gaps of up to 12 days between showers and no recorded refusals. Staff interviews revealed that showers were often missed during busy or understaffed shifts, and the only documentation method was through shower sheets signed by nurses. The DON confirmed that staffing issues were not an acceptable reason to skip showers, but the facility failed to ensure consistent ADL care.
Infection Control, Precautions, and Water Management Failures
Penalty
Summary
The facility failed to operationalize an effective infection control program, failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing, and failed to follow transmission-based precautions and enhanced barrier precautions for multiple residents. The report states that the Infection Preventionist had only been overseeing the infection control program for about a month, had not completed February line listings, could not provide verification of staff infection control education or infection control audits, and could not explain the facility’s reporting process for communicable diseases, monitoring of infections, or immunization tracking. The Infection Preventionist also reported multiple recent changes in infection control oversight and that the facility was still working on a new process with corporate. For one resident on enhanced barrier precautions related to tube feeding, an RN provided wound care, repositioned the resident, assessed oxygen saturation, and placed socks on the resident without wearing a gown, even though the resident’s TAR required gown and glove use for high-contact care activities and wound care. The RN later stated she did not think a gown was needed unless she was providing care related to the feeding tube, then acknowledged she probably should have worn one. The same RN also reported she had sent a CNA home because the CNA had come to work ill and vomiting. For a resident on contact precautions for C. difficile, a housekeeping aide entered the room multiple times without gown or gloves, cleaned items in the room, handled the trash, coughed into her hand while inside the room, and exited without hand hygiene. The aide later stated she did not know the resident was on contact precautions. For another resident on contact precautions for MRSA in urine, a social services staff member entered the room without gown or gloves and stated he did not put them on because he did not touch or provide care to the resident. For a resident on enhanced barrier precautions related to peritoneal dialysis, a CNA transferred the resident from wheelchair to bed and handled oxygen equipment without gown or gloves, despite signage and orders requiring gown and glove use for transferring. The report also documents staff illness and water management concerns. A CNA was observed working while coughing, wearing a mask below the nose, and later stated she felt sick, had not tested for COVID-19, and had not been told what to do if she came to work ill. Maintenance staff reported flushing only the hot water system weekly, with no water sampling being done. Observation found a spa tub with dust and dead bugs in the bottom, a mop sink filled with stored items instead of being used, towels stored openly near shower areas, and clean sanitary supplies stored under wastewater lines in the basement. The Water Management Plan was dated March 1, 2024, had no evidence of annual review, had expired on March 1, 2025, and there was no documentation of an updated program team or meeting minutes.
Widespread Environmental Uncleanliness and Poor Housekeeping Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, orderly, and homelike environment in resident rooms, shared bathrooms, hallways, and common areas, as well as inadequate housekeeping response to visible soil and bodily substances. Multiple cognitively intact residents reported dissatisfaction with the cleanliness of their rooms, including one resident whose window had a long streak of old tape and residue that had been present since admission, and another who had tied bags of soiled linens and trash left on the floor near her bed along with trash and debris under and around the beds. Other residents’ rooms were observed with visibly soiled floors, paper and food debris, dust and trash accumulations under beds and along walls, and soiled floor mats with dried stains that remained unchanged over multiple days. In one room, a large dried spill or stain was present on the floor near dialysis equipment, and a wall gouge was noted near the bed. Additional observations showed that several residents with dementia, cognitive communication deficits, and muscle weakness were living in rooms with dirty floor mats, crumbs and debris in mat seams, and stained walls adjacent to their beds. Shared bathrooms between resident rooms were repeatedly observed with unflushed urine in toilets, brown smears and splatters resembling fecal matter on toilet seats, bowls, walls, and floors, sticky/tacky floors, dust and debris around perimeters and baseboards, deteriorated grip strips that were torn and peeling, and darkened buildup or damaged caulk around toilet bases. These unsanitary conditions persisted across multiple observations on different days, including one bathroom that continued to have dirt, debris, stale urine odor, sticky floors, and dried brown splatter resembling fecal matter on and around the toilet despite prior similar findings. The memory care unit and spa/shower rooms were also found in unclean condition. In the locked memory care unit, surveyors observed heavy accumulations of dust and debris at double doors, in the dining room corners and along walls, and on wall-mounted fan blade guards, with these accumulations remaining unchanged on subsequent days. Hallways outside resident rooms contained trash, broken plastic pieces, and large dust balls. In spa and shower rooms, there were dust and dead bugs in the bottom of a spa tub, brown crusted debris on a shower chair, dozens of small ants on the floor emerging from floor junctures, and white wet debris resembling toilet paper on another shower chair. During a confidential resident council meeting, most residents present reported that rooms and shared spaces were not consistently kept clean and some reported bedding was not changed frequently enough. The Ombudsman reported ongoing complaints from residents and families about facility cleanliness over several months. Housekeeping staff stated that only two housekeepers were responsible for cleaning all resident rooms and the locked unit daily, and described a process in which CNAs were expected to clean visible bowel movements and urine before housekeeping would disinfect, while a CNA acknowledged leaving a resident unsupervised in the bathroom and not returning to assist with cleanup after toileting.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% when 6 of 32 observed medication administrations were not given in accordance with physician orders and professional standards of practice, resulting in a medication error rate of 18.75%. The deficient practice involved two residents and included wrong dosages being administered and medications that were not to be crushed being crushed before administration. Resident #33 was a female with diagnoses including heart failure, diabetes, heart disease, cognitive communication deficit, anemia, depression, high blood pressure, kidney failure, and muscle weakness. During observation, an LPN prepared and administered scheduled medications crushed in pudding because the resident had difficulty swallowing pills. The medications included Vitamin D3 125 mcg, Metoprolol Succinate ER 25 mg, Vitamin B-12 500 mcg, Imipramine HCl 50 mg, and Potassium Chloride ER 20 mEq. Review of the physician orders showed the ordered doses for Vitamin D3 and Vitamin B-12 did not match what was administered, and the Metoprolol ER and Potassium Chloride ER were crushed even though they should not have been crushed. The record also showed an order allowing crushable medications, but no documentation was provided before survey exit showing physician approval to crush the extended-release medications. Resident #54 was a female with diagnoses including protein-calorie malnutrition, kidney failure, and anemia. During observation, an LPN prepared and administered Ferrous Sulfate 325 mg. Review of the physician order showed the resident was ordered Ferrous Sulfate ER 45 mg, and the medication was administered at the wrong dosage. The survey findings identified these medication administration errors as part of the overall error rate calculation.
Infection Preventionist Lacked Time and Documentation to Oversee Infection Control Program
Penalty
Summary
The facility failed to designate an Infection Preventionist with adequate time to perform infection prevention responsibilities and oversee the infection control program. During interview, the Infection Preventionist reported she had been overseeing the program for the last month while also serving as the DON and Unit Manager, and she was unable to state how much time she spent on infection control tasks each day or week. She reported she was trying to keep track of infection control tracking but could not manage all of the tasks and oversight because she was working in three different roles. The Infection Preventionist was unable to provide verification of staff education completed in the last year related to infection control, verification of infection control audits, or documentation showing that audits had been completed over the last month. She also reported ongoing concerns that staff were not following TBP and EBP and could not provide verification of related education. In addition, she was unable to explain how the facility monitored staff illness call-ins, which communicable diseases were reportable, the reporting protocol to local/state health authorities, how early infections were detected and monitored after identification, or how resident immunizations were being monitored. Review of the Infection Control binder showed line listings for January 2026 and part of February 2026, but the line listings only included residents prescribed antibiotics and did not contain audits, education, or other documentation to verify ongoing infection control surveillance.
Failure to Notify Responsible Party of UTI Diagnosis and Antibiotic Treatment
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party of a change in condition, specifically a newly identified urinary tract infection (UTI) and initiation of antibiotic treatment. The resident was an adult female with dementia, depression, muscle weakness, a cognitive communication deficit, and a documented need for assistance with personal care. Her MDS assessment showed a BIMS score of 4 out of 15, indicating severe cognitive impairment. The admission record identified a family member as the resident’s POA for care, first emergency contact, and responsible party. During an interview, this family member reported that the facility had not been consistently notifying her of changes in the resident’s condition and that she only learned of the UTI treatment when the resident mentioned she was receiving “shots” during a visit. Record review showed that on a specified date, the physician evaluated the resident’s urine after a nursing request and documented pyuria, bacteriuria, and a urine culture with more than 100,000 organisms of Proteus mirabilis, sensitive to Rocephin. The physician’s plan included Rocephin 1 g IM daily, and an order was entered for ceftriaxone IM once daily for five days for UTI. Nursing notes documented administration of IM antibiotic injections on multiple days with no adverse reactions. However, there was no documentation in the medical record that the responsible party was notified of the abnormal lab findings, confirmed UTI, or new antibiotic orders. The administrator confirmed the facility could not locate documentation of such notification, and both an LPN and an RN stated in interviews that for cognitively impaired residents or those who are not their own responsible party, the resident representative should be notified of newly identified infections, changes in condition, new physician orders, and abnormal lab results.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a resident's call light was within reach. Resident #7 had diagnoses including need for assistance with personal care and muscle weakness, and the care plan identified the resident as being at risk for falls due to impulsiveness, traumatic brain injury, agitation, weakness, confusion, a history of falls, poor judgment, and lack of insight into limitations. The care plan also included interventions for the call light to be clipped on the resident when in bed, the call light clip to be replaced, and a soft touch call light to be kept in reach. During observation, Resident #7 was found lying in bed with the call light on the floor and out of reach. Later, after RN M completed wound care and left the room, the resident's call light was again observed on the floor and out of reach. When questioned, RN M stated she did not know if the resident could use the call light and said he would yell out if he needed staff. RN M also confirmed the resident was at risk for falls and had a history of attempting to get up on his own when he needed assistance. In a later observation, the resident was sitting in his chair with the touch pad call light in reach and used it to request assistance.
Failure to Provide Written Transfer and Bed Hold Notices
Penalty
Summary
The facility failed to ensure that written Notice of Transfer and Bed Hold documentation was provided prior to transfer from the facility for one resident who was transferred to a local emergency department for evaluation of an acute change in condition. The resident had diagnoses including end stage renal disease, dependence on renal dialysis, and dementia. Progress notes showed the resident was transferred to the emergency department on two occasions, and review of the medical record found no Notice of Transfer documentation for either transfer. Review of the resident’s record also found no Bed Hold information provided when the resident was transferred to the emergency room on the later transfer. The Medical Records/Scheduler, DON, and NHA each reviewed the record and were unable to locate documentation showing that a Notice of Transfer or Bed Hold form had been provided to the resident or resident representative for either transfer, and the NHA stated that these forms should be given in writing prior to transfer. Facility policies stated that transfer/discharge forms are retained in the medical record and that bed hold policy and agreement are to be provided immediately upon discharge and documented in the medical record.
Improper Crushing of Extended-Release Medications
Penalty
Summary
The facility failed to follow professional standards of practice for medication administration for Resident #33, a female with diagnoses including heart failure, diabetes, heart disease, cognitive communication deficit, anemia, depression, high blood pressure, kidney failure, and muscle weakness. During an observation and interview, an LPN prepared scheduled medications for the resident and reported that all of her medications were crushed in pudding because she had difficulty swallowing pills. The LPN was observed crushing and administering Metoprolol Succinate ER 25 mg, Imipramine HCl 50 mg, and Potassium Chloride ER 20 mEq to the resident while she was seated in the dining area on the memory care unit. Record review showed active physician orders for Metoprolol Succinate ER 25 mg daily for HTN, Imipramine HCl 50 mg daily for depression, and Potassium Chloride ER 20 mEq daily for low potassium. The record also included an order dated 12/28/25 stating, "OK to crush allowable medications and administer together." During interview, RN H stated nurses are to use professional knowledge and judgment when deciding whether medications can be crushed and that Metoprolol ER and Potassium Chloride ER should not be crushed. RN H also stated there is a powdered immediate-release form of potassium chloride available if a resident cannot swallow the extended-release tablet. LPN I reported that extended-release medications should not be crushed, but stated Resident #33's medications, including the extended-release medications, were crushed because of difficulty swallowing pills and that the physician had previously been notified and gave orders to crush all of the resident's medications. However, no documentation was provided before survey exit showing physician approval to crush the resident's extended-release medications. The unit manager later reported speaking with the physician and obtaining new orders to discontinue Metoprolol ER and dissolve Potassium Chloride ER in water prior to administration. The pharmacist confirmed that Metoprolol ER and Potassium Chloride ER should not be crushed and noted alternative formulations were available; the pharmacist also stated Imipramine HCl 50 mg tablets are not recommended to be crushed and that a liquid formulation is available.
Failure to Provide Pressure Ulcer Prevention and Monitoring
Penalty
Summary
The facility failed to assess and implement pressure ulcer preventive care for Resident #7, who was admitted with diagnoses including need for assistance with personal care and muscle weakness. A Braden Assessment dated 1/7/26 showed a score of 12, indicating high risk for pressure injury development. The resident later developed a left heel pressure wound, and a progress note dated 2/11/26 documented scant serosanguineous drainage with skin prep and bordered foam dressing applied per wound nurse orders. A skin and wound consult on 2/14/26 identified a new left heel deep tissue injury measuring 2 cm x 2 cm x 0 cm and described it as pressure-induced deep tissue damage, with follow-up in one week and consideration of offloading boots when in chair and bed as tolerated. A subsequent wound note on 2/18/26 described the left heel wound as a stage 2 pressure injury measuring 1.7 cm x 0.7 cm x 0 cm and again noted consideration of offloading boots. Orders also included left heel wound care with betadine twice daily and later cleansing with wound wash, xerofoam, and comfort foam dressing daily and as needed. The resident’s care plan, initiated 2/20/26, included interventions for impaired skin integrity, frequent repositioning, a pressure reducing mattress, barrier cream, and a pressure reducing device in the chair, including the geri chair. However, during observations on 3/03/26 and 3/05/26, the resident was lying in bed with his feet directly on the bed without a pillow under them to reduce pressure. During the 3/05/26 observation, RN M stated it was important for staff to place pillows under the resident’s feet to reduce pressure and confirmed the resident remained at risk for deterioration if pressure-reducing measures were not in place. The Interim DON also stated staff were supposed to prop the resident’s feet with pillows, that offloading boots had been recommended, and that weekly skin assessments were supposed to be completed, but the last documented weekly skin assessment was 2/2/26.
Failure to Maintain Head-of-Bed Elevation During Tube Feeding
Penalty
Summary
Adequate care was not provided for a resident receiving enteral nutrition through a feeding tube. Resident #7 was admitted with diagnoses including dysphagia following a cerebral infarction and pneumonitis due to inhalation of food and vomit. The resident had an order for Jevity 1.5 continuous tube feeding at 50 mL/hr, and the care plan directed that the head of bed be elevated to 45 degrees during tube feeding and for 30 minutes afterward. During observation, the resident was found lying flat on his back while the tube feeding was running at 50 mL/hr, and the head of bed was not elevated to 45 degrees. When the RN entered the room, she adjusted the bed to 45 degrees and confirmed the resident needed that elevation while the enteral feed was running to prevent aspiration. She also stated that aides were not good at ensuring the resident’s head of bed was elevated and that she often reminded staff that he could not lie flat during tube feeding. The resident was coughing before the bed was adjusted.
Oxygen tubing stored improperly and flow rate exceeded physician order
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for Resident #87, who had diagnoses including chronic respiratory failure, other disorders of lung, and other forms of dyspnea and was ordered oxygen at 2 liters per minute via nasal cannula. During observations, the resident was receiving oxygen from a bedside concentrator at the ordered rate, but the resident’s wheelchair had a portable oxygen tank with separate tubing attached, and the tubing, including the nasal prongs, was coiled and resting directly on the wheelchair seat pad rather than being stored in a bag between uses. RN H later confirmed the tubing should have been stored in a bag and not left on the wheelchair seat pad. The resident’s oxygen flow rate was also found to be set above the physician’s order. On one observation, the concentrator was running at 4 liters per minute instead of 2 liters per minute, and RN H confirmed she had seen it set incorrectly earlier that morning. LPN K stated she had increased the oxygen to 4 liters per minute during the night, believed there might have been parameters allowing it, but the order did not include such parameters. She did not contact a physician for a new order and did not document the change or the reason for it. The IDON confirmed the resident’s order remained at 2 liters per minute, that staff should not have been giving oxygen at 4 liters per minute, and that there was no documentation addressing the increase.
Incomplete medical records and conflicting code status documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for 2 of 18 residents reviewed. For Resident #61, the record showed a female resident with diagnoses including high blood pressure, paraplegia, muscle weakness, depression, anxiety, and chronic kidney disease, and she was her own responsible party. Her MDS assessment showed a BIMS score of 14, indicating she was cognitively intact. The resident’s Medical Treatment Decisions/Advanced Directives form, signed by the resident, indicated she wished to have CPR, but the active physician order in the order summary listed DNR, and the care plan also reflected that the resident and family had elected DNR. Social Services later reported that the resident was spoken with to confirm her wishes and that the orders were updated to reflect FULL CODE. For Resident #7, the record showed an admission diagnosis of need for assistance with personal care and muscle weakness. Review of the weekly skin assessments showed the last documented weekly skin assessment was not current, and the February 2026 TAR contained missing documentation for ordered treatments, including left heel wound care, weekly weights, and weekly weights related to weight loss. The Interim DON confirmed that nurses were expected to complete weekly skin assessments for all residents and document them in the medical record, and also confirmed that Resident #7 had not had a documented weekly skin assessment since the last recorded date. The Interim DON further stated nurses were expected to document completion of treatments or the reason a treatment was missed in the TAR.
Failure to Assess and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure COVID-19 vaccination education, offering, administration, or valid declination documentation for Resident #87. Resident #87 was admitted with diagnoses including pneumonia and pulmonary hypertension. Review of the immunization record showed SARS-COV-2 (COVID-19) Dose 2 listed as pending historical with no administration date. During interview, the Infection Preventionist stated the resident’s immunization history should have been reviewed on admission to determine eligibility for COVID-19 immunization and, if eligible, the vaccine should have been offered and administered. The Infection Preventionist confirmed the facility had not assessed Resident #87’s vaccination status to determine whether the resident was eligible for or wanted the second dose of COVID-19 immunization.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to maintain professional standards of food service safety, as evidenced by multiple observations of improper food handling, storage, and sanitation practices. Dietary staff were observed not wearing required hair restraints during food service, and there was a lack of knowledge and documentation regarding the proper cooling and temperature monitoring of leftover foods. Open food items in various storage areas were frequently found without proper labeling, dating, or secure sealing, and some items were stored past their use-by or discard dates. Additionally, food was found stored open and exposed in the freezer, and some items requiring refrigeration were left unrefrigerated after opening. Sanitation and cleanliness issues were prevalent throughout the kitchen and nourishment rooms. Water leaks were observed in dry storage and pantry areas, with makeshift coverings such as blankets used to contain puddles. The walk-in cooler had structural deficiencies, including gaps at the floor juncture and a loose door latch, allowing for potential pest entry and cold air escape. Accumulations of dirt, debris, and food residue were noted on storage racks and floors, and clean pots and pans were found with encrusted grease. Air conditioning units above food preparation areas were heavily soiled, and the dish machine's pressure gauge was not being monitored as required, with staff unaware of proper temperature verification methods. Hand hygiene practices were inadequate, with staff observed failing to wash hands after changing tasks, touching their face masks, or using their phones, and one staff member was seen wearing artificial nails without gloves while handling food. Handwashing sinks were either out of order or blocked by carts, limiting accessibility. Refrigerator temperature logs showed repeated instances of temperatures above the safe threshold, with unclear responsibility among staff for monitoring and addressing these issues. There was also a lack of documentation when food was discarded due to unsafe temperatures. These deficiencies collectively created an environment with a potential for foodborne illness among residents consuming food from the kitchen.
Failure to Ensure Adequate Staffing and Meal Service
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, specifically regarding staffing and meal service. Multiple interviews and record reviews revealed ongoing issues with insufficient staffing, resulting in long call light wait times, missed showers, and inadequate assistance with transfers and care. Residents reported that aides were overworked, and staff often responded to call lights without returning to provide needed care. Staff interviews confirmed that holes in the schedule frequently went unfilled, with night shifts sometimes staffed by only one or two nurses for the entire building, including high-acuity units. Staff were reportedly discouraged from contacting the DON about staffing concerns, and showers were often not completed when staffing was low. Additionally, the facility failed to provide adequate meal service, with residents and staff reporting small portion sizes, unrecognizable or inedible food, and inconsistencies between the posted menu and actual meals served. There were instances where basic food items, such as bread and syrup, were unavailable, and dietary supplements were not consistently provided. Both residents and the Ombudsman reported that these concerns had been communicated to management, but no improvements were observed. The administration acknowledged awareness of these issues but did not implement effective corrective interventions, resulting in ongoing deficiencies impacting all residents.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for multiple residents, as evidenced by ongoing issues with hot water availability, unaddressed maintenance concerns, and unsanitary conditions. One male resident with Parkinson's disease, legal blindness, and dementia reported missing scheduled showers due to a lack of hot water, an issue persisting for months. Another female resident with cerebral palsy and muscle weakness also reported frequent hot water shortages during showers and was observed in a room with significant peeling paint and debris on the floor. A third male resident with diabetes and debility described his room as dirty upon admission, with chipped paint and a dirty pillow on the floor. Observations confirmed the presence of peeling paint, rusted door frames, chipped tiles, foul odors, and trash in common areas, as well as a damaged American flag and discarded gloves outside the facility. Staff interviews corroborated the residents' complaints, with an LPN acknowledging recent hot water issues in the shower room and the Maintenance Director stating that staff were instructed to let the water run to warm up. Despite these instructions, residents continued to experience discomfort and dissatisfaction with their living conditions, including missed showers and exposure to unclean and deteriorating environments.
Failure to Provide Showers/Baths per Resident Preference and Care Plan
Penalty
Summary
The facility failed to provide showers and baths according to resident preferences and care plans for four out of seven residents reviewed. Multiple residents with significant physical and cognitive impairments, including those with stroke, Parkinson's disease, cerebral palsy, and Huntington's disease, did not receive scheduled showers as documented in their care plans and physician orders. Documentation revealed missed showers on several scheduled days, with no record of completion or refusal, and residents reported not receiving the expected number of showers per week. Residents and their family members reported dissatisfaction with the frequency and quality of bathing, citing issues such as lack of hot water, short-staffing, and missed scheduled shower days. One resident reported that the facility had ongoing problems with hot water, resulting in missed showers or incomplete bathing experiences. Family members corroborated these concerns, noting that they sometimes had to provide showers themselves due to inadequate hygiene care at the facility. The facility's documentation practices were inconsistent, with some missed showers lacking any explanation or record. Staff interviews confirmed that shower schedules were in place and that documentation was expected, but there were gaps in both the provision of care and the recording of refusals or missed showers. These failures led to resident dissatisfaction and the potential for discomfort and impaired self-worth, as residents were not consistently assisted with activities of daily living as required by their care plans.
Failure to Provide Sufficient Nursing Staff and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by multiple reports of long call light wait times, missed showers, and unmet personal care needs. Several residents, all cognitively intact, reported not receiving scheduled showers, experiencing delays in assistance, and being left in situations where their hygiene and dignity were compromised. Documentation confirmed missed showers for multiple residents, and interviews revealed that these issues were linked to both short-staffing and, in some cases, lack of hot water. Staff interviews consistently described inadequate staffing levels across various shifts and units, with frequent unfilled positions and minimal attempts by management to address these gaps. Nurses and CNAs reported that when staffing was low, essential care tasks such as showers were the first to be omitted, and residents often waited extended periods for assistance. Staff also indicated that management rarely assisted on the floor, and that holes in the schedule were common and not proactively filled, sometimes leaving only one CNA on a unit for several hours. The facility's own assessment and staffing policies outlined higher staffing expectations than what was routinely provided, particularly on the River and View Units. Despite these documented standards, actual staffing often fell below the stated requirements, with staff and residents both reporting that care was delayed or omitted as a result. The deficiency was further corroborated by the facility's policies, which require prompt response to call lights and sufficient staffing to meet resident needs, both of which were not consistently met according to the findings.
Failure to Follow and Clearly Post Current Menu Cycle
Penalty
Summary
The facility failed to follow the posted menu and serve food items as scheduled, did not post the current menu in a manner accessible for residents to review, and did not update the menu with changes when they occurred. Observations revealed that the menu posted in the main dining room was not clearly marked to indicate the current week of the menu cycle, requiring residents to flip through multiple pages to determine what meals were scheduled. There were no dates on the menu to clarify which week was current, and the menu visible was consistently for Week 4, regardless of the actual week. Interviews with dietary staff confirmed that meals served did not always match the scheduled menu due to issues such as missing ingredients and confusion among newer staff about which week of the menu cycle was being followed. A resident with cerebral palsy, major depression, muscle weakness, and a need for assistance with personal care reported that the food served was often inconsistent with the posted menu and that she was frequently unaware of what would be served until the meal tray arrived. Dietary staff acknowledged serving meals from different weeks and substituting menu items based on availability, rather than following the planned menu. These actions resulted in inconsistencies in meal service and a lack of clear communication to residents regarding their meal options.
Failure to Provide Palatable, Adequate, and Properly Tempered Meals
Penalty
Summary
The facility failed to provide adequate portions of palatable food, served at an appetizing temperature, to multiple residents. Residents and their family members reported dissatisfaction with the quality, temperature, and portion sizes of the meals. Specific complaints included food being bland, flavorless, unrecognizable, and often served lukewarm or cold. Some residents, including those with visual impairments, were unable to identify their food, and staff were reportedly unable to provide information about the meals being served. There were also reports of food items being substituted due to shortages, such as sandwiches being made with hamburger buns instead of bread, and waffles being served without syrup due to lack of supplies. Observations and interviews revealed that residents frequently received small portion sizes, with some meals described as insufficient, such as a breakfast consisting of half a glass of orange juice, a hard-boiled egg, and a piece of toast. Residents with specific dietary needs, such as those requiring supplements or extra portions due to medical conditions, did not consistently receive appropriate food or supplements. There were also instances where residents received food inconsistent with their ordered diets, and staff had to improvise to make the food suitable for consumption, such as moistening dry ground meat with mayonnaise packets when gravy was unavailable. Test tray observations confirmed that food was served at temperatures below recommended levels, with hot foods such as chicken tenders, green beans, and stuffing measured at 104°F, 113°F, and 128°F, respectively, upon delivery to the unit. Dietary staff acknowledged shortages of key items like Magic Cups and yogurt, and nursing staff reported ongoing issues with cold food, small portions, and missing supplements. These findings were corroborated by multiple interviews with residents, family members, dietary staff, and nursing staff, all indicating persistent problems with food quality, temperature, and adequacy.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to obtain informed consent for the administration and changes of psychotropic medications for one resident with severe cognitive impairment. The resident, who had diagnoses including psychotic disorder with delusions, depression, and unspecified dementia with agitation, was prescribed multiple psychotropic medications such as Duloxetine, Mirtazapine, Olanzapine, and Quetiapine. Despite the resident's cognitive status, there was no evidence that informed consent was obtained from the resident's representative prior to the initiation or adjustment of these medications. Family members reported they were not notified about changes to the resident's medications and only became aware of the use of certain psychotropic drugs after reviewing a medication list provided by the facility. The family expressed concern and confusion regarding the reasons for the prescriptions, indicating a lack of communication and education from the facility regarding the resident's medication regimen. The resident's spouse/guardian was not fully informed about all medications until a care conference was held, well after the medications had been prescribed and administered. Interviews with facility staff, including the social worker and the nursing home administrator, confirmed that there were no signed consent forms for the psychotropic medications in the resident's medical record, except for verbal consent documented during a care conference. The social worker acknowledged that, given the resident's severe cognitive impairment, consent should have been obtained from the spouse/guardian rather than the resident. The director of nursing also confirmed that consent is required for the administration of psychotropic medications, but such documentation was not present.
Failure to Administer Ordered Medications Timely for Two Residents
Penalty
Summary
The facility failed to ensure that ordered medications were administered timely according to physician orders for two residents, resulting in delays in care. One resident, who had multiple serious diagnoses including MRSA infection, sepsis, and peripheral vascular disease, was admitted with orders for intravenous antibiotics. Despite the physician's order for Ceftaroline Fosamil to be administered every eight hours, the resident did not receive any doses during his stay because the medication was not available. The pharmacy required payment authorization due to the high cost, and the facility did not provide this authorization until several days after the order was placed. During this period, the resident's condition worsened, with increased pain and significant discoloration and necrosis of his toes, ultimately leading to a hospital transfer and subsequent above-the-knee amputation. Another resident, admitted with a seizure disorder, diabetes, and hypertension, also experienced a delay in receiving a critical medication. The resident was ordered to receive Lacosamide for seizure control twice daily, but missed a total of ten scheduled doses over several days. The delay was due to the lack of a signed prescription, which was not obtained promptly from the physician. Nursing staff documented that the medication was on order and that the physician was aware, but the prescription was not signed and accepted by the pharmacy until several days after admission. During this time, the resident did not receive the ordered seizure medication. In both cases, the facility did not follow its own policy requiring medications to be administered in accordance with physician orders. The delays were attributed to administrative and communication failures between the facility, pharmacy, and physician, resulting in missed doses of essential medications for both residents. The documentation shows that staff were aware of the missed doses and the reasons for the delays, but did not ensure timely resolution to provide the necessary care as ordered.
Failure to assess hot liquid safety and monitor toileting-related fall interventions
Penalty
Summary
The facility failed to implement interventions to reduce accident hazards for residents who were given hot beverages without being assessed for their ability to safely handle hot liquids. Resident #103 had diagnoses including altered mental status, muscle weakness, and cognitive communication deficit, and an MDS assessment showed a BIMS score of 12/15. The care plan identified risk for injury from spills of hot liquids and included interventions to encourage staff assistance and use of a clothing protector. However, the resident was not assessed for hot liquid safety for about 7 months between assessments, despite the facility policy requiring assessment on admission, quarterly, and with significant change. On 11/13/25, Resident #103 spilled an entire cup of hot coffee on herself and sustained a burn to the chest. Nursing documentation described the resident yelling in pain, clothing being removed, the area rinsed with cold water, and aloe burn gel being applied. An LPN reported finding a hand-sized reddened area and an open burn about the size of a quarter. The resident was observed afterward with a bandage on the upper chest and was alert but confused, repeatedly asking the interviewer’s name. Staff interviews also revealed the facility had no vinyl-backed clothing protectors and the kitchen continued not to provide cup lids on food carts, despite those items being identified in the hot liquids policy. Three other residents were observed with hot beverages without lids or clothing protectors and without documented hot liquids safety assessments. Resident #106, who had hemiplegia and hemiparesis following cerebral infarction and noncompliance with treatment, was observed with a hot coffee cup on the bedside table and no lid or clothing protector. Resident #107, who had hypertensive encephalopathy, muscle weakness, cerebral infarction, attention and concentration deficits, and dementia, was observed with a hot beverage on the bedside table without a lid or clothing protector, and her hot liquids assessment had not been updated since 1/29/25. Resident #108, who had traumatic subarachnoid hemorrhage and neuropathy, was observed sipping a hot beverage from an uncovered cup while wearing a hospital gown and no clothing protector, and no hot liquids safety assessment was found in the record. The facility also failed to monitor and modify interventions for Resident #101, who had traumatic subarachnoid hemorrhage, difficulty walking, need for assistance with personal care, and dementia, with a BIMS score of 4/15. The care plan identified fall risk related to cognitive impairment, incontinence, history of falls, and poor safety awareness, with interventions including toileting every 1-2 hours. Incident reports showed 11 falls over a three-month period, and 8 of those falls occurred while the resident was trying to complete toileting tasks without staff assistance. Interviews with staff and the DPOA described frequent urinary urgency, distress when the resident was soiled, attempts to clean himself up or walk to the bathroom without help, and repeated concerns that toileting assistance was not consistently provided. Staff also reported the resident’s urinal was often not within reach, and the facility could not confirm that toileting assistance was being provided as planned.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Agency within the required timeframe for one resident who had Alzheimer’s disease, cognitive communication deficit, and a history of nasal bone fracture. The resident’s MDS showed the resident was rarely to never understood, could not complete a BIMS, and was dependent for rolling in bed and transferring from bed to wheelchair. The care plan identified the resident as at risk for falls and injury, including intentionally bumping the head against the dining room table, and included interventions such as a fall mat, padding on the bed rail, and an activity pad on the table. On 9/10/25, an RN observed a hematoma on the resident’s forehead and reported it to the UM, who stated it was from a fall that had occurred about 2 weeks earlier; the RN did not see the UM view the injury and assumed it was not new based on the phone conversation. A CNA reported the hematoma was initially small but became more elevated as the day progressed and stated she had cared for the resident the previous day without seeing any injury. The DON and NHA later confirmed the hematoma was an injury of unknown origin that should have been reported within 24 hours, but the incident report showed it was not reported to the State Agency until 5 days after it was first identified.
Failure to Thoroughly Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate multiple incidents of potential mistreatment involving residents with severe cognitive impairment and injuries of unknown origin. The cited concerns involved five intakes and included residents with diagnoses such as Alzheimer’s disease, vascular dementia, and other frontotemporal neurocognitive disorder. Several of the residents were rarely or never understood, and one resident was dependent for rolling in bed and transferring from bed to wheelchair. For one resident, staff observed a hematoma on the forehead that was initially reported to a UM by an RN, but the UM did not come view the injury and instead assumed it was from a fall that had occurred about two weeks earlier. Another CNA reported the hematoma was present and became more elevated during the day, and that she was not interviewed during the investigation. A provider later documented bruising and a hematoma of uncertain origin, and an ER note described a large bruise and contusion on the head with a nose fracture and noted the injury was of unknown origin or from an unknown fall. Additional incidents involved a bruise on one resident’s hand and finger, a new bruise over the whole backside of another resident’s hand, a skin tear on a resident’s right forearm with no documentation in the record, and bruising including a purple eye and multiple other bruises on another resident. Staff interviews indicated some injuries were initially thought to be from falls but later determined not to be, and multiple CNAs stated they were not interviewed during investigations. The NHA reported there were six instances of injuries of unknown origin between the cited dates, but for one incident only five random witness statements were taken and no 3rd shift staff were interviewed, while no witness statements were obtained for the other five incidents. The NHA also reported no monitoring of staff interactions after the injuries were discovered and no protective measures such as unannounced management visits. The facility’s abuse and neglect policy required monitoring for bruises and injuries of unknown origin, tracking trends that may constitute abuse, and investigating all patterns, trends, or incidents suggesting possible abuse or neglect.
Staff Lacked Behavioral Health Competency
Penalty
Summary
The facility failed to ensure 6 staff members reviewed for behavioral competency had the skills needed to provide care that supported residents’ psychosocial wellness. Interviewed staff reported difficulty caring for residents in the memory care unit and described that some staff did not know how to approach residents without triggering stress responses. CNA P stated she struggled to care for several residents in memory care and said she apologized to residents there more than anywhere else because they became so upset. CNA E reported seeing staff trigger residents’ stress responses, with residents responding by flailing their arms and banging against things, and questioned whether this contributed to more residents being found with injuries of unknown origin. CNA Z reported that several staff members did not seem to have the skills needed to avoid triggering psychological stress responses and that it was not uncommon for CNAs to say they could not complete personal care for certain residents because the residents became too upset when approached. RN GG reported some staff did not know how to effectively care for residents prone to bouts of psychological distress and had witnessed staff approaching residents in ways that led to unnecessary emotional distress. The DON stated staff were expected to have the skills needed to work in any area of the facility, including memory care. Record review showed RN BB, CNA P, and CNA TT had not completed nursing competencies in the last 12 months, including behavioral health competency, and the competencies for CNA Z, CNA UU, and RN BB were greater than 12 months old. Staffing schedules showed these staff remained actively employed and provided care throughout the building.
Failure to Report Injury of Unknown Origin as Potential Abuse
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after staff failed to operationalize the facility’s abuse policy for a resident with severe cognitive impairment. Resident #100 had diagnoses including Alzheimer’s disease, cognitive communication deficit, and fracture of nasal bones, and was documented as rarely to never understood and dependent for rolling in bed and transferring from bed to wheelchair. The care plan noted the resident was at risk for falls and injury, including intentionally bumping her head against a dining room table. On 9/10/25, RN GG noticed a 2x2 hematoma on the resident’s forehead and immediately called UM U to report an injury of unknown origin. RN GG reported UM U told her the injury was from a fall that had occurred about 3 weeks earlier, and UM U did not come assess the resident. DON B and NHA A later confirmed the forehead hematoma was mistakenly attributed to the prior fall, but it was actually an injury of unknown origin that should have been reported to the NHA immediately as a potential abuse situation. UM U also confirmed she assumed the injury was old and only later realized it was new and should have been reported immediately.
Inappropriate First Aid for Burn Injury
Penalty
Summary
The facility failed to provide appropriate first aid care for a burn for Resident #103, who had diagnoses including altered mental status, muscle weakness, cognitive communication deficit, and type 2 diabetes mellitus. The resident’s MDS assessment showed a BIMS score of 12/15, indicating moderate cognitive impairment. The care plan identified the resident as at risk for injury from spills of hot liquids due to weakness and included interventions to encourage staff assistance with hot liquids and use of a clothing protector. On 11/13/25, the resident spilled hot coffee on her chest and was found yelling in pain. The incident report documented that clothing was removed, the affected area was rinsed with cold water, and aloe burn gel was applied to the wound; the injury was described as a burn to the chest with an open area. During interview, the LPN reported she poured 16 oz of cold water on the burn and applied aloe burn gel before contacting the physician. The MD stated he was not contacted before the gel was applied and would not have recommended it, and the DON stated a nurse should not apply treatment to an injury without a physician’s order.
Failure to Promptly Assess New Head Trauma
Penalty
Summary
The facility failed to promptly recognize and assess a resident with new head trauma. Resident #100 had diagnoses including Alzheimer’s disease, cognitive communication deficit, and a prior fracture of the nasal bones, and was rarely to never understood per the MDS. The care plan identified the resident as at risk for falls and injury, including a history of intentionally bumping the head against surfaces. On 9/10/25, RN GG noticed a 2x2 hematoma on the resident’s forehead and reported it to UM U as an injury of unknown origin, but UM U assumed it was from a fall that had occurred about 3 weeks earlier. Based on that assumption, the resident was not assessed at that time, and RN GG reported the injury was not evaluated because she was told it was not new. Subsequent interviews and record review showed the injury was later determined to be new. CNA N reported the hematoma was initially small on 9/10/25 and became more elevated במהלך the day, and she had not seen any injury the previous day. The DON assessed the resident on 9/15/25 and documented bruising to the forehead and right temple with a raised area on the right side of the head, noting the timeline was outside the time related to the previously reported fall and that the bruise origin was unknown. A provider note on 9/15/25 described bruising and a hematoma in stages of healing and stated it was unsure when and how it formed. No provider assessed the resident between 9/10/25 and 9/15/25, and the NP reported she was not aware of the injury until 5 days after it was first identified. The resident was later sent to the emergency room on 9/16/25 after staff reported the resident was more difficult to arouse.
Failure to Prevent Unnecessary Psychotropic Medication Use and Inadequate Monitoring
Penalty
Summary
A resident with severe cognitive impairment and a history of cerebral infarction, dementia, and behavioral disturbances was prescribed psychotropic medications, specifically Haldol (haloperidol) and Olanzapine (Zyprexa), without an adequate psychiatric diagnosis to justify their use. The medications were initiated and increased over time, despite the absence of documented psychiatric conditions such as schizophrenia or bipolar disorder. The care plan did not include a mental health diagnosis or PASARR documentation to support the use of antipsychotic medications, and non-pharmacological interventions were not developed or implemented prior to the administration of these drugs. Staff interviews and record reviews revealed that the resident began experiencing increased sedation, weight loss, decreased ability to communicate, and multiple falls after the initiation of the psychotropic medications. Documentation showed that Haldol was administered even after the resident was no longer agitated, and there was a lack of evidence that non-pharmacological interventions were attempted before resorting to medication. Progress notes and medication administration records indicated that PRN Haldol was given multiple times without proper documentation of the behaviors leading to its use or the effectiveness of alternative interventions. The resident's guardian was not adequately informed about medication changes, and consent forms lacked critical information such as dosage, route, frequency, and expected benefits or side effects. Observations and interviews with staff highlighted issues of short staffing, lack of individualized care, and insufficient monitoring of the resident's condition, including hydration and nutritional status. The resident was found to be lethargic, unable to eat or drink, and had significant weight loss and dehydration, ultimately requiring transfer to a hospital. The facility's interdisciplinary team and medical director were not fully aware of the extent of the psychotropic medication regimen, and there was a failure to ensure appropriate oversight and monitoring of the resident's response to these medications.
Removal Plan
- Obtain an order from the facility Psychiatrist/Resident's Physician to discontinue medication.
- Add 1:1 for safety of self and other residents due to increased aggression.
- Complete a chart audit on all residents currently prescribed an antipsychotic medication to ensure an adequate indication for use and appropriate documentation is present to support use of the medication.
- Audit all residents who receive antipsychotic medication.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three Certified Nursing Assistants (CNAs) who had been employed for more than 12 months. Personnel file reviews for these CNAs showed no evidence of annual performance evaluations within the past year. This was confirmed by both the Business Office Manager (BOM) and the Nursing Home Administrator (NHA), who acknowledged that the required evaluations had not been conducted or documented as per facility policy. Interviews with facility staff further confirmed the absence of these reviews, with the BOM stating that performance evaluations are expected annually and should be maintained in employee files. The facility's policy specifies that additional training should be provided based on areas of weakness identified in performance reviews, and that such education should be completed within 90 days of the appraisal. The lack of completed performance reviews resulted in the potential for unidentified performance concerns and unmet training needs for the CNAs involved.
Failure to Implement Effective QAPI Program and Address Dementia Care Deficiencies
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) program effectively identified and corrected quality deficiencies, particularly in the dementia care unit. Interviews and record reviews revealed that the QAPI committee did not consistently review or analyze data, nor did it develop plans of action when concerns were identified. The QAPI plan document was incomplete, lacking essential information such as the facility name, vision, mission, and purpose. The Nursing Home Administrator, who served as the QAPI Coordinator, acknowledged that records of ongoing data review and analysis were limited, and necessary reports were not being generated due to significant management turnover. As a result, issues such as the use of psychotropic medications and staff training deficiencies were not adequately monitored or addressed. A resident with dementia did not receive individualized care despite interventions provided by her Durable Power of Attorney (DPOA) to reduce stress responses. Staff interviews indicated a lack of knowledge regarding effective interventions for this resident, and concerns raised by staff were not acted upon. The QAPI committee was aware of deficiencies in staff performance evaluations and training but did not implement a Performance Improvement Plan (PIP). The facility was unaware of non-compliance related to psychotropic medication use until it was identified during the survey.
Failure to Ensure Medical Director Attendance at QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director or their designee attended the Quality Assurance and Performance Improvement (QAPI) committee meetings at least quarterly, as required by facility policy. Review of QAPI committee sign-in sheets showed that neither the medical director nor a designee attended any meetings from April to August 2025. During an interview, the Nursing Home Administrator (NHA) stated that significant management turnover and a change in medical directors contributed to the lack of attendance, with the former medical director not attending as required and the new medical director missing meetings due to scheduling issues. Facility policy specifies that the QAPI committee must be interdisciplinary and include the medical director or designee, meeting at least quarterly.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to maintain an effective training program for all new and existing staff members, as evidenced by interviews and record reviews. The Director of Nursing (DON) reported that the facility previously used a computer-based training platform, but after discontinuing the service, they lost access to records of completed staff training. There was no current staff training program in place, and any training that was completed was supposed to be recorded in employee files. However, a review of employee files for several CNAs revealed no documentation of training related to Quality Assurance and Performance Improvement (QAPI), Infection Control, Compliance and Ethics, Communication, or Resident Rights within the past 12 months. Further interviews with the Nursing Home Administrator (NHA) confirmed that the facility had not been tracking staff training and was aware that some training requirements had not been met. The NHA also stated that there was no Performance Improvement Plan in place to address the lack of annual staff training. A review of the facility's assessment indicated that the training program was supposed to include ongoing training for existing staff, covering topics such as effective communication, resident rights, infection control, QAPI, and compliance and ethics, but this was not being implemented as described.
Failure to Provide and Document Required CNA In-Service Training
Penalty
Summary
The facility failed to implement an effective in-service training program for nurse aides, specifically not supporting mandatory attendance, tracking participation, or ensuring continuing competence. Review of personnel files for three CNAs revealed that documentation did not reflect the required 12 hours of annual training. The Director of Nursing reported that the facility had been without a staff educator and that she was attempting to cover those responsibilities, but had not yet established a staff training plan. Additionally, the facility had discontinued use of a computer-based training system and could not access previous staff training records. The Business Office Manager confirmed that the personnel files for the reviewed CNAs lacked evidence of the required annual training. The Nursing Home Administrator acknowledged awareness of the non-compliance with the 12-hour annual training requirement and confirmed that there was no current staff training plan in place. These findings indicate that the facility did not maintain an appropriate and effective nurse aide in-service training program as required by policy.
Call Light Accessibility Not Ensured for Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure that call lights were within reach for a resident who was severely cognitively impaired and required assistance with most activities of daily living, as documented in the Minimum Data Set. Multiple observations showed that the resident's soft-touch call light was either under the sheet at waist level or clipped to the fitted sheet at the head of the bed, both out of the resident's sight and reach. During interviews, the unit manager acknowledged that the call light should have been accessible and explained that staff placed it under the sheet so the resident might activate it by rolling onto it, but confirmed that staff should not have done this.
Failure to Provide Resident-Centered Activities for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide resident-centered activities designed to support the leisure needs of a resident with severe cognitive and visual impairments. The resident, who had diagnoses including vascular dementia with behavioral disturbances, adjustment disorder, and sequelae of cerebral infarction, was assessed as severely cognitively impaired and highly visually impaired. Documentation indicated that the resident was dependent on staff for mobility and unable to participate in traditional leisure activities due to these deficits. Despite this, the activity attendance log showed minimal participation in sensory stimulation and inaccurately documented independent engagement in activities such as religious study and jigsaw puzzles, which the resident's durable power of attorney (DPOA) and staff interviews confirmed were not possible due to the resident's limitations and lack of interest. Interviews with the DPOA revealed that staff never consulted her regarding the resident's past leisure interests, and she stated the resident could not accurately express his preferences. The DPOA also reported that the resident could not engage in activities like reading, puzzles, or watching television, and that religion was not important to him, contradicting the activity records. Staff interviews further confirmed that the resident required one-on-one assistance for any leisure activity and was rarely observed participating in any activities. The activity assistant reported not being informed of the resident's preferences and resorted to placing various supplies in front of the resident to gauge interest, but noted the resident appeared emotionally distressed and unable to participate in group activities. Additional interviews with facility staff, including the activity director and former social services director, highlighted concerns about the quality and quantity of individualized activities offered in the memory care unit. The activity director acknowledged that documentation of self-propelling a wheelchair or looking out the window was inaccurately recorded as leisure activity participation. The nursing home administrator confirmed awareness of the need for more individualized activities in the memory care setting, as current practices did not adequately address the resident's needs for meaningful engagement.
Failure to Provide Person-Centered Dementia Care and Activities
Penalty
Summary
The facility failed to develop and implement person-centered dementia care interventions for a resident diagnosed with vascular dementia and severe cognitive impairment. The resident exhibited behaviors such as wandering, disorientation, emotional frustration, and stress, but the care plan did not accurately reflect the resident's needs or preferences. The care plan included an incorrect nickname, omitted specific non-pharmacological interventions suggested by the resident's DPOA, and did not address known triggers or effective calming techniques such as gentle handling of the resident's hands or back rubs. Additionally, the care plan did not document the resident's preference for napping after breakfast, which was known to reduce agitation. Observations revealed that the resident spent extended periods in bed with no access to preferred items such as a radio, books, or magazines, and the call light was out of reach. The activity attendance log showed minimal participation in sensory stimulation activities, and interviews with staff indicated a lack of knowledge about the resident's preferences and effective interventions. Staff members, including LPNs and activity assistants, reported not receiving dementia care training and expressed difficulty in managing the resident's behaviors. The resident's DPOA and guardian reported that their input regarding triggers and calming strategies was not incorporated into the care plan or daily care practices. The facility's dementia care policy required individualized, person-centered care and staff training, but these standards were not met. There were no planned activities for men or for residents on the locked dementia unit after certain hours, and staffing levels were insufficient to provide appropriate care and activities, especially in the evenings. Staff interviews confirmed that residents with dementia were not receiving adequate attention, activities, or individualized interventions, contributing to ongoing behavioral issues and emotional distress for the resident.
Inaccurate Medical Record Documentation for Cognitively Impaired Resident
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident with severe cognitive impairment and multiple diagnoses, including vascular dementia and complications from a stroke. The resident's care plan inaccurately listed a nickname that was not used by the resident, and the Durable Power of Attorney (DPOA) confirmed that using this nickname would cause confusion. The DPOA also stated that the resident could not participate in traditional leisure activities and had not attended any outings, which would have required her permission. Multiple staff interviews corroborated that the resident did not participate in group activities due to cognitive deficits. Despite this, the activity attendance record documented the resident as having participated in various group activities and outings, including after the resident had already been discharged to an acute care setting. The Activity Director acknowledged that some activities recorded, such as self-propelling a wheelchair or looking out a window, did not meet the definition of leisure activities and confirmed that outings were not offered by the facility. The Activity Director also noted that the activity assistant responsible for documentation had difficulty accurately recording attendance, likely resulting in erroneous entries. These inaccuracies resulted in a medical record that was not factual, accurate, complete, or current.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that a resident in need of dialysis received care and services that met safety and appropriateness standards. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standard for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Implement Gait Belt Use and Wheelchair Footrest Safety
Penalty
Summary
The facility failed to ensure proper accident prevention measures were implemented for two residents. For one resident with a history of muscle weakness and a displaced intertrochanteric fracture of the left femur, a Physical Therapy Assistant (PTA) was observed assisting her to ambulate in the hallway without the use of a gait belt. Multiple staff interviews, including those with the Therapy Director, Certified Nurse Assistants, and the Director of Nursing, confirmed that facility policy and staff orientation require the use of a gait belt when assisting any resident with ambulation in the hallway, regardless of their independence in their room. The resident's care plan indicated a need for supervision and assistance with ambulation due to a history of falls and weakness, but the intervention was not followed during the observed event. In a separate incident, another resident with Alzheimer's disease, muscle weakness, and severe cognitive impairment was transported in a wheelchair by a Physical Therapist without footrests in place. The therapist was observed pushing the resident down the hallway, then leaving her unattended to retrieve the footrests, during which time the resident placed her feet on the floor. Staff interviews confirmed that the expectation is for footrests to be in place whenever a resident is transported in a wheelchair. Both incidents demonstrate a failure to follow established safety protocols for ambulation and wheelchair transport, as observed and confirmed by staff and record review.
Unattended Narcotic Medication Left on Medication Cart
Penalty
Summary
A narcotic medication, specifically Lorazepam, was observed left unattended in a plastic medication cup on top of a medication cart in the common area of the secure unit. The cup, labeled with a resident's name and containing a white substance submerged in liquid, was left next to a plastic drinking cup of tan colored liquid. This situation occurred while there were seven residents present in the room, including one resident who was ambulatory, and a CNA who was not monitoring the medication cart. The medication and supplement remained unattended and out of staff line of sight for a total of 37 minutes, during which time staff and visitors moved in and out of the area. Interviews with staff confirmed that the assigned nurse, RN R, had left the medication unattended while off the unit for approximately 15 minutes. RN R acknowledged the medication was a prescription narcotic intended for a resident present in the area and admitted it should not have been left unattended. Additional staff interviews and review of facility policy confirmed that medications, especially controlled substances, are required to be under direct observation or locked at all times. The facility's policy also specifies that all drugs and biologicals must be stored in locked compartments, and controlled substances must be double-locked, which was not followed in this instance.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inadequate Dietary Management Leads to Disrupted Meal Service
Penalty
Summary
The facility failed to ensure that the dietary manager had the necessary competencies and skill set to manage the food and nutrition service, resulting in the potential for unmet nutrition and hydration needs for all residents dependent on the facility kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, consisting only of milk, eggs, and a few loaves of bread, and that menu items could not be served as planned due to missing ingredients. Staff described having to use emergency food supplies, which were not replenished, and substituting menu items due to lack of availability. There was also a reported shortage of thickened juice required for therapeutic diets, and staff were unclear about when the dietary manager or interim manager would be present, as both were PRN and not full-time. Further interviews revealed confusion and lack of oversight in the ordering process, with the interim dietary manager admitting to not knowing how to place food orders and relying on training that had not yet occurred. The registered dietitian clarified that she was not overseeing daily kitchen operations and would not be present daily, despite being named as the full-time dietitian. The previous dietary manager confirmed she was no longer responsible for the kitchen and had only briefly assisted with food ordering. Observations also noted expired food items in the kitchen. These findings demonstrate a lack of competent and consistent management in the dietary department, leading to disruptions in meal service and potential unmet nutritional needs for residents.
Failure to Follow Menus and Obtain Dietitian Approval for Substitutions
Penalty
Summary
The facility failed to follow its planned menus, resulting in the potential for inadequate nutritional value and unmet nutritional needs for all residents consuming food from the kitchen. During a kitchen tour, dietary staff reported that recent food deliveries were insufficient, providing only milk, eggs, and bread, and that there was not enough of certain items, such as bread and bacon, to fulfill the menu requirements. Staff described having to make unapproved substitutions, such as serving scrambled eggs and toast instead of sausage gravy and biscuits, and using ham in place of pot roast because the latter was not thawed. The dietary staff indicated that they often had to be creative with meal preparation due to unavailable menu items, and that the dietary manager or interim manager, both PRN staff, were responsible for approving substitutions, though their presence in the facility was inconsistent. Further investigation revealed that the registered dietitian had not been notified of menu substitutions and had not visited the facility during the relevant period. The dietitian confirmed she had not approved any substitutions or signed off on a substitution log, as required. Staff interviews indicated a lack of awareness or use of a substitution log, and the dietary manager was not present to oversee or document menu changes. The administrator reported that some food items, such as sausage gravy, were unusable due to damage, necessitating substitutions that were not properly communicated or documented. This lack of adherence to menu planning and required oversight by the dietitian led to the cited deficiency.
Inadequate Time and Oversight for Infection Preventionist Role
Penalty
Summary
The facility failed to ensure that a qualified Infection Preventionist (IP) was dedicated at least part-time to the infection prevention and control program, and that the IP was provided sufficient time to fulfill the responsibilities of the role. The individual assigned as IP was also serving as the Assistant Director of Nursing (ADON) and, more recently, as the Unit Manager (UM) for the rehab unit. This staff member reported being pulled to cover open shifts on the floor, being on call, and handling additional administrative and clinical duties, which significantly limited the time available for infection control tasks. The IP estimated spending only about 3 hours per week on infection control, despite stating that 20 to 25 hours per week would be appropriate for the role. Interviews and record reviews revealed that the IP's infection control activities were limited, with audits focusing only on the availability of gowns and gloves rather than staff compliance with personal protective equipment (PPE) use. The IP acknowledged that staff were not compliant with PPE requirements for residents on Enhanced Barrier Precautions (EBP) and that there had been insufficient time to reeducate staff on proper PPE use. The last infection control education provided to staff was several months prior, and the IP had only recently completed uploading resident immunization data from the previous fall. The facility's own assessment and job descriptions indicated that the IP role was intended to be a distinct responsibility, but in practice, it was combined with multiple other roles, resulting in inadequate oversight and management of the infection prevention and control program.
Failure to Develop Person-Centered Care Plan for Foley Catheter and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to develop a person-centered care plan that accurately reflected the current care needs of a resident with severe cognitive impairment and a history of psychotic disorder with delusions and dementia with behavioral disturbances. The resident was observed with a Foley catheter in place, and medical orders indicated the need for regular assessment of catheter patency. However, the care plan only addressed fall risk related to incontinence and the use of a Foley catheter for urinary retention, without including any focus, goals, or interventions for enhanced barrier precautions associated with the presence of the catheter. Interviews with facility staff, including the ADON/Unit Manager/Infection Preventionist, LPN Supervisor, and DON, confirmed that enhanced barrier precautions should have been implemented and care planned for any resident with a Foley catheter. Staff acknowledged that the resident did not have a care plan in place for enhanced barrier precautions, despite the presence of the catheter and the facility's expectations and protocols. This omission resulted in an inaccurate reflection of the resident's current care needs and the potential for unmet care needs.
Failure to Update Resident Care Plan for Dietary and Hydration Needs
Penalty
Summary
The facility failed to revise and maintain an accurate, person-centered care plan for a resident with a history of traumatic subdural hemorrhage and severe cognitive impairment. The resident's diet and hydration needs had changed, including advancement of diet and discontinuation of G-tube feedings, but the care plan continued to reflect outdated interventions such as a pureed diet and nectar thick liquids. Observations and interviews revealed that visual cues and current orders indicated the resident was on a mechanical soft diet with honey thick liquids, but these changes were not reflected in the care plan. Multiple staff interviews confirmed that the care plan had not been updated to match the resident's current needs, and there was confusion regarding responsibility for updating the care plan due to the absence of a dietary manager and changes in unit management. The deficiency was identified through review of records, staff interviews, and direct observation, which showed discrepancies between the resident's current dietary orders, visual staff cues, and the documented care plan. The care plan was not revised in a timely manner to reflect the resident's current nutritional and hydration requirements, resulting in an inaccurate and incomplete description of the resident's care needs. This failure created the potential for unmet care needs due to staff relying on outdated care plan information.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide scheduled activities of daily living (ADL) care, specifically showers, to dependent residents who required assistance. Two residents with significant physical disabilities and cognitive intactness reported not receiving showers as scheduled, with one resident going up to a week and a half without a shower and another going about nine days without one. Review of facility records confirmed gaps in shower documentation, with periods of 7 to 12 days between documented showers for both residents. There were no documented refusals for showers during these periods, and the residents' care plans indicated they were to receive showers twice weekly on specific days. Interviews with staff revealed that showers were often missed during busy or understaffed shifts, with CNAs prioritizing other tasks such as passing dinner trays, feeding residents, and putting residents to bed. Staff reported that showers were documented only on shower sheets, which were then signed off by nurses, and that refusals were to be documented in progress notes. The Director of Nursing confirmed that short staffing was not an acceptable reason to skip scheduled showers and that the standard of care was two showers per week. Despite these expectations, the facility did not ensure that dependent residents consistently received their scheduled showers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 182 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Three Rivers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Optalis Health And Rehabilitation Of Three Rivers | 4 mi | ★★★★★ | 41 | 0 |
| Fairview Nursing And Rehabilitation Community | 7.6 mi | ★★★★★ | 1 | 0 |
| Medilodge Of Portage | 14.7 mi | ★★★★★ | 4 | 0 |
| Froh Community Home | 17.8 mi | ★★★★★ | 0 | 0 |
| Bronson Commons | 18.5 mi | ★★★★★ | 2 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for The Orchards At Three Rivers.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.