Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Edenbrook Pine Haven during CMS and state inspections, most recent first.
Nursing staff were not properly oriented or competency-checked for medication administration, leading to widespread missed medications for multiple residents. An RN on their first independent shift off orientation was unfamiliar with which residents received insulin or time-sensitive meds and failed to complete all scheduled meds, treatments, and vital signs. An LPN told the RN to stop passing meds and document the omissions, but neither the RN nor the LPN notified the DON or provider about the missed insulins and other medications. The DON later confirmed the orientation program lacked oversight and structured competency evaluations, and the RN's file had no nurse-specific orientation or competency tracking documentation.
The facility administration team failed to oversee a competency-based nurse orientation program. The DON confirmed a newly hired RN was placed on the schedule and worked independently without verified clinical competency, and the RN stated orientation omitted high-risk meds, provider notification, and post-fall protocols. The administrator later confirmed there was no nurse-specific orientation or competency tracking in personnel files and no operational process to verify competency before independent floor shifts.
The facility failed to maintain a competency-based nursing orientation process and lacked required competency records for newly hired RNs and LPNs. Staff reported that orientation had been shortened from eight days to three or four days, nursing leadership was excluded from final competency review, and completed checklists were sent to HR instead of the DON. The DON confirmed an RN was placed on the floor independently without verified competencies and that this occurred during the RN’s first solo shift on the 28-resident front medication cart, resulting in a widespread medication error incident.
Resident council concerns about delayed call light response times and delayed care were not effectively acted upon. Residents reported long waits for help with toileting, transfers, showers, and medications, with some saying call lights were answered and then not followed through, and one resident reporting a 40-minute wait on the toilet. The administrator confirmed the concerns had been raised repeatedly, but no manual call light audits had been completed and the DON had not been notified of the ongoing issues through resident council.
The facility failed to promptly notify providers about widespread missed meds, treatment omissions, and missed assessments affecting multiple residents. An RN and LPN confirmed they did not contact the provider about missed insulin and other critical meds, and the DON stated the first provider notification occurred only after the DON called the NP the next morning. For one resident with chronic diastolic HF, the chart showed a 6-lb weight gain in 24 hours with no documented provider notification despite orders to report weight increases.
A facility failed to keep residents free from significant medication errors when nursing staff omitted or delayed many scheduled meds, treatments, and assessments for multiple residents. Errors included missed insulin, anticoagulants, narcotics, diuretics, blood pressure meds, blood glucose checks, wound care, and daily weights, with progress notes often lacking nurse assessments or provider notifications. Interviews showed staff were aware of the widespread omissions, some doses were not given because of time, and the DON and NP were not notified in a timely manner.
Expired and discontinued medications were found unsecured on counters in three medication storage rooms, mixed with active stock and awaiting disposal. The items included multiple prescription drugs, syringes, creams, inhalers, and OTC medications from discharged residents. An LPN said the medications were supposed to be moved for final disposal but did not know how long they had been left out, and the DON confirmed the delay was related to staffing challenges.
Failure to Use Required PPE During EBP Staff did not consistently wear the required gown and gloves during high-contact care for multiple residents on EBP. Observations showed an NA and LPNs entering rooms without proper PPE while providing transfer assistance, incontinent care, PEG tube care, catheter-related care, and wound-related care. Residents involved had devices or conditions including Foley or suprapubic catheters, PEG tubes, chronic wounds, and pressure injuries, and staff interviews showed inconsistent understanding of when gowns were required.
Dignified Dining Assistance Not Provided: A NA stood while assisting 3 residents with meals at the same time, including residents who were dependent with ADLs and enrolled in hospice. The NA confirmed the practice, and an LPN and the ADON/IP stated staff assisting with feeding were expected to be seated for face-to-face contact; the facility policy also stated to sit next to the resident and feed one resident at a time, not standing while feeding.
Failure to Provide Timely Toileting Assistance: A resident with severe cognitive impairment, dementia, frequent incontinence, poor safety awareness, and a history of falls had a care plan directing staff to offer toileting upon awakening, after meals, and every 2 hours at night, and to assist immediately when she requested the bathroom. Instead, after she told dietary staff she needed to use the restroom, she was left waiting while staff were occupied with other tasks and was not assisted for more than an hour. Interviews showed staff knew she often tried to toilet herself when left alone, and the DON stated toileting should occur within 2 to 5 minutes of a request.
Survey results were not readily available or accessible to residents and visitors. A binder at one location contained only an older recertification survey, while the current 2024 and 2025 recertification and complaint survey results were missing from the display area. Residents stated they did not know the survey results were available for review, and staff gave conflicting accounts about where the binders were kept and whether the current results were on the hallway or had been removed for use.
Failure to Post Daily Nurse Staffing Hours: The facility did not consistently post the current daily nurse staffing list at the start of each shift. Surveyors observed that the prior day's staffing list remained posted instead of the current list, and the Administrator confirmed the staffing hours for the day were not posted. The facility also did not provide the requested policy on posted nursing hours.
A facility failed to investigate the root cause of repeated missing resident clothing. Five grievances were filed for missing clothing, and staff described a process of searching the unit and laundry room, using a no-name cart for unclaimed items, and reimbursing families if items could not be found. Interviews also showed the laundry label maker was old and not working properly, labels did not always stay on, and the facility had noticed a pattern of missing clothing but had not identified why items were disappearing.
A resident on hospice had DNR/DNI orders and a POLST in scanned hospice documents, but the EMR banner lacked code status and staff gave inconsistent responses about where to verify it. Some staff found the POLST only after searching the document tab, while others said no code status meant full code or CPR would be started. The DON stated code status was expected to be verified on the banner or POLST, but the resident’s banner was not updated.
Failure to timely notify the provider of repeated medication refusals by a resident with AFib, CHF, DM, and other significant diagnoses. The resident repeatedly refused scheduled meds and treatments from the same RN, including apixaban, insulin, and other vital medications, while staff believed the provider was aware. The MD and DON stated notification was expected after repeated refusals, but no provider-notification policy was provided.
Failure to Offer and Document Non-Pharmacological Pain Relief Two residents receiving PRN opioid pain meds had no documented evidence that non-pharmacological interventions were offered before medication administration. One resident with intact cognition and multiple chronic pain-related diagnoses stated ice packs helped but were not offered, and the care plan and MAR/TAR lacked evidence of non-pharmacological measures. A second resident with severely impaired cognition and multiple serious medical conditions also had a care plan listing comfort measures such as heat, cold, repositioning, rest, music, and relaxation, but the MAR/TAR and progress notes did not show these interventions were attempted before PRN hydromorphone.
The facility failed to ensure proper hand hygiene for a resident on contact precautions for C-diff and failed to ensure proper PPE use for two residents on enhanced barrier precautions. An RN handled items and exited the room without washing hands when required, and staff caring for residents with indwelling devices and wounds did not consistently wear gowns during high-contact care activities such as transfers, toileting, and catheter care. Staff interviews confirmed the expected handwashing and gown use were not followed.
Failure to Offer Updated Pneumococcal Vaccination: A resident was not offered or provided an updated pneumococcal vaccine in accordance with CDC guidance. The resident’s record showed prior PCV13 and PPSV23 immunizations, but no record of PCV20, and the consent form only addressed COVID-19 and influenza vaccines. The IP stated the resident was believed to be complete and confirmed there was no record of shared decision-making or an offer of PCV20, while the DON stated the facility was expected to follow CDC guidelines for vaccine offering.
A resident with dementia reported being physically abused by a staff member, but the LTC facility failed to report the allegation to the State Agency within the required 2-hour timeframe. The delay was due to communication failures between the RN and DON, resulting in the report being made several hours late, contrary to the facility's policy.
A resident with moderately impaired cognition reported physical abuse, resulting in bruises on the inner thigh. Despite multiple staff observations, the facility failed to conduct a comprehensive skin assessment or establish a monitoring plan, as the existing policy did not address non-pressure skin concerns.
A resident with respiratory issues did not receive oxygen therapy as ordered due to inaccurate transcription and administration of physician orders. The resident experienced low oxygen saturation levels, and staff sometimes forgot to reapply oxygen after removing the CPAP machine. Facility policies on oxygen administration and medication orders were not followed, leading to inconsistent care.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with extensive wounds, leading to a deficiency in infection prevention. Despite the presence of an EBP sign, an LPN was observed not wearing a gown during wound care, contrary to policy. Staff were trained on EBP and PPE use, but adherence was not maintained during the observed care.
The facility failed to ensure staff donned appropriate PPE for two residents on contact and enhanced barrier precautions, leading to potential infection risks. One resident with a history of Clostridium difficile and MRSA was not properly protected by staff, and another resident with a urinary catheter was transferred without PPE. Additionally, the facility did not maintain a clean laundry area and improperly stored ice packs with food, lacking a policy for laundry cleanliness.
The facility failed to ensure proper sanitization of dishware due to a dishwasher not reaching the required rinse temperature of 180 degrees F, with only three out of 36 entries meeting the standard. Additionally, mineral buildup was observed on water/ice machines in two care units, with unclear responsibility for cleaning. These deficiencies potentially impacted all 29 residents in the affected units.
A resident with interstitial pulmonary disease was left unsupervised to self-administer a nebulizer treatment, despite a discrepancy in their self-administer medications assessment indicating a need for assistance. Facility staff inconsistently applied the policy on self-administration, leading to the resident incorrectly handling the medication. Interviews revealed a lack of proper assessment and understanding of the policy requirements.
A facility failed to create a comprehensive care plan for a resident with bipolar disorder receiving psychotropic medications. The care plan lacked specific non-pharmacological interventions to support the resident's mood and reduce self-isolation and lethargy. Staff interviews revealed a lack of awareness and guidance on managing the resident's behaviors, and the interim DON confirmed the care plan was not adequately individualized.
The facility failed to monitor and document skin conditions for two residents. One resident with dementia had an undocumented bruise, while another with MASD had open wounds that were not properly assessed or measured. Nursing staff interviews revealed communication and documentation lapses, and facility policies did not adequately address these issues.
A facility failed to ensure proper catheter management for a resident with an indwelling catheter. The care plan lacked details on catheter type, change schedule, and removal plan, and there was no evidence of education on catheter risks. Staff interviews revealed a lack of awareness and documentation regarding the catheter's necessity and the resident's refusal to remove it. The facility's catheter care protocol was undated and lacked guidance on timely removal and resident education.
A facility failed to deliver supplemental oxygen according to physician orders and did not maintain oxygen tubing per standards for a resident with respiratory needs. The resident's care plan lacked documentation of oxygen requirements, and observations showed inconsistent oxygen administration and tubing on the floor. Staff interviews revealed uncertainty about tubing change protocols, and the facility's policy required weekly changes and proper storage, which were not documented or consistently practiced.
A facility failed to ensure proper collaboration with a dialysis facility for a resident requiring dialysis. The resident's medical records lacked critical contact information for the dialysis facility, leading to communication failures, such as not notifying the facility about new antibiotics or missed appointments. Interviews revealed staff were unaware of the dialysis facility details, and policies were outdated, compromising the resident's care.
A pharmacist failed to report an increase in a psychotropic medication for a resident with bipolar disorder, missing the change in monthly reviews. The resident's care plan required monitoring of behaviors, but no behaviors were documented to justify the increase. Interviews revealed a lack of communication among the healthcare team, with the nurse practitioner and clinical pharmacist unaware of the medication change, highlighting a breakdown in the medication review process.
A resident with bipolar disorder experienced an unjustified increase in Depakote dosage after a GDR, despite stable mood and no documented behaviors. The increase was due to inadequate communication among healthcare providers, including a lack of awareness by the psychiatrist of the recent GDR. Interviews revealed gaps in the medication review process and communication, with leadership changes possibly contributing to the oversight.
The facility failed to offer the PCV20 pneumococcal vaccine to two residents, despite CDC guidelines recommending it for adults aged 65 and older. Both residents had received previous pneumococcal vaccinations, but their records lacked evidence of being offered PCV20 or any shared clinical decision-making. Interviews with staff confirmed the oversight, and the facility's policy did not include information on PCV20, contributing to the deficiency.
Failure to Orient and Competency-Check Nursing Staff for Medication Administration
Penalty
Summary
Nursing staff were not appropriately oriented and trained for safe medication administration, resulting in widespread medication administration errors affecting 16 residents. On 7/15/26, RN-A worked the day shift on their first independent shift off orientation and was assigned to pass medications for 28 residents. RN-A stated they were unfamiliar with which residents received insulin or time-sensitive medications and, by 2:30 p.m., had not passed all day medications, completed treatments, or taken vital signs. LPN-B instructed RN-A to stop passing the day medications and document the omissions, but RN-A did not notify a medical provider or the DON about the missed insulins or medications. RN-A stated orientation did not cover provider notification protocols. LPN-B stated RN-A reported missing approximately 50 percent of the scheduled day medications, but LPN-B did not contact medical providers or nursing leadership regarding the missed medications and did not review the specific omissions for each resident. LPN-B notified an NP about only one resident who had high blood sugar after a missed medication dose, while multiple residents experienced elevated blood sugars during the evening shift. The DON later confirmed the facility's orientation program lacked nursing department oversight and structured competency evaluations, and the administrator confirmed RN-A's personnel file contained no nurse-specific orientation or competency tracking documentation. The NP stated the facility did not provide notification of the multiple missed medications and treatments until 7/17/26 and that missed treatments and medications create a potential for resident decline.
Failure to Verify Nurse Competency Before Independent Medication Administration
Penalty
Summary
The facility administration team failed to provide oversight and implementation of a competency-based nursing orientation program. The administrator’s job description stated responsibility for eliminating and controlling safety and health hazards by regularly reviewing work practices and providing employee training and instructions, and the DON’s job description stated responsibility for staff development, effective departmental orientation, and ensuring staff were adequately oriented and trained to perform duties. However, the DON confirmed that RN-A was a newly hired nurse just off orientation and had not been properly evaluated for clinical competency before being placed on the schedule, and the DON did not know who determined RN-A was ready to work independently. RN-A stated that the day shift was their first shift off orientation and their first time passing medications to 28 residents in the front section. RN-A stated that insulin management was covered, but other high-risk medications, provider notification protocols, and post-fall evaluation protocols were omitted from orientation. RN-A also stated the facility had originally promised eight days of orientation, but HR reduced it to three days, and that the scheduler was the only person who communicated about floor placement. The administrator later confirmed that personnel files for LPN-A, LPN-C, LPN-D, and RN-A contained no nurse-specific orientation or competency tracking documentation, and that the facility lacked an operational process for checking nurse competency before scheduling independent floor shifts.
Incomplete Nursing Orientation and Competency Verification
Penalty
Summary
The facility failed to develop and implement a comprehensive, competency-based nursing orientation program and failed to maintain required competency records in the personnel files of newly hired nurses. Review of the files for four nurses hired within the last seven months showed no orientation documents or completed competency evaluations specific to the LPN or RN roles. The facility’s Facility Assessment dated 10/23/25 required nursing staff competencies at hire and annually, including lifts, isolation, PPE donning and doffing, hand hygiene, wound and skin assessment, safe drug administration, medication pass, wound care, blood glucose monitoring, and medication errors. During interviews, staff described a shortened orientation process and a lack of nursing department oversight. An RN in orientation stated floor nurses signed off on checklists but questioned whether the compressed training timeframe was sufficient. An LPN who was precepting the RN stated orientation had recently been reduced from eight days to three days and was insufficient for learning the unit and medication pass responsibilities. The DON confirmed RN-A had been placed on the floor independently without proper competency evaluations and that this occurred during RN-A’s first solo shift on the 28-resident front medication cart, resulting in a widespread medication error incident. The DON, scheduler, and administrator also confirmed that completed competency forms were routed to HR rather than nursing leadership, and that the facility lacked a valid process to verify nurse competency before assigning independent floor shifts.
Resident Council Concerns About Call Light Delays and Care Response Were Not Acted Upon
Penalty
Summary
The facility failed to honor the resident council’s grievances and recommendations regarding delayed call light response times and delayed resident care. During a resident council meeting, 9 residents reported concerns about morning medication delays, perceived low staffing levels, long waits for call lights to be answered, and delays with transfers, toileting, showers, and other care needs. Residents stated that each hallway had only one nursing assistant, that two staff were now required for transfers, and that this change caused additional delays because staff were tied up with transfers while other residents waited for help. Residents described repeated experiences of waiting for assistance, including call lights being answered and then not followed up on, waits ranging from 5 minutes to more than an hour, and one resident reporting waiting 40 minutes on the toilet before being helped off. One resident reported bowel accidents after waiting 2 to 3 hours to be changed. Residents said they had raised these concerns for several months in resident council, but felt they had not received a real response from the facility and did not know what was being done. They also reported that a shower day had been changed and that the situation felt worse since two staff were required for transfers without adding more help. During interviews, the administrator confirmed that staffing concerns and call light response times had been repeatedly raised in resident council meetings and that concerns were recorded and sent to a department manager. The administrator stated the facility had discussed staffing numbers and call light audits, but no manual call light response audits had been completed and the facility had only recently learned the call light system could not generate wait-time reports. The DON stated they had not been notified of ongoing call light concerns through resident council and had not conducted spot audits or other projects related to resident wait times. Facility policies required prompt response to call lights, prompt efforts to resolve grievances, and that the facility listen to resident views and act upon concerns and recommendations affecting resident care and quality of life.
Failure to Notify Providers of Missed Medications and Resident Change in Condition
Penalty
Summary
The facility failed to ensure immediate provider notification for 16 of 25 sampled residents who experienced significant medication administration errors, treatment omissions, and missed clinical assessments. Licensed nursing staff on the day, evening, and night shifts did not contact the attending providers or complete required physical assessments after the missed medications and related issues occurred on the unit. During interviews, the DON stated the provider was not notified by the day, evening, or night shift nurses about the missed medications and that the first notification to the medical provider occurred when the DON personally contacted the NP the next morning. The DON stated the provider should have been notified immediately regarding missed or late insulin and other missed critical medications. RN-A confirmed working the day shift and stated they did not contact a provider regarding missed insulin or other late or missed medications, and also stated provider notification for errors had not been covered in orientation. LPN-B, who worked the afternoon shift, acknowledged awareness that approximately half of the day shift medications had been missed but did not contact providers about the missed medications, only notifying the NP about one resident with a high blood sugar when the NP happened to be on the floor. For R4, the resident was cognitively intact and had diagnoses including chronic diastolic heart failure. The physician orders included daily weights and notification of the provider for a weight gain greater than 2 pounds in 24 hours or 5 pounds in 1 week, along with torsemide 60 mg daily. The TAR showed a weight of 210.6 pounds, then 216.4 pounds the next day, with no weight recorded the following day and no progress note addressing the increase or the missed daily weight. The ADON could not locate a change in condition notification for R4's 6-pound weight gain in 24 hours, and the MD stated the expectation was to receive notification based on the resident's orders and facility policy. The facility policy on change in condition required provider and responsible party notification for changes in condition, including medication errors or adverse reactions, and required the nurse to complete and document assessment findings and provider notification.
Significant medication errors with missed and delayed critical medications
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors. Surveyors found that nursing staff administered multiple scheduled medications late, omitted medications entirely, and also missed ordered treatments and assessments for numerous residents. The report identified 16 of 25 reviewed residents as affected, including residents with diabetes, heart failure, chronic kidney disease, dementia, chronic pain, and other complex conditions. Several of the omitted or delayed medications were time-sensitive or critical, including insulin, anticoagulants, diuretics, blood pressure medications, narcotics, and Parkinson’s medications. For one cognitively intact resident with congestive heart disease and COPD, morning medications scheduled for 6:30 a.m. were not given until 11:30 a.m., and a 7:00 a.m. pantoprazole dose was given at 11:31 a.m. Another resident with Lewy body neurocognitive disorder, chronic pain, and diabetes had multiple morning medications omitted, including hydromorphone, lorazepam, a lidocaine patch, acetaminophen, and diclofenac gel. A resident receiving hospice services had a missed hydromorphone dose, a delayed later dose, and omitted Ensure and diclofenac gel, while another resident with CHF and venous insufficiency had multiple day-shift medications omitted, including vitamin B-12, furosemide, bowel medications, losartan, calcium/vitamin D, and acetaminophen. The report also documented missed insulin and blood glucose monitoring for residents with diabetes, including delayed Lantus and other medications, omitted blood sugar checks, and omitted sliding-scale insulin doses. Several residents had omitted daily weights, wound care, skin treatments, pain assessments, oxygen saturation checks, and other ordered monitoring. Progress notes frequently lacked documentation of nurse assessments or provider notifications for the missed or late medications and treatments. Interviews showed that RN-A, LPN-B, and other staff were aware of widespread omissions, that some medications were not given because of time, and that provider notification did not occur until later. The DON and NP stated the missed medications and treatments were not reported to the provider in a timely manner, and the facility policy required medications to be administered within one hour of the prescribed time.
Expired and Discontinued Medications Left Unsecured in Medication Rooms
Penalty
Summary
The facility failed to ensure that discontinued and expired medications were locked and stored separately from active medications and were disposed of in a timely manner in the 200/300-unit, 500-unit, and 600-unit medication storage rooms. During observation of these three medication rooms, expired and discontinued medications were found on the counters, unsecured and awaiting disposal. The medications were from residents who had been discharged between 05/04/26 and 07/03/26 and included Eliquis, Hydrochlorothiazide, Prochlorperazine, Nitroglycerin, Naloxone, Enoxaparin syringes, nasal saline solution, Mupirocin cream, artificial tears, zinc oxide, and Fluticasone inhalers. Additional unsecured items observed included bottles of Acetic Acid, Nystatin powder, Fluorouracil cream, Lidocaine, Gabapentin, Haloperidol, Acetaminophen, Docusate/senna, Phenytoin sodium capsules, Hyoscyamine, Glycerin suppositories, Proctozone-HC suppositories, Acetaminophen suppositories, Pediapap liquid, Trazodone, Vitamin D3, Eplerenone, Fluoxetine, Propranolol, Torsemide, Baclofen, Pantoprazole, Lantus SoloStar prefilled pens, Potassium Chloride, Clopidogrel, Mirtazapine, Mucus relief, Metoprolol, Olanzapine, Cetirizine, and several bottles of stock OTC medications. An LPN stated the medications on the 200/300-unit counter were supposed to be transferred to the 600-unit medication room for final disposal and was unsure how long they had been left out. The DON confirmed the medications in all three rooms were expired or discontinued and required disposal, and stated the delay was due to recent staffing challenges. Facility policy stated expired and discontinued medications were to be placed in a designated, secure location for destruction.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper PPE was used for residents on Enhanced Barrier Precautions (EBP) during high-contact care activities. The report identified 5 residents with EBP orders or care plans related to indwelling catheters, PEG tubes, chronic wounds, or other infection-related risks, and survey observations showed staff entering rooms and providing care without the required gown and, in some instances, without gloves. The facility’s EBP policy stated that gown and glove use was required during high-contact resident care activities such as transferring, dressing, hygiene, changing linens, device care, and wound care. R7 had severe cognitive impairment, was dependent for transfers and toileting, had an indwelling urinary catheter, frequent bowel incontinence, and a stage 3 sacral pressure injury. During observation, the EBP sign on the door indicated staff must wear gloves and gowns for high-contact care, but one NA entered without gloves or a gown and another wore gloves but no gown while assisting with transfer-related care, handling the urinary drainage bag, positioning the mechanical lift sling, and moving the resident. The resident’s clothing and bedding came into contact with staff clothing during the transfer, and the drainage bag was moved during the process. R17 had diagnoses including resistance to multiple antimicrobial drugs, a PEG tube, and a suprapubic catheter, and was on EBP. During observation, an LPN entered the room with gloves and a mask but no gown and administered medications via PEG tube. R35 had a left buttock wound and was on EBP; during observation, an NA provided incontinent care with gloves but no gown and then reentered the room without gloves or a gown to assist with a mechanical lift transfer. R59 had a chronic vascular wound and was on EBP; during observation, an LPN entered without gloves or a gown, assisted with socks, transferred the resident from bed to wheelchair and then to the toilet, and provided care after medication administration. R1 had an indwelling Foley catheter, PEG tube, and EBP; during observation, an LPN entered without gloves or a gown, adjusted the PEG tube and catheter secure tape, and later reentered without gloves or a gown while the resident was being transferred with a mechanical lift and the Foley bag was being managed. Staff interviews showed inconsistent understanding of EBP, with some stating gowns were only needed for bodily fluids or wound care, while others stated gowns and gloves were required for high-contact care.
Dignified Dining Assistance Not Provided
Penalty
Summary
The facility failed to ensure a dignified dining experience for 3 residents who required assistance with meals. R29 and R43 were documented in the EMR as dependent with activities of daily living and enrolled in hospice programs. During an observation, 4 residents were seated at a dining table, and 3 residents were in Broda chairs while NA-C stood and assisted all 3 residents with eating at the same time. NA-C confirmed that the residents needed meal assistance and stated that the residents were fed one at a time while she remained standing. During interviews, LPN-C confirmed that R29, R37, and R43 needed assistance with meals and stated that staff assisting with feeding were expected to be seated. The ADON/IP also verified that staff assisting a resident to eat should be seated for face-to-face contact and stated that it was not dignified to stand over a resident while helping with a meal. The facility policy titled Dinning and Food Service, revised 2/15/25, stated to sit down next to the resident and feed one resident at a time, and not to stand while feeding a resident.
Failure to Provide Timely Toileting Assistance
Penalty
Summary
The facility failed to ensure care was provided in accordance with a resident’s care plan for 1 of 1 residents reviewed for ADLs. R22 had severe cognitive impairment, dementia, a history of non-traumatic brain dysfunction, frequent bowel and bladder incontinence, poor safety awareness, reduced mobility, a history of falls, and a history of femur fracture. R22’s care plan, NA kardex, and MAR directed staff to offer toileting upon awakening, after each meal, and every 2 hours after going to bed, and to assist immediately when R22 asked to use the bathroom because she often transferred without staff assistance and had a history of falls related to toileting needs. During observation, R22 told dietary staff she needed to go to the restroom, but instead of being assisted right away, staff used a walkie talkie to request help while R22 began leaving the dining room independently. R22 was then observed wheeling through the dining room and later remained there while staff were occupied with call lights, medication pass, and other residents. R22 was not taken to the restroom until 1 hour and 7 minutes after first stating she needed to use it. When the surveyor informed NA-D and NA-E that R22 needed the restroom, staff took her to her room and attempted multiple times to encourage her to toilet, but R22 became frustrated and headed for the bedroom door, and staff allowed her to leave to avoid further agitation. Interviews supported that R22 often resisted assistance and attempted to toilet herself when staff walked away. Family stated most of R22’s falls were related to needing to use the bathroom. NA-F stated R22 could be feisty and would sometimes say she did not need the bathroom and then try to toilet herself after staff left. NA-E stated staff try to assist residents within 5 minutes but residents had waited longer that day because of staffing issues, and the DON stated she would expect toileting within 2 to 5 minutes of a resident’s request and that a 1-hour wait was absolutely too long. The facility policy on ADLs stated residents would be assisted with using the bathroom and maintaining cleanliness based on the care plan.
Survey Results Not Readily Available to Residents
Penalty
Summary
The facility failed to ensure the past 3 years of survey results were readily available and accessible to residents and visitors. During observation, a survey results binder was found in a wall-mounted holder between the oxygen storage room and storage room A, but it contained only the recertification survey results dated 10/17/23 and no recertification or complaint survey results for 2024 or 2025. The administrator reviewed the binder and stated the 2024 and 2025 survey results should have been inside, but staff might have removed them for use. During a Resident Council meeting, residents stated they did not know past survey results were available for review and no one recalled staff informing them where the results were located. Later, the administrator retrieved three survey binders from the opposite side of the building, and the Scheduler stated the facility kept survey results at both building entrances, showed an empty holder outside their office, and stated they had given the 2023 and 2024 binders to the Administrator earlier that day while never having the 2025 results on their hallway.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that daily nurse staffing hours were consistently posted at the start of each shift. On 7/13/26, the facility posted the daily staffing list, and on 7/14/26 at 10:00 a.m., the daily staffing list was posted. However, on 7/15/26 at 7:23 a.m., the staffing list from the previous day, 7/14/26, was still posted, and the current staffing list for 7/15/26 had not been posted. During an interview on 7/15/26 at 12:43 p.m., the Administrator confirmed that the staffing hours for 7/15/26 were not posted and that the displayed list was from 7/14/26. The Administrator stated that staff were expected to post the current staffing hours every morning. The surveyor requested the facility policy regarding posted nursing hours, but the facility did not provide it.
Repeated Missing Resident Clothing Without Root Cause Investigation
Penalty
Summary
The facility failed to prevent the loss of residents’ personal clothing by not investigating the root cause of repeated missing items. Facility grievance records dated 3/25-8/25 showed five grievances related to missing clothing, and the resolution for each was to reimburse the resident or family after the item was replaced. During interviews, the administrator stated social services completed an inventory of belongings and uploaded a checklist to the resident chart, and laundry staff labeled clothing items. A laundry aide stated any staff could report a missing item, staff would search the unit and laundry room, and unclaimed clothing was kept on a no-name cart. She also stated clothing was placed in green bags for laundry, but the label maker was old and the pressing plate was missing, so labels did not always stay on; when labels fell off, staff used a marker to label clothing. Additional interviews showed the same process was used for all washable items, with missing-item forms sent to social services and families able to request reimbursement if the item could not be found. The maintenance director stated he was not aware the laundry label maker was broken. The administrator later stated the facility had noticed a pattern of missing clothing but had not identified the reason, and identified possible contributing issues including rehab residents’ clothing sometimes being sent unlabeled when families changed their minds about doing laundry themselves, and isolation carts having separate receptacles for laundry and garbage that could lead to clothing being placed in the wrong receptacle. The facility grievance policy stated the grievance official would use a root cause analysis process for resolution, but the report showed no root cause investigation was completed for the repeated missing clothing grievances.
Code Status Not Timely Updated in EMR for Resident on Hospice
Penalty
Summary
The facility failed to ensure a proper procedure was in place to identify and update a resident’s resuscitation wishes in the EMR in a timely manner based on a signed POLST for one resident reviewed for advance directives. The resident was admitted to the facility and the EMR banner indicated hospice status, but the banner lacked a code status. Hospice admission documents in the record included orders for DNR/DNI signed on the resident’s behalf, and a POLST dated the same month was found within the scanned hospice documents. During observation and interview, RN-A stated the quickest place to identify code status was the EMR banner or the paper chart binder, but the paper charts could not be located. RN-A later searched the document tab and found the POLST, then verified the resident’s code status from that document. RN-A stated the hospital included code status during verbal report on admission and that the admission paperwork was given to the admissions team or nurse manager to verify and enter code status into the EMR so the banner would reflect it. RN-A also stated that if there was no code status on the banner and no POLST, the resident would be considered full code and CPR would be started. Multiple staff members gave differing responses about where code status should be found and how hospice status affected resuscitation decisions. Some staff stated code status should be verified on the banner or by locating the POLST in scanned documents, while others stated that if no code status was listed the resident would be full code by default or CPR would be started when in doubt. Several staff assumed hospice meant DNR/DNI, while others stated there should be no such assumption because some hospice residents are full code. The DON stated staff were expected to verify code status on the banner or POLST, that code status was updated by whoever viewed the POLST upon admission, and that if no code status was on the banner the resident was expected to be treated as full code. A policy for advance directive was requested and not received.
Failure to Timely Notify Provider of Repeated Medication Refusals
Penalty
Summary
The facility failed to notify the physician in a timely manner when one resident frequently refused important medications from a specific nurse. The resident had intact cognition and diagnoses including atrial fibrillation, heart failure, hypertension, diabetes mellitus, depression, left knee amputation, and a stage 3 pressure ulcer. The care plan included interventions to maintain blood glucose levels, reduce risk related to atrial fibrillation, stroke, and pulmonary embolism, maintain mood, and report changes to the provider. The resident’s orders included multiple scheduled medications and treatments, including apixaban, insulin, cefadroxil, gabapentin, torsemide, and other medications for pain, cholesterol, constipation, and insomnia. The medication administration record showed repeated refusals of all evening medications and treatments by the same nurse on multiple dates in July and August 2025. The resident stated there had been an incident with the nurse on Christmas, that a grievance was completed, and that all cares and medications were refused when that nurse was assigned to the unit, even when another nurse from another unit came to provide care. The RN stated the resident refused medications and treatments from that nurse and thought the provider was aware. The medical director stated the expectation was to be notified if a resident was not taking medication, especially after three days in a row, and the DON stated staff were expected to notify the provider after three doses of the same medication were refused. A policy for provider notification was requested but not provided.
Failure to Document and Offer Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to assess and develop non-pharmacological interventions to promote comfort for 2 residents who were receiving PRN pain medication. For one resident, the admission MDS indicated intact cognition, frequent pain that occasionally affected sleep, rehabilitation therapy, and day-to-day activities, and a pain rating of 2 out of 10. The resident had diagnoses including lumbar vertebral fractures, low back pain, spinal stenosis of the cervical region, fibromyalgia, polyneuropathy, and disease of the spinal cord. The resident stated that ice packs helped with pain but were not offered, and the care plan did not show evidence of offering or identifying non-pharmacological interventions before PRN medication use. The resident’s MAR/TAR showed PRN oxycodone orders for pain, administered 43 times for the lower dose and 14 times for the higher dose during the month reviewed. Pain scores were documented and medication effectiveness was recorded, but the MAR/TAR lacked evidence that non-pharmacological interventions were offered before administration. Progress notes from the same period also lacked evidence of non-pharmacological interventions being offered for pain. Interviews with nursing staff and management confirmed that non-pharmacological interventions should be attempted and documented, and that this was not documented for the resident. For the second resident, the significant change MDS indicated severely impaired cognition, frequent pain that occasionally affected sleep and day-to-day activities, and a pain rating of 2 out of 10. Diagnoses included end stage renal disease, malnutrition, acute kidney failure, alcoholic cirrhosis with ascites, heart attack, and chronic liver failure. The resident stated that staff did not offer ice packs or heating pads and that no non-pharmacological interventions were offered for pain management. Although the care plan listed non-pharmacological interventions such as heat, cold, repositioning, rest, music, family/friend time, and relaxation, the MAR/TAR and progress notes lacked evidence that these interventions were offered before PRN hydromorphone was administered.
Failure to Follow Hand Hygiene and PPE Requirements for Isolation Precautions
Penalty
Summary
The facility failed to ensure proper hand hygiene for a resident on contact precautions for C-diff. The resident was cognitively intact, independent with most activities of daily living, and had diagnoses including cancer, chronic kidney disease, diabetes, and malignant lung cancer. The care plan identified C-diff infection and directed contact-based precautions, including hand washing with antibacterial soap and disposable towels after care tasks and activities. During observation, an RN entered the resident’s room with proper PPE, assisted the resident, removed PPE, and used hand sanitizer after handling the resident’s meal tray. The RN then handled an empty water pitcher without washing his hands first, placed the pitcher on the counter, washed his hands afterward, and then filled the pitcher. The RN later took a red bag outside to the main garbage after using hand sanitizer, and then washed his hands upon returning. During interview, the RN confirmed hand sanitizer is not effective against C-diff and stated staff should wash hands upon exiting the room; he also confirmed he should have washed his hands before touching the water pitcher and when exiting with the garbage. The facility also failed to ensure proper PPE use for residents on enhanced barrier precautions. One resident had an indwelling Foley catheter with an order for enhanced barrier precautions related to the device, and staff observed during catheter care did not initially wear a gown when entering the room. The nurse later returned wearing a gown and gloves for the catheter change, but after removing PPE and washing hands, she re-entered without a gown or gloves and assisted the resident with standing, pulling up pants, transferring to a wheelchair, and putting on a sweater. Another resident had diabetes, peripheral vascular disease, and a wound, and was on enhanced barrier precautions with orders for wound care. During observation, a nursing assistant wore gloves but no gown while positioning a mechanical lift, fastening a transfer belt, touching the resident’s upper body, transferring the resident to the bathroom, and handling trash and supplies. The nursing assistant confirmed she did not put on a gown and stated gown and gloves should be worn with all transfers for residents on enhanced barrier precautions. The infection preventionist and DON stated staff were expected to follow the precaution signs posted outside the rooms.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that one sampled resident, R23, was offered and/or provided an updated pneumococcal vaccination in accordance with CDC guidance. R23’s quarterly MDS assessment indicated the resident was [AGE] years old, was not up to date on pneumococcal vaccination, and that the pneumococcal vaccine was not offered. R23’s immunization record showed receipt of PCV13 in 11/2015 and PPSV23 on 8/8/2001, but there was no record of PCV20 being given. R23’s vaccine consent form dated 10/27/23 showed consent for COVID-19 and influenza vaccines, but it did not include an offer for the pneumococcal vaccine. During interview, the IP stated the facility offers PCV20 through immunization clinics in the summer and fall and that new admissions are offered vaccines individually, but the last clinic was in 10/24 and R23 did not participate because of COVID-19. The IP stated he believed R23’s pneumococcal vaccination status was complete because R23 had received PCV13 and PPSV23, and confirmed there was no record of shared decision-making or offering PCV20 to R23. The DON stated the facility was expected to follow CDC guidelines and offer vaccinations upon admission and during the appropriate season. The facility policy stated residents would be offered immunizations against pneumococcal disease in accordance with ACIP recommendations, including shared clinical decision-making for adults 65 years or older to receive PCV20 if they had received PCV13 and PPSV23 at or after the specified age.
Failure to Timely Report Resident Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of staff-to-resident physical abuse to the State Agency (SA) within the required 2-hour timeframe. A resident with moderately impaired cognition and a diagnosis of dementia reported to a registered nurse (RN-D) that she had been physically abused by a staff member approximately two weeks prior. The resident described being kicked in the leg, pinched in the groin area, and slapped on the cheek, which resulted in her glasses being knocked off. Despite the resident's report at 4:10 p.m., the incident was not reported to the SA until 9:27 p.m., exceeding the 2-hour reporting requirement. The delay in reporting was due to a series of communication failures. RN-D attempted to contact the Director of Nursing (DON) shortly after the resident's report but was unable to reach her immediately and left a voicemail. The DON did not receive the message until later and instructed RN-D to gather more information before reporting to the SA. The DON and other staff members, including the Director of Social Services and the Administrator, acknowledged the reporting delay and the facility's policy requiring immediate reporting of abuse allegations within 2 hours. The facility's policy on abuse, neglect, and misappropriation of resident property mandates that all allegations be reported per federal and state law, which was not adhered to in this instance.
Failure to Monitor and Document Non-Pressure Skin Injuries
Penalty
Summary
The facility failed to assess and monitor non-pressure related skin injuries, specifically bruises, for a resident who was reviewed for abuse. The resident, who had moderately impaired cognition, reported allegations of physical abuse, including being pinched and kicked, resulting in bruises on the inner thigh. Despite these allegations and visible bruises, the facility did not conduct a comprehensive skin assessment or establish a monitoring plan for the bruises, as evidenced by the lack of documentation in the resident's medical record. Interviews with staff revealed that the bruises were observed by multiple staff members, including a registered nurse and the director of nursing, but were not properly documented or monitored. The facility's existing skin ulcer policy did not address the process for monitoring non-pressure skin integrity concerns, contributing to the deficiency. The director of nursing acknowledged the absence of a comprehensive skin assessment and monitoring in the resident's medical record, which should have been in place according to facility policy.
Failure to Accurately Transcribe and Administer Oxygen Orders
Penalty
Summary
The facility failed to ensure accurate transcription and administration of a physician's order for oxygen therapy for a resident with respiratory issues. The resident, who had intact cognition and diagnoses of respiratory failure and obstructive sleep apnea, was supposed to receive oxygen therapy. However, the facility did not clearly document whether the oxygen therapy was to be administered continuously or as needed. This lack of clarity led to inconsistent oxygen administration and monitoring. On several occasions, the resident's oxygen saturation levels were not adequately monitored or recorded, and the oxygen was not administered as ordered. For instance, after a bathing session, the resident's oxygen level dropped to 82% on room air, prompting the initiation of standing house orders for hypoxia. Despite this, there were instances where the resident was left without oxygen, leading to low oxygen saturation levels, such as 84% when checked by a nursing assistant. The resident reported that staff sometimes forgot to put the oxygen back on after removing the CPAP machine in the morning. The facility's staff, including a registered nurse and the director of nursing, acknowledged that the oxygen orders were not transcribed correctly and that there was a failure to clarify the orders with the provider. The director of nursing stated that the resident's oxygen order should have been to ensure the resident was receiving 1-2 liters to keep saturations above 90%. The facility's policies on oxygen administration and medication orders were not followed, contributing to the deficiency in care.
Failure to Implement Enhanced Barrier Precautions for Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with extensive wounds, leading to a deficiency in infection prevention and control. The resident, identified as R6, had multiple diagnoses including bullous pemphigoid, chronic venous hypertension with ulcers, and subacute osteomyelitis, requiring complex wound care. Despite the presence of an EBP sign outside the resident's room, a Licensed Practical Nurse (LPN) was observed not wearing a gown while performing wound care, contrary to the facility's infection prevention policy. The resident's care plan and physician orders detailed specific wound care treatments, including the use of various dressings and ointments. The facility's policy required staff to wear gowns and gloves during high-contact activities, such as wound care, to prevent the spread of infections. However, during an observation, the LPN was only wearing gloves and not a gown, as required by the EBP sign and facility policy, citing discomfort due to heat as the reason for not wearing the gown. Interviews with staff, including a Nursing Assistant (NA) and a Registered Nurse (RN), revealed that staff were trained on EBP and the use of personal protective equipment (PPE) through online education and in-services. The Director of Nursing (DON) confirmed that staff were expected to follow the EBP policy, which included wearing gowns, gloves, masks, and eye protection when necessary. Despite this training, the failure to adhere to EBP during wound care for the resident was identified as a deficiency.
Inadequate PPE Use and Infection Control Lapses
Penalty
Summary
The facility failed to ensure staff donned appropriate personal protective equipment (PPE) for enhanced barrier precautions (EBP) and contact precautions for two residents. One resident, identified as R207, had a history of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) and was on contact precautions. However, a nursing assistant entered the resident's room without donning gloves or a gown, despite signage indicating the need for such precautions. The care plan for R207 lacked evidence of any precautions, and there was confusion among staff about the necessity of PPE, with some staff members incorrectly stating that PPE was only required for certain procedures. Another resident, R48, was on enhanced barrier precautions due to having a urinary catheter. Despite this, a nursing assistant transferred the resident to bed without wearing a gown, contrary to the signage outside the resident's door. The staff member acknowledged the oversight and mentioned a misunderstanding of the regulations. The facility's infection preventionist confirmed the need for PPE during such interactions to prevent infections. Additionally, the facility failed to maintain a clean laundry area, with observations of dust and lint blowing onto clean linens. The facility also improperly stored resident ice packs alongside food items in unit refrigerators, posing a risk of contamination. The facility lacked a policy for laundry cleanliness, and the director of nursing acknowledged the need for in-house education to prevent the spread of infection.
Dishwasher and Ice Machine Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that the high-temperature sanitizing dishwasher reached the required rinse temperature of 180 degrees Fahrenheit to properly sanitize dishware used for resident service. Observations revealed that the dishwasher in the 500/600 wing kitchenette consistently recorded rinse temperatures below the required threshold, ranging between 161 degrees F and 177 degrees F, with only three out of 36 documented entries meeting the necessary temperature. The dietary aide was unaware of the correct temperature requirements and relied on an electronic temperature gauge that was set to alarm only if temperatures fell below 160 degrees F. Additionally, the dishwasher exhibited significant white crusty mineral-like buildup, indicating a lack of regular cleaning and maintenance. The facility also failed to maintain cleanliness of the resident water/ice machines in two care units, with observations noting white and brownish mineral buildup on the machines. Interviews with staff revealed a lack of clarity regarding responsibility for cleaning these machines, with maintenance staff unaware of the last cleaning date and stating that cleaning was done quarterly. The facility's policies directed more frequent cleaning and maintenance, which was not adhered to, potentially impacting all 29 residents in the affected care units.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to appropriately assess and determine the clinical appropriateness of self-administration of medication for a resident, identified as R25, who was left alone to administer a nebulizer treatment without staff supervision. R25's quarterly Minimum Data Set (MDS) assessment indicated intact cognition and a diagnosis of interstitial pulmonary disease, requiring assistance for activities of daily living and mobility. Despite a care plan allowing R25 to self-administer inhalers, there was a discrepancy in the self-administer medications (SAM) assessment, which indicated a need for assistance with inhalant medications. During an observation, R25 was seen administering a nebulizer treatment alone, incorrectly handling the medication, and expressing a lack of understanding about the medication being used. Interviews with facility staff, including a trained medication assistant (TMA), a licensed practical nurse (LPN), a registered nurse (RN), and the director of nursing (DON), revealed inconsistencies in the understanding and implementation of the facility's policy on self-administration of medication. The TMA and LPN admitted to setting up nebulizer treatments and leaving the resident unsupervised, while the RN and DON emphasized the need for a SAM assessment and a physician's order for self-administration. The facility's policy required an interdisciplinary team assessment to ensure safe self-administration, which was not adequately followed, leading to the deficiency.
Failure to Develop Individualized Care Plan for Resident on Psychotropic Medications
Penalty
Summary
The facility failed to develop a comprehensive and individualized care plan for a resident receiving psychotropic medications. The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was noted to receive psychotropic medications routinely. However, the care plan lacked specific non-pharmacological interventions to support the resident's mood and minimize self-isolation, lethargy, and refusals of care. The care plan included outdated interventions and did not address the resident's current needs effectively. Interviews with staff revealed a lack of awareness and guidance regarding the resident's behaviors and mood management. Nursing assistants and LPNs were not informed of effective interventions for the resident's mood changes or delusions. The interim DON confirmed that the care plan was not adequately individualized and did not meet the facility's expectations for monitoring and addressing the resident's behaviors and mood changes. The deficiency was identified during a review of the resident's care plan and staff interviews.
Deficiencies in Monitoring and Documenting Skin Conditions
Penalty
Summary
The facility failed to properly identify and monitor bruising for a resident with dementia and severe cognitive impairment. The resident, who required assistance with activities of daily living and mobility, was observed with a golf ball-sized bruise on her left forearm on two separate occasions. Despite physician's orders for weekly skin inspections and a care plan requiring daily observations for skin changes, the bruise was not documented or reported by the nursing staff. Interviews with nursing assistants and licensed practical nurses revealed a lack of communication and documentation regarding the bruise, which was not noted in the resident's medical record. Additionally, the facility did not routinely assess or document the healing progress of open wounds related to moisture-associated skin damage (MASD) for another resident. This resident, who was cognitively intact and had a history of diabetes and chronic skin breakdown, had open areas on the buttocks that were not measured or properly documented. Despite the presence of bleeding and drainage, the nursing staff failed to include necessary wound assessments and measurements in the medical record or in communication with the provider. Interviews with nursing staff and the interim director of nursing highlighted inconsistencies in wound care documentation and assessment practices. The facility's policies on skin alterations and pressure ulcers did not adequately address the monitoring and documentation of bruises or non-pressure wounds. The lack of proper documentation and monitoring of skin conditions for both residents indicates a deficiency in the facility's adherence to care protocols, potentially compromising resident safety and care quality.
Deficiency in Catheter Management and Resident Education
Penalty
Summary
The facility failed to ensure proper catheter management for a resident, identified as R207, who was reviewed for catheter care. R207's admission Minimum Data Set (MDS) assessment indicated that the resident had an indwelling catheter and was dependent on staff for toileting hygiene and transfers. However, the facility did not attempt a trial of a toileting program. The care area assessment (CAA) noted that R207 had a diagnosis of urinary retention requiring a Foley catheter and had been treated for a urinary tract infection upon admission. Despite these conditions, the facility's documentation lacked critical information regarding the catheter's management, such as when it was last changed, when it should be removed, and the type of catheter used. The care plan for R207 was insufficient, as it only included monitoring for signs and symptoms of a urinary tract infection without detailing the type of catheter, its change schedule, or removal plan. There was also no evidence of education provided to R207 about the risks and benefits of catheter use or interventions to restore urinary function without a catheter. Interviews with staff revealed a lack of awareness and documentation regarding the catheter's necessity and the resident's refusal to have it removed. The physical therapist assistant working with R207 noted the absence of bladder retraining efforts, and the LPN acknowledged the lack of education and documentation about the catheter. The facility's catheter care protocol was undated and lacked guidance on the timely removal of catheters, care plan interventions for resident education, and documentation of the implications of continued catheter use. Interviews with the director of nursing highlighted the expectation for staff to provide education to residents about the risks of catheter use, but this was not reflected in R207's care plan or medical record. The deficiency in catheter management and resident education contributed to the facility's failure to prevent potential complications such as infections.
Failure to Maintain Proper Oxygen Administration and Tubing Maintenance
Penalty
Summary
The facility failed to ensure that supplemental oxygen was delivered according to physician orders and did not maintain oxygen tubing per professional standards for a resident with respiratory care needs. The resident, who had a medical history including acute systolic congestive heart failure, unspecified dementia, and chronic obstructive pulmonary disease, was observed with inconsistent oxygen administration. The physician's orders specified supplemental oxygen at 2 to 3 liters via nasal cannula to maintain oxygen saturations of 90% or higher, but the orders lacked information on when to change the oxygen tubing. The resident's care plan also did not reflect the need for oxygen, and the medication and treatment administration records lacked documentation on tubing changes. Observations revealed that the resident's oxygen tubing, including the nasal cannula, was frequently found on the floor, and the oxygen was not consistently administered as ordered. Interviews with staff indicated a lack of clarity on when to change the tubing, and the facility's policy required weekly changes and proper storage of the tubing. The director of nursing confirmed that the nasal cannula should not be on the floor and emphasized the importance of following oxygen orders for infection control. Despite the facility's policy, there was no documentation or consistent practice to ensure the oxygen tubing was changed weekly or stored correctly.
Failure in Dialysis Coordination and Communication
Penalty
Summary
The facility failed to ensure proper collaboration with the dialysis facility for a resident who required dialysis services. The resident, identified as R14, had multiple medical conditions including acute kidney failure, chronic kidney disease, and peripheral vascular disease, necessitating regular dialysis. Despite having physician orders for pre- and post-dialysis assessments and monitoring of the hemodialysis catheter, the facility's documentation lacked critical information such as the contact details of the dialysis facility and instructions on when to contact them. The resident's medical records, including the medication administration record (MAR), treatment administration record (TAR), and electronic medical record (EMR), were incomplete, missing essential details about the dialysis facility. This lack of information led to communication failures, such as the dialysis facility not being notified when the resident started a new antibiotic or when the resident refused dialysis due to feeling unwell. The facility's care plans also did not include necessary contact information for the dialysis facility, which was crucial for coordinating care and ensuring the resident's medical stability. Interviews with nursing staff revealed a lack of awareness about which dialysis facility the resident attended, further highlighting the communication breakdown. The facility's policies on dialysis care were outdated and did not address the need for notifying the dialysis facility about medication changes or appointment cancellations. This deficiency in communication and documentation compromised the resident's care and the facility's ability to manage the resident's dialysis needs effectively.
Pharmacist Fails to Report Psychotropic Medication Increase
Penalty
Summary
The pharmacist failed to identify and report an increase in a psychotropic medication for a resident without implementing non-pharmacological interventions or confirming the clinical significance of the increased dose after a gradual dose reduction (GDR). The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was receiving psychotropic medications routinely. Despite the care plan's directive to monitor behaviors and mood, the medical record lacked evidence of behaviors that would justify the medication increase. The pharmacist's medication regimen reviews from October 2023 to June 2024 did not identify any irregularities, missing the increase in Depakote dosage ordered by a psychiatrist in November 2023. Interviews revealed a lack of communication and awareness among the healthcare team regarding the medication changes. The nurse practitioner was unaware of the previous GDR and the subsequent increase in Depakote, which was not communicated by the clinical pharmacist or nursing staff. The clinical pharmacist admitted to missing the increased dose in subsequent reviews and acknowledged that it should have been brought to the team's attention. The interim Director of Nursing noted leadership changes and expected the team to be aware of medication changes, highlighting a breakdown in communication and oversight in the medication review process.
Inadequate Communication Leads to Unjustified Psychotropic Medication Increase
Penalty
Summary
The facility failed to ensure that an increased dose of a psychotropic medication was clinically indicated for a resident after a gradual dose reduction (GDR). The resident, who had mild cognitive impairment and a diagnosis of bipolar disorder, was receiving psychotropic medications on a routine basis. Despite the absence of behaviors such as delusions, refusal of care, or increased self-isolation, the resident's Depakote dosage was increased from 250mg to 375mg daily without clear clinical justification. This increase occurred after a previous GDR had reduced the dosage, and there was no documentation explaining the rationale for the increase. The report highlights a lack of communication and coordination among the healthcare providers involved in the resident's care. The nurse practitioner who initially reduced the Depakote dosage was not aware of the subsequent increase, and there was no progress note or communication from the psychiatrist regarding the change. The clinical pharmacist, who tracks GDRs, was also unaware of the dosage increase and noted that the psychiatrist's progress note did not acknowledge the recent GDR. This lack of communication led to the resident receiving a higher dosage of Depakote than was previously deemed necessary. Interviews with facility staff, including a licensed practical nurse, a nurse practitioner, and the interim Director of Nursing, revealed gaps in the medication review process and communication among the care team. The interim DON acknowledged that leadership changes might have contributed to the oversight. The facility's expectation was for nursing, pharmacy, and providers to be aware of any changes in psychotropic medication dosages to ensure appropriate administration, which was not met in this case.
Failure to Offer Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to ensure that two residents, identified as R48 and R36, were offered or received the pneumococcal vaccination in accordance with CDC recommendations. The CDC guidelines specify that adults aged 65 years and older should receive either the PCV20 vaccine or a combination of PCV15 followed by PPSV23. However, the facility's documentation and interviews revealed that these residents were not offered the PCV20 vaccine, nor was there evidence of shared clinical decision-making regarding this vaccination. Resident R48, who was admitted to the facility with intact cognition and a history of malignant neoplasm of the colon, anemia, and hemiplegia following a stroke, had received PPSV23 in 2012 and PCV13 in 2017. Despite this, the resident's medical records and consent forms lacked any mention of PCV20, and there was no documentation of shared clinical decision-making. Similarly, Resident R36, with diagnoses including chronic kidney disease and type 2 diabetes, had received PPSV23 in 2011 and 2016, and PCV13 in 2015. Like R48, R36's records did not indicate that PCV20 was offered or that any clinical decision-making discussions took place. Interviews with the facility's infection preventionist and director of nursing confirmed the oversight. The infection preventionist acknowledged that the consent forms did not include information about PCV20 and that discussions regarding clinical decision-making had not occurred for these residents. The director of nursing noted the need for a short-term program for pneumococcal vaccines due to the risk of pneumonia. The facility's policy, dated February 2020, followed CDC guidelines for PCV13 and PPSV23 but did not address PCV20 or shared clinical decision-making, contributing to the deficiency.
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Illustrative
What surveyors actually found near you
We read the 173 citations issued within 25 miles in the last 12 months — including the 3 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pine Island
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Zumbrota Care Center | 6.1 mi | ★★★★★ | 7 | 0 |
| Rochester Rehabilitation And Living Center | 11.7 mi | ★★★★★ | 16 | 0 |
| Madonna Towers Of Rochester | 12.5 mi | ★★★★★ | 5 | 0 |
| Edenbrook Rochester West | 13.5 mi | ★★★★★ | 25 | 0 |
| Edenbrook Of Rochester | 13.7 mi | ★★★★★ | 19 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.