Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Highland Chateau Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with stroke-related expressive aphasia, cognitive impairment, and multiple comorbidities was allowed to leave independently for community outings without a documented assessment of community safety skills or corresponding care plan interventions. The MDS noted moderate cognitive impairment and did not assess community ambulation abilities, while the care plan addressed independence with ADLs and communication supports but not independent leave. Nursing notes showed repeated unsupervised outings, and staff interviews revealed no standardized process or clear criteria to determine which residents could safely go out alone, no provider order authorizing independent leave, and no consultation with therapy disciplines to evaluate communication and functional safety in the community, despite facility policies requiring comprehensive, person-centered assessment and care planning.
A resident with dementia, repeated falls, and documented exit-seeking and wandering behaviors was assessed as an elopement risk and placed on a wander guard with care plan interventions for wandering/elopement. In the days before the incident, staff notes described the resident attempting to elope, becoming aggressive when redirected, and requiring one-to-one supervision, with baseline confusion and chronic short-term memory loss. On the day of the event, the resident repeatedly approached an exit and triggered the wander guard alarm while waiting in a common area for transportation to another facility; during a busy shift change and staff handoff for supervision, staff lost track of the resident, who left the building undetected while still wearing the wander guard. Staff later reported they did not know whether the wander guard alarmed or how the resident exited, and camera footage only showed the resident outside talking with others and then moving away from the building, demonstrating a failure to provide adequate supervision and effective elopement prevention for a known high-risk resident.
Two residents with complex medical and behavioral histories received 30‑day discharge notices that lacked required contact information for the LTC ombudsman and the state agency appeals coordinator. One resident, a smoker with liver disease, COPD, and mental health diagnoses, was repeatedly observed smoking in his room despite education on facility policy and was issued a discharge notice with an incorrect transfer date and no ombudsman details; he believed he was being discharged for being mean to others and had to obtain the ombudsman’s number from staff. Another resident with DM, chronic pain, opioid dependence, depression, and anxiety, identified as a vulnerable adult due to substance abuse and trauma, was discharged after being found using illicit drugs and sent to the hospital, but his notice also omitted ombudsman and appeal contact information, leaving him thinking his only option was to beg the administrator to stay. The ADON acknowledged the omissions, and the LTC ombudsman reported that notices should include this information and that there was a delay in receiving copies of the notices.
The facility did not have a registered nurse designated as the full-time DON after the previous DON's departure. For two weeks, an LPN acted in the role, and staff interviews showed uncertainty about who was responsible for DON duties, with the facility relying on a team approach and awaiting corporate hiring decisions.
A resident experienced a significant decline in functional status, requiring increased assistance with ADLs and mechanical lift transfers following multiple hospitalizations and new diagnoses. Despite these changes and new therapy orders, the care plan was not updated to reflect her current needs, and staff were inconsistent in their understanding and implementation of required interventions.
A resident with acute and chronic respiratory failure, tobacco use, and an oxygen order was repeatedly documented smoking unsafely and keeping cigarettes, tobacco, and lighters in his room despite prior education and restrictions. During a survey observation, he was seen on the smoking patio with a portable O2 tank attached to his wheelchair and in close proximity to other residents who were smoking; he admitted to smoking while oxygen was on, and staff later observed him smoking again with the tank still present.
Kitchen sanitation, temperature monitoring, and ice machine cleaning failures: Staff stored metal pans while they were still wet and one pan still had visible residue. Dish machine temps were not documented as required by the posted log instructions, and food temps were observed being taken without being recorded. The dietary mgr stated the facility had no process for documenting food temps or training staff on it. The maintenance supervisor also stated he had never cleaned the two ice machines according to the manufacturer’s instructions.
QAPI Program Lacked Ongoing Audit Data and PIP Documentation The facility failed to sustain QAPI oversight of repeat survey deficiencies and did not have evidence of an active PIP focused on problem-prone areas. Interviews and record review showed the QAPI committee met monthly, but audits were not being conducted due to leadership turnover, and there was no data tracking compliance with prior survey findings. Meeting minutes reflected ongoing issues with skin assessments, staffing, care plan follow-through, and antibiotic time-outs, but no ongoing analysis was documented.
Infection prevention and control failures were identified involving a glucometer that was disinfected with an alcohol wipe instead of per manufacturer guidance, staff not following EBP for two residents during direct care, a resident having a dirty uncovered water mug in the room, and a lift that was not cleaned after use before being parked in the hallway. The facility also lacked key elements of a Legionella water management program, including a water flow diagram, monitoring details, normal parameter levels, and actions for out-of-range results.
A facility failed to maintain an effective pest control program to eliminate mice, with repeated sightings reported by residents and staff in rooms, hallways, closets, the dining room, and near nurses’ stations. Residents with both impaired and intact cognition described mice in their rooms, and housekeeping staff reported dead mice, droppings, and live mice on sticky traps. The pest control vendor documented numerous rodent sightings and stated the mice could not be eliminated entirely.
Failure to assess and document safe self-administration of bedside medications. Four residents had medications or supplements at the bedside, but the chart lacked clear physician orders, completed assessments, and care plan entries showing they were approved to self-administer. One resident was observed taking pills from a cup with no nurse present, another had home medications on the overbed table, and two others had eye drops, vitamins, and supplements at the bedside despite records showing self-administration was not established.
Insufficient nursing staff led to prolonged call light waits and delayed ADL care for multiple residents with high assistance needs. Residents who were dependent for toileting, bathing, dressing, transfers, and brief changes reported waiting from many minutes to hours for help, and staff confirmed they often had to search for another aide for two-person care, had no mobile communication system, and could not consistently answer call lights within expected time frames.
A resident with CHF, obesity, DM, depression, and anxiety waited hours to be changed from a soiled diaper while staff told her they needed to find another NA to help. When care was finally provided, her gown and pad were wet and saturated, stool was present, and her skin was reddened. The resident said she had asked multiple people for help and felt awful lying in wet, soiled linens for hours; the DON acknowledged staff should have responded to the call light the first time.
A resident who no longer had a feeding tube still had an undated bag of formula and a feeding pump left in the room for several days. The resident said she did not want the equipment there and that it did not feel home-like. A NA and an LPN confirmed the bag and pump remained in the room after the tube came out, and the DON stated it was not a home-like environment to keep the nutrition equipment there.
Inaccurate MDS coding was found for two residents. One resident was coded as having adequate hearing, but the resident and an NA confirmed she was hard of hearing and used a whiteboard to communicate; the regional director of clinical reimbursement later confirmed the MDS hearing entry was incorrect. Another resident’s MDS showed insulin injections 7 days a week, but the physician orders and care plan did not include insulin, and the resident stated he was not diabetic and had never used insulin.
Missing Care Plan for Antipsychotic Monitoring: A resident with schizoaffective disorder, bipolar type, PTSD, and other mental health diagnoses was receiving olanzapine for sleep, anxiety, and later delirium and sleep, but the care plan did not include a specific antipsychotic care plan. The CAA triggered for psychotropic drug use and noted the need to address psychotropic medications in the care plan, while staff and the consulting pharmacist stated psychotropics should include target behaviors and side effect monitoring.
Care plans were not revised to match current assessments and orders for three residents. One resident with CKD and dependence on renal dialysis had a care plan that lacked specific dialysis details, including AV graft monitoring and dialysis contact information. Another resident with stroke-related deficits and dysphagia had orders for a mechanical soft diet with meal supervision, but the care plan still listed her as independent with eating and did not note missing dentures. A third resident with chronic respiratory failure had an oxygen order, but the care plan did not include oxygen-related care.
A resident with cognitive impairment, hemiplegia, apraxia, and dysphagia had an SLP-ordered mechanical soft diet with supervision and cueing during meals after losing dentures and having difficulty chewing and swallowing. During dining room observations, no nursing staff stayed with the resident, the activity director was not trained to assist with eating, and the resident was served foods that did not match the ordered diet. The resident was also observed taking food from another resident’s plate while no staff were present to supervise the meal.
Failure to provide scheduled bathing assistance to a resident dependent on staff for ADLs. The resident had chronic respiratory failure, HTN, kidney failure, and A-fib, and the care plan called for bathing support and consideration of preferences. The resident repeatedly reported missing scheduled showers and said staff told her they did not have time, while POC documentation conflicted with the resident’s statements. The DON stated showers were expected as scheduled unless the resident was unavailable or declined.
A facility failed to carry out wound care orders for two residents with venous ulcers, including delayed start of updated dressing treatments and lack of leg elevation. It also failed to document ordered thigh measurements for a resident with edema/possible lymphedema and failed to obtain an admission weight for a resident with HF, despite orders for daily weight monitoring and potassium therapy. Staff and the DON confirmed the orders were not transcribed, not documented in the EMR, or not started as expected.
Failure to ensure a resident with R-sided hemiplegia and limited ROM used a care-planned palm brace. The resident was observed without the brace, with a curled R hand and limp R arm, and the chart lacked clear orders, TAR/MAR entries, and documentation of refusals. Staff interviews showed inconsistent knowledge of the splint, and the record did not include directions for what to do when the resident refused it.
Failure to implement a dietician-recommended nutritional supplement for a resident with severe protein-calorie malnutrition. The RD recommended Glucerna or a similar HNS TID between meals, but the physician orders did not include the supplement and the resident reported not receiving or being offered any nutritional drink since admission. An LPN confirmed there was no supplement order in the EMR, and the RD, NP, and RN-C all expected the emailed recommendation to be entered and carried out.
A resident with a G-J tube, dysphagia, and severe cognitive impairment did not receive tube feeding according to the ordered schedule, and the formula bag was observed without proper labeling. Staff also administered medications through the J port instead of the ordered G port. The RD, NP, DON, and pharmacist all acknowledged that the feeding was not given as ordered and that using the wrong tube for medications was a medication error.
A resident with OSA, HF, morbid obesity, and respiratory failure was not provided CPAP therapy as ordered because the mask, tubing, and power cord were missing. The resident said he had asked to restart CPAP after a hospital stay, but staff had not replaced the needed supplies. An LPN reported notifying the RN/care coordinator, the RN said she informed the DON, and the NP and DON were not aware the resident was not using the CPAP.
Missed ordered pain medication for a resident with chronic pain. The resident had diabetes, polyneuropathy, morbid obesity, and severe pain in the feet and legs, with repeated pain scores up to 10/10. MAR and progress notes showed buprenorphine doses were missed because the medication was not available or not on hand, and the resident reported going without pain meds over the weekend. Staff acknowledged missed doses, said pharmacy delivery was available, and confirmed missed meds are medication errors.
A resident with CHF, DM2, CKD, and dependence on renal dialysis did not have dialysis-specific physician orders or a care plan with details such as AV graft location, dialysis provider contact information, or directions for graft-site assessment. The resident said nurses did not check the dialysis site and he removed the dressings himself. Staff were unsure where to find dialysis instructions or how to communicate with the dialysis provider, and the EMR showed no AV graft assessments on multiple dialysis treatment dates.
Medication Error Rate Exceeded 5%: The facility had 3 medication errors out of 35 opportunities, resulting in an 8.57% error rate. An LPN administered tube medications through the J tube instead of the ordered G tube for a resident with stroke-related deficits and dysphagia, and another resident’s Sinemet for parkinsonism was given late. The DON and pharmacist identified the tube-route issue as a medication error, and the LPN verified the late dose.
A resident with moderate cognitive impairment, chronic respiratory failure, cellulitis, and HF had an order for doxycycline for infection, but the antibiotic was interrupted after the first dose. Pharmacy sent a therapeutic interchange notice to switch from doxycycline hyclate to doxycycline monohydrate, yet the nursing record did not show the new order was transcribed when received, and the resident missed two doses before the substituted order appeared on the MAR.
A resident with CVA-related dysphagia, hemiplegia, apraxia, and cognitive impairment lost dentures and was placed on a mechanical soft diet, but the facility did not timely arrange a dental referral. Staff documented the missing dentures, searched the room, and noted the resident had difficulty chewing and eating, yet no dental appt was set up within the policy timeframe and no clear reason for the delay was documented.
A resident with hemiplegia, apraxia, dysphagia, and missing dentures was ordered a mechanical soft, no-bread diet with supervision, but the meal ticket still showed a regular diet. The resident was observed eating a donut and other regular foods in the dining room without nursing supervision, while staff and the DON confirmed the diet order had not been reflected in the kitchen system and that the resident should not have had the donut.
The facility failed to implement its antibiotic stewardship program for a resident receiving doxycycline for cellulitis. The resident had moderate cognitive impairment, chronic respiratory failure, heart failure, and cellulitis of the lower extremities, but the record lacked monitoring documentation for the infection. An LPN said monitoring orders were usually added with antibiotics, but none were in place, and the acting IP, RN, and DON acknowledged staff were not completing infection monitoring or documenting assessments while residents were on antibiotics. The antibiotic stewardship policy stated the program was to monitor antibiotic use but did not give guidance for monitoring signs of improving or worsening infection or a time-out period.
Failure to Offer and Document Pneumococcal Vaccination: The facility did not ensure two residents were offered the pneumococcal vaccine, educated on its risks and benefits, or documented as vaccinated or refusing. One resident with HF, acute respiratory failure, OSA, and other significant diagnoses said no one had offered the vaccine since admission and he would be interested in receiving it; another resident with COPD and other conditions had a prior Pneumovax 23 record but no documentation of later offers, education, or refusal. The DON confirmed both residents were not offered the vaccine during the prior year.
A resident with multiple fractures, trauma, and diabetes experienced severe pain that was not promptly managed, waiting approximately nine hours for prescribed narcotic pain medication after admission. The resident's blood glucose and vital signs were not monitored as ordered, and the facility's emergency medication kit was out of the required medication, leading to the resident calling 911 and returning to the hospital for pain management.
A resident with multiple fractures and trauma did not receive oxycodone HCl according to physician orders, with records showing administration of doses more frequently and in greater quantities than prescribed. Staff interviews revealed medication errors due to lack of medication availability, improper documentation in the narcotic count book, and failure to transcribe or follow updated orders. The pharmacy and DON confirmed that the facility was not adhering to the most current prescription, and errors were not reported as required.
Multiple residents with complex medical needs experienced significant delays in receiving assistance with toileting, repositioning, and other ADLs due to insufficient staffing and lack of oversight. Call light response times frequently exceeded the facility's policy, with some residents waiting over an hour or more for help. Agency nursing assistants were observed using cell phones while on duty, and there was inadequate supervision and training. Facility leadership acknowledged the delays but did not consistently review or address call light response data, resulting in unmet resident needs.
The facility did not provide adequate orientation, training, or competency verification for both employed and agency NAs, as evidenced by incomplete documentation, lack of job-specific training materials, and resident reports of unprepared staff. Two NAs lacked required skill competencies and in-service trainings, and residents reported that agency NAs were unfamiliar with facility procedures and equipment.
The facility did not employ a full-time RD or a qualified DM to manage food and nutrition services, as required. The DM could not provide evidence of necessary certifications, and her personnel file was incomplete. The RD was a part-time consultant, and the facility could not verify the qualifications of either staff member, potentially affecting all residents receiving meals.
The facility did not maintain an effective pest control program, as evidenced by repeated mouse sightings, droppings in the kitchen and storage areas, improper food storage, and unsanitary conditions. Staff frequently left doors propped open and dumpsters uncovered, failed to consistently log pest sightings, and did not ensure food was stored in sealed containers, leading to ongoing pest activity throughout the facility.
Surveyors identified multiple deficiencies in food storage and labeling, including unlabeled and undated food items, improper storage of opened foods, food containers with residue, and kitchen equipment with visible debris. Facility staff and management confirmed these lapses, which were not in accordance with established food safety and sanitation policies.
Two residents were not provided with appropriate clothing, with one left wearing only a robe and slippers for an extended period due to lack of personal belongings and discontinued facility gowns, and another resident was spoken to in an undignified manner by a staff member after an incident involving soiled clothing. Staff and leadership interviews confirmed awareness of these issues, and facility policy requires residents to be treated with dignity and respect, including support for preferred clothing and respectful communication.
A resident with severe cognitive impairment and multiple medical conditions experienced a change in health status, resulting in a hospital transfer. The facility did not notify the resident's family about the change in condition or the transfer, and the family only learned of the hospitalization from a hospital physician. The DON confirmed that family notification should have occurred but did not.
A resident who required staff assistance for dressing reported missing clothing to nursing staff, but no grievance form was completed and no investigation was initiated. Key facility staff were unaware of the issue until it was brought up during the survey, despite facility policy requiring prompt investigation of such complaints.
A resident's MDS assessment was inaccurately coded, failing to document the use of an anticoagulant medication despite the resident receiving it during the review period. The DON confirmed the omission and acknowledged the need for accurate MDS coding, as the assessment forms the basis for payment and care planning.
A resident admitted with an infection and inflammatory reaction related to a joint prosthesis did not receive a summary of the baseline care plan within the required timeframe. Documentation was lacking in the EMR, and staff interviews confirmed that the care conference and provision of the baseline care plan summary did not occur as required by facility policy.
Two residents with significant medical needs did not have comprehensive care plans addressing their risks for pressure ulcers and respiratory impairment. One resident at moderate risk for pressure ulcers lacked documented preventive interventions, while another using oxygen and a non-invasive ventilator had no care plan for respiratory care. Staff and the DON confirmed these omissions, which were not in line with facility policy requiring individualized, updated care plans.
The facility did not consistently conduct required care conferences for three residents, including those with cognitive impairment, recent admission, and complex medical needs. In some cases, care conferences were canceled and not rescheduled, or not held with the full interdisciplinary team, and residents sometimes did not recall participating. Facility staff misunderstood requirements, leading to missed or incomplete care planning meetings.
A resident with severe cognitive impairment and quadriplegia, fully dependent on staff for ADLs, was repeatedly observed with long, dirty fingernails despite care plans and facility policy requiring regular nail care. Staff interviews revealed confusion about responsibility for nail trimming, and a family member's request for nail care was not addressed, resulting in ongoing neglect of the resident's personal hygiene.
A resident with a history of joint infection, heart failure, and recent knee surgery did not receive prescribed compression stockings or wound care due to improper transcription of physician orders into the electronic health record. Nursing staff were unaware of the active orders, leading the resident to manage his own wound care and compression therapy. The care plan was not updated to address edema or the use of ted stockings, and documentation of required treatments was missing.
A resident with multiple risk factors, including immobility and incontinence, was not consistently repositioned or provided with appropriate heel protection, despite being at high risk for pressure ulcers. The care plan lacked specific interventions for skin breakdown prevention, and staff did not follow recommended repositioning schedules. As a result, the resident developed new pressure ulcers while under care.
A resident with a medical marijuana card and chronic pain was observed vaping THC in bed without the facility's knowledge or assessment for safe vaping practices. Although the DON and ADON were aware of the resident's marijuana use, there was no documentation in the care plan or physician orders, and no assessment for safe self-administration or supervision was conducted. The facility's policies prohibited vaping indoors and required care plan updates and assessments, but these were not followed, resulting in unaddressed accident hazards.
Failure to Assess and Care Plan Resident’s Safety for Independent Community Outings
Penalty
Summary
The deficiency involves the facility’s failure to assess and implement individualized interventions to ensure safe independent community access for a resident with expressive aphasia and cognitive impairment. The resident had multiple diagnoses including stroke, bipolar disorder, aphasia, diabetes type II, anxiety disorder, cognitive symptoms, and encephalopathy. The admission MDS documented moderate cognitive impairment and noted that community ambulation abilities (such as navigating uneven surfaces, managing curbs/steps, and car transfers) were not assessed. The resident’s care plan identified independence with ADLs, transfers, and ambulation, and noted vulnerability due to communication impairment with interventions such as clear, simple instructions and visual prompts, but it did not address community outings or independent leave. Nursing notes documented multiple occasions when the resident left the facility independently for outings, with staff noting expected return times, but there was no documentation between the admission date and the survey period of any assessment of the resident’s ability to safely navigate community environments, manage emergencies, or obtain assistance while outside the facility. During observation and interview, the resident was seen ambulating independently and demonstrated use of a cell phone to call family members, but the contact list did not include the facility’s phone number or address. Staff interviews revealed inconsistent understanding and lack of clear criteria regarding which residents were safe to leave independently; CNAs and RNs relied on factors such as ability to walk, absence of a WanderGuard, or checking the care plan or provider orders, but they did not reference any standardized assessment tool. Clinical staff, including a speech therapist and occupational therapist, reported they had not been consulted to assess the resident’s safety for independent community access, despite the speech therapist expressing concerns related to communication and suggesting that written word lists could assist the resident. The vice president of clinical services described an informal approach using hospital history, elopement assessment, and cognition to determine safety, and stated she would document in the care plan if a resident was not safe to leave alone, but there was no such documentation for this resident. The nurse practitioner stated she would expect an assessment of cognition, mobility, and functional abilities such as crossing the street, using a bus, or handling money before a resident went out independently. Facility policies on resident leave of absence and comprehensive person-centered care planning did not include protocols or criteria for determining when residents could leave independently, contributing to the lack of a formal assessment and care plan interventions for this resident’s unsupervised community outings.
Failure to Prevent Elopement of High-Risk Resident Despite Wander Guard and Known Exit-Seeking Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate, individualized interventions to prevent elopement for a resident who had been assessed as an elopement risk. The resident was admitted with diagnoses including repeated falls, dizziness and giddiness, unspecified mental disorder, and dementia with behavioral disturbance, and used a wheelchair. An elopement risk assessment identified the resident as an elopement risk due to verbal expressions of wanting to go home, wandering behavior, recent admission, and not accepting the situation. Suggested clinical actions included notifying staff of wandering and elopement risk, using exit alarms, and frequently monitoring the resident’s location. The care plan included a focus on wandering/elopement with goals that the resident would not leave the facility unattended and would remain safe, and interventions such as identifying de-escalation behaviors and providing reorientation. A nursing order directed staff to check the resident’s wander guard on the wrist daily and its function weekly. In the days leading up to the elopement, multiple progress notes documented escalating exit-seeking and behavioral issues. Notes indicated the resident wanted to go back to a prior place, was wandering, attempting to elope, hitting staff, and looking for her husband. The resident was described as alert and oriented to self with confusion at baseline, with chronic disorientation, some confusion, and chronic short-term memory loss. Staff documented that the resident had been on one-to-one supervision on a previous shift after attempting to leave the facility and becoming aggressive when redirected. On the morning of the elopement, a progress note recorded that the resident came into the hallway undressed, kicking and cursing at staff. Staff interviews confirmed that the resident had previous exit-seeking behaviors, was not easy to redirect, would refuse care, and was often kept at the nursing station for increased supervision. On the day of the elopement, staff assigned to the resident reported difficulty keeping track of residents during shift change and could not explain how the resident left the building while under their assignment. One NA stated the resident kept approaching the exit and setting off the wander guard alarm and that he had been assigned to watch the resident in the common area for a period before taking a break. At shift change, responsibility for watching the resident was to be handed off to other staff, but when the NA returned from break, the resident was missing. Another nurse reported that the resident had packed belongings and was waiting in the common area for transportation to another facility, and that around shift change staff left to find a replacement to supervise the resident; when they returned, the resident could not be located. Staff were unsure whether the wander guard alarm sounded, whether someone assisted the resident out the door, or how the resident exited the building, and the resident was still wearing the wander guard when later found. The facility’s location near several bus stations and the lack of camera coverage on the inside of the exit door were noted, and camera footage from outside showed the resident talking with other residents who were smoking and then following turkeys down a hill away from the building. The facility’s own policies required staff to attempt to prevent a resident’s departure if observed leaving and allowed use of a wander management system for residents at risk of elopement, but the events show that despite the resident’s known risk and documented behaviors, supervision and monitoring were not effectively maintained at the time of the elopement.
Removal Plan
- Facility began an investigation.
- Transferred R1 to a sister nursing facility with the capacity to keep her in a secured memory unit.
- Completed mandatory staff education on elopement, missing residents, facility policies and procedures, and the specific elopement event.
- Re-educated nursing staff on completing the elopement risk assessment accurately and completely.
- Checked the wander guard system and confirmed it was in working order for all residents identified as an elopement risk.
- Reviewed charts and care plans for other at-risk residents and added interventions as needed.
Failure to Include Required Appeal and Ombudsman Information on 30‑Day Discharge Notices
Penalty
Summary
The deficiency involves the facility’s failure to ensure that 30‑day discharge notices contained all required information related to residents’ needs, appeal rights, and ombudsman contact information for two residents. One resident had multiple diagnoses including alcoholic cirrhosis, chronic hepatitis C, COPD, left above‑knee amputation, anxiety disorder, and depression, and was cognitively intact and independent with transfers. This resident had a smoking care plan identifying him as a smoker with interventions to instruct him on facility smoking policies and safety. Progress notes documented that he was observed smoking in his room on one evening, was reminded of the policy and risks, and stated he did not care and would continue due to the cold weather. A subsequent note indicated he continued to smoke in his room despite multiple staff requests to stop. A 30‑day notice was then issued, but the progress note did not specify the reasons for the notice, and the discharge form contained an incorrect transfer date and lacked required contact information for the state agency appeals coordinator and the LTC ombudsman. The same resident later produced two discharge notices from his drawer, one older notice and a second dated later with a list of homeless shelters stapled to the back. He stated he believed he was being discharged for being mean to other residents, was unaware that the notice was related to smoking policy violations, and reported that ombudsman contact information was not listed on the form. He indicated he had to obtain the ombudsman’s number from a staff member and that the facility only provided him with a list of homeless shelters, which he did not want to use. The ADON reported she had been instructed by the administrator in training to give this resident a 30‑day discharge notice due to repeated smoking policy violations and acknowledged she did not notice that the ombudsman contact section on the form was blank. A second resident, with diagnoses including diabetes mellitus, chronic pain syndrome, opioid dependence, depression, and anxiety, was also cognitively intact and independent with transfers and ADLs. This resident’s care plan identified him as a vulnerable adult due to alcohol/substance abuse and traumatic life events, with interventions to notify the provider if he posed a potential threat to self or others. His discharge form, signed by the ADON, stated he would be transferred and cited endangerment to the safety and health of individuals in the facility as the reason, but similarly omitted the email address for the state agency appeals coordinator and the contact information for the LTC ombudsman. The ADON stated this resident was given a 30‑day notice because he was found using illicit drugs in the facility and required 911 transport to the hospital. The resident reported that the ombudsman contact information was not on his notice and that he initially believed his only option was to plead with the administrator to stay because the facility had not helped him find another placement. The LTC ombudsman stated that 30‑day notices should include ombudsman contact information to allow assistance with the appeal process and reported a delay in receiving copies of the discharge notices from the facility, despite an earlier request.
Failure to Designate a Full-Time Registered Nurse as DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing (DON) on a full-time basis after the previous DON was terminated. For approximately two weeks, an LPN was the only administrative staff on duty and had been acting as the DON, despite not being a registered nurse. Interviews with facility staff, including the Director of Human Resources and the Administrator, revealed uncertainty about who was currently fulfilling the DON role, with the corporate office handling the hiring process for a new DON. The facility was relying on a team approach involving the assistant director of nursing, nursing staff, and the President of Clinical Services to cover the responsibilities of the DON, but no one was officially designated or able to assume the role full-time. No facility policy regarding required nursing services was provided upon request.
Failure to Revise Care Plan After Resident's Decline and Change in Condition
Penalty
Summary
The facility failed to revise the care plan for a resident after significant changes in her condition and care needs, as required by regulation and facility policy. Initially, the resident was assessed as independent in most activities of daily living (ADLs), including dressing, eating, personal hygiene, toilet use, and transfers. However, over the course of her stay, the resident experienced multiple hospitalizations, falls, and a decline in functional status, resulting in increased dependence on staff for ADLs and the need for mechanical lift assistance for transfers. Despite these changes, the care plan was not updated to reflect her increased care needs, new therapy orders, or the implementation of a home exercise program recommended by physical therapy. Medical records and staff interviews revealed that the resident's condition deteriorated significantly, with new diagnoses including metabolic encephalopathy, heart failure, neuropathy, and essential tremor. She became dependent on staff for toileting, bathing, dressing, and transfers, and required maximum assistance or mechanical lift for mobility. Orders for rehabilitation services and therapy were not processed or incorporated into the care plan, and goals related to pain management and functional improvement were not added. Staff members were inconsistent in their understanding and implementation of the resident's care needs, with some unaware of her current status or the interventions required. Interviews with nursing staff, therapy staff, and administration confirmed that the care plan had not been revised since the resident's admission, despite multiple significant changes in her condition and care requirements. The RAI coordinator acknowledged not updating the care plan after completing the MDS assessment, citing inexperience. Other staff members were unaware of therapy orders or failed to document education and interventions related to the resident's noncompliance and deconditioning. The facility's policy required care plans to be updated after significant changes, but this was not followed in the resident's case.
Unsafe Smoking With Oxygen Present
Penalty
Summary
The facility failed to ensure smoking safety interventions were identified, implemented, and monitored for a resident who used oxygen and smoked, and failed to provide adequate supervision to keep oxygen out of the designated smoking area. The resident had diagnoses including acute and chronic respiratory failure and was ordered oxygen at 2 liters per minute by nasal cannula during evening and night shift, with instructions to keep oxygen saturation at or above 90%. The resident’s records also showed a history of tobacco use, repeated smoking-related concerns, and prior documentation that he was unable to smoke safely, including being lethargic, dropping ashes on himself, and being unable to use an ashtray to extinguish tobacco or marijuana. The resident’s chart contained multiple notes showing unsafe smoking behavior before the survey event. Staff documented that he had smoked in his room while oxygen was present, had cigarettes and a lighter in his room, and had tobacco removed from his room on more than one occasion. Notes also reflected that he continued to keep cigarettes, tobacco, and lighters in his room despite education and prior incidents. One note stated he smoked in his room while wearing oxygen and another stated he smoked in his room because of a panic attack. A later note indicated he insisted on keeping cigarettes with him and said he could go outside and would not smoke in his room again. On the evening of the survey observation, the resident was seen on the outdoor smoking patio seated in a wheelchair with a portable oxygen tank attached to the back of the chair and oxygen connected via nasal cannula at 2 liters per minute. He was in close proximity to other residents who were actively smoking, and he was observed turning the oxygen knob to zero. He admitted to smoking while oxygen was on and made statements indicating he was willing to take the risk. Shortly afterward, he was observed smoking with the oxygen tank still on the back of his wheelchair, and when staff discussed the safety concern, he became upset and threw the oxygen tank to the ground, where it was observed whistling under pressure. Staff interviews confirmed that oxygen was not supposed to be outside where smoking occurred and that the resident had previously kept cigarettes and a lighter in his room.
Kitchen sanitation, temperature monitoring, and ice machine cleaning failures
Penalty
Summary
The facility failed to ensure metal pans were clean and dry before being stacked and stored. During a kitchen observation, several metal pans were found stacked upside down on a wire cart with wet interior surfaces, and one large pan still had visible residue that appeared to be from chicken and dumplings. A dietary aide stated the pans had been dried only for a minute or two before being put away, and he could not recall whether he had been educated on the importance of fully drying dishes and pans before storage. The facility also failed to monitor and document dish machine temperatures as directed. A temperature log posted in the dishwashing area showed wash and rinse temperatures recorded only once daily through 9/8/25, even though the form instructed staff to record temperatures two times daily. Dietary staff could not explain whether temperatures were actually being taken without being recorded or not taken at all, and the dietary manager stated she expected temperatures to be monitored once daily and recorded, despite the form’s instructions. The log was later removed from the dishwashing area, and the dietary manager could not verify whether staff had monitored temperatures during the time it was absent. In addition, the facility failed to document food temperatures when meals were being prepared and served. A cook was observed taking food temperatures with a thermometer, but the temperatures were not written down, and the dietary manager stated the facility did not document food temperatures and had not implemented a process or trained staff to do so. The facility also failed to follow manufacturer instructions for cleaning and sanitizing two ice machines used for resident ice and water service. The maintenance supervisor stated he had never cleaned the machines and only performed light cleaning, while the administrator acknowledged that a company had previously cleaned them but no longer did so. Training records requested for dietary staff showed no documentation of orientation or training specific to kitchen or dietary duties for two employees, and one employee’s signed document was a job description rather than training.
QAPI Program Lacked Ongoing Audit Data and PIP Documentation
Penalty
Summary
The facility failed to ensure its Quality Assurance Assessment and Performance Improvement (QAPI) committee sustained ongoing compliance related to repeat citations from prior surveys and deficiencies identified during the current survey. The report states the facility had repeat deficiencies involving accuracy of assessments, quality of care, ADL care, accidents, nutrition, tube feeding, sufficient nursing staff, food procurement, infection prevention and control, and pest control. The facility also did not have evidence of a Performance Improvement Project (PIP) focused on high-risk or problem-prone areas, and there was no documentation showing thorough data collection, analysis, or evaluation of the identified concerns during QAPI. The Provider History report dated 9/15/25 identified repeat deficiencies including F641, F684, F689, F692, F554, F677, F812, F880, F656, F698, F725, and F759. The QAPI meeting minutes dated 8/14/25 documented ongoing concerns about skin assessments not being completed consistently, staffing challenges, weekly skin assessments not being completed, nurses not proactively leading CNAs in completing assessments, care plans not being followed, antibiotic time-outs not being done consistently, and kitchen floor repair needs. The minutes also noted a plan for additional rounds on high-risk medications and retraining staff on following care plans, but the facility lacked ongoing data related to the repeat citations. During interviews, the medical director stated he was unaware of what current audits were still taking place because of leadership changes, although he understood the facility was expected to perform audits and document areas of concern addressed during QAPI. The COO, serving as administrator, and the VP of clinical services stated the QAPI committee met monthly and that the medical director completed the minutes, but they confirmed the facility was not currently conducting audits due to leadership turnover. They also stated there was no data or documentation tracking compliance with previous surveys, they could not recall the facility’s PIP, and there was no information posted regarding any active PIP. A follow-up interview confirmed there was no documentation to support that a PIP had been identified or performed.
Infection Prevention and Control Failures
Penalty
Summary
The facility failed to ensure a glucometer was disinfected according to the manufacturer’s instructions during blood glucose testing for a resident with diabetes and a left below-the-knee amputation. An Evencare G3 operators manual stated the meter should be disinfected between each resident and listed approved products, but alcohol wipes were not included. During observation, an LPN obtained the glucometer from the medication cart, checked the resident’s blood glucose while the resident was eating breakfast, then placed the meter back on the cart and moved to the next room. Sanitizing wipes were not observed on the cart, and the glucometer was later wiped with an alcohol wipe. The DON stated residents should have personal glucometers in their rooms and that Sani-Wipes, not alcohol wipes, should be used, but a facility policy for disinfecting equipment was not provided. The facility also failed to follow enhanced barrier precautions for two residents and failed to ensure one resident had a clean water cup in place. One resident had venous wounds that were deteriorating, but the electronic record did not indicate enhanced barrier precautions were required and there was no signage on the room door. The resident had a clear mug with no cover and a straw on the bedside table, with a dark black/brown substance around the rim and in the groove where a lid would snap on. The resident stated the cup had been used for a few weeks. A nursing assistant confirmed the mug was very dirty and said water mugs should be changed out each morning, while also stating the kitchen did not always have clean mugs available. For another resident with severe neurologic impairment, dependence for all activities of daily living, and an enhanced barrier sign on the door, staff entered the room without gowns while providing direct care. During one observation, nursing assistants used a mechanical lift to transfer the resident and provide peri-care, but one assistant entered without a gown and the lift was parked in the hallway afterward. During another observation, two nursing assistants entered the room wearing gloves but no gowns while checking the brief and providing perineal care. The facility also failed to clean the lift after use before parking it in the hallway during a transfer of another resident. In addition, the facility’s Legionella water management program lacked a diagram of water flow and distribution, did not specify what was to be monitored or where, did not identify normal parameter levels, and did not include actions to take when parameters were not met.
Pest Control Program Failed to Eliminate Mice
Penalty
Summary
The facility failed to implement an effective pest control program to eliminate mice in the building. Residents and staff reported repeated mouse sightings throughout the facility, including in resident rooms, hallways, the dining room, nurses’ stations, closets, and near doors and heat registers. The pest control company’s sighting reports documented 35 rodent sightings between 5/29/25 and 8/30/25, including mice and baby mice, with reports coming from both residents and staff. Several residents described seeing mice in their rooms and common areas. One resident with moderately impaired cognition reported mice running in the hallway, entering the bathroom, and going under the closet door. Another resident with intact cognition reported a mouse running under the bed and said he bought his own mouse traps, which were observed in the room. A third resident with intact cognition reported seeing two mice in the room and said traps were in the closet. A fourth resident with intact cognition reported seeing mice in the room near the bed and door and stated that crumbs on the floor attracted the mice at night. Housekeeping staff also reported seeing mice, dead mice, and mouse droppings, including in resident closets, vacated rooms, a linen closet, and on both the first and second floors. The interim administrator stated the facility had a known rodent problem and that residents occasionally reported mice, while the pest control employee stated he checked sighting reports, traps, bait stations, and the outside of the building but believed the mice could not be eliminated entirely. The facility’s pest control policy stated that ongoing measures were to be taken to prevent, contain, and eradicate common household pests, and that staff were to report all pest sightings for intervention.
Failure to Assess and Document Safe Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to ensure residents were assessed for safe self-administration of medications for four residents who had medications at the bedside. The report states that residents could self-administer drugs only if the interdisciplinary team determined it was clinically appropriate and safe, with documentation in the medical record and care plan. For the four residents identified, the record review found missing or incomplete physician orders, assessments, and care plan entries related to self-administration. R14 had diagnoses including chronic respiratory failure, high blood pressure, kidney failure, and atrial fibrillation, and her MDS indicated intact cognition and substantial assistance with ADLs. Her record did not include an assessment for self-administration, her care plan did not address it, and provider orders did not indicate she was able to self-administer medications. During observation, she was seen in her wheelchair taking pills from a medication cup at her bedside while no nursing staff were present. An LPN later stated she had given R14 her morning medications in a cup and had not considered that as self-administration, and confirmed there was no order, assessment, or care plan for it. R37 had diagnoses including obstructive sleep apnea, chronic pain, pre-diabetes, allergic rhinitis, and ichthyosis vulgaris, and his MDS indicated intact cognition and dependence on staff for most ADLs. Although two electronic self-administration assessments had been completed, both were inconclusive, and his care plan and provider orders did not indicate self-administration. During observation, he had antacid tablets, eye drops, and Allegra on his overbed table and stated he brought them from home and used them himself. The LPN stated the medications should have been accompanied by a physician order, assessment, and care plan, and the DON confirmed the assessments appeared incomplete and that neither resident had authorization for self-administration. R13 had moderate cognitive impairment and diagnoses including chronic respiratory failure, cellulitis of the left lower extremity, and heart failure. Her self-administration assessment stated staff were unable to determine whether she wanted to self-administer medications and that she was not able to identify medication expiration dates, and her care plan and provider orders did not indicate self-administration. She was observed with refresh eye drops and gummy multivitamins at her bedside, and she stated she had always taken them and was continuing to do so. R1 was cognitively intact with diagnoses of sciatica, edema, and chronic pain, but her self-administration assessment also stated staff were unable to determine whether she wanted to self-administer medications, and her care plan and provider orders did not indicate self-administration. She was observed with multiple supplement bottles at her bedside, stated staff knew she took them, and an LPN confirmed the medications were present and that there should have been a provider order indicating she could self-administer them.
Insufficient Nursing Staff and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs and to ensure a licensed nurse was in charge on each shift, as shown by repeated long delays in answering call lights, delays in providing toileting and hygiene care, and residents waiting extended periods for assistance. Multiple residents with significant care needs, including dependence for toileting, bathing, dressing, transfers, and brief changes, were observed waiting while call lights remained unanswered or were turned off before help was provided. Staff interviews confirmed that residents often required two-person assistance, that aides had difficulty finding another aide to help, and that call lights were not consistently answered within the expected time frame. R4, who had intact cognition, used a wheelchair, and needed assistance with toileting, bathing, and dressing, was observed in bed with his call light on and stated he wanted to get up but staff had turned his light off and left him waiting. He later stated staff told him they could not get him up yet because they needed another person and were too busy. R18, who was dependent for toileting hygiene, bathing, dressing, and used a wheelchair, had his call light on for a prolonged period before staff entered and told him they would help when able; he stated he had been waiting a long time for a brief change. R29, who used a manual wheelchair and needed assistance with transfers and personal hygiene, also waited extended periods for help, including one instance where his call light remained on for over 30 minutes before assistance arrived. The call light logs documented repeated long response times for several residents, including waits measured in tens of minutes and, for some residents, over an hour or more. R4’s logs included waits up to 141 minutes, R53’s up to 110 minutes, R3’s up to 85 minutes, R29’s up to 267 minutes, and R37’s logs showed numerous activations with waits ranging from 20 minutes to over two hours. R43 reported waiting over an hour at times, and R23 was observed lying in bed waiting since early morning to be changed from a soiled brief; when finally assisted, her gown and incontinent product were saturated and stool was caked between her buttocks. Resident council minutes and grievances also reflected ongoing concerns about long call light times, including reports of residents waiting hours for help with toileting and incontinence care. Staff interviews described difficulty answering call lights because aides were busy with other residents, many residents required two staff for transfers and care, and staff had no mobile communication system to locate another aide quickly. Several aides stated they expected call lights to be answered within five minutes but were unable to do so, and some reported working past the end of their shifts to finish care and charting. The facility assessment listed staffing ratios and noted a contingency staffing plan, while the facility’s staffing policy stated licensed nurses and CNAs were to be available 24 hours a day, seven days a week to provide competent resident care and respond to resident needs.
Delayed Toileting Assistance and Dignified Care
Penalty
Summary
The facility failed to ensure timely toileting assistance and dignified care for a resident who had diagnoses of congestive heart failure, obesity, diabetes, depression, and anxiety. The resident’s quarterly MDS indicated intact cognition, clear speech, and independence with ADLs, and physician orders directed staff to monitor for signs and symptoms of depression. The care plan identified impaired coping skills and later noted the resident was at risk for depression due to anxiety and depression. During an observation and interview, the resident stated she had been waiting since 6:30 a.m. to be changed out of a soiled diaper and said a nursing assistant kept telling her she needed to find a second assistant. When staff finally provided care, her gown was wet, the incontinent pad was saturated, greenish material was present in the pad, her labia were reddened, her inner right thigh was sore and reddened, and a large brown stool was observed between her buttocks. The resident stated she had told multiple people she needed to be changed and felt awful having to lie in a soiled pad, wet gown, and wet sheets for hours. The DON acknowledged staff should have responded to the call light the first time and that it was not acceptable for the resident to wait hours in a soiled incontinent pad. Review of call light records showed 198 activations over the prior month, including 41 response times between 20 and 60 minutes and 8 between 60 minutes and 3 hours.
Feeding Tube Equipment Left in Resident Room After Tube Removal
Penalty
Summary
The facility failed to ensure a homelike environment for one resident who no longer had a feeding tube but still had feeding tube formula and a Kangaroo Omni feeding tube pump left in the resident’s room. The resident’s MDS indicated intact cognition, a diagnosis of malnutrition, and a feeding tube. Orders showed regular diet and thin liquids, along with an enteral feeding order for Nutren or Isosource 1.5 at 100 mL per hour via feeding tube. The resident’s MAR showed enteral feeding continued until the feeding tube was no longer in use, and progress notes documented that the feeding tube fell out and the resident did not want it replaced. Despite the tube no longer being present, observations and interviews showed an undated bag of 1000 mL of brownish fluid hanging on the feeding pump in the resident’s room for several days. The resident stated the equipment had been in the room for days, did not want it there, and said it bothered her because it was no longer home-like. A nursing assistant and an LPN both confirmed the feeding bag and pump were still in the room after the tube had come out, and the LPN stated it should have been removed right away. The DON also stated it was not a home-like environment to continue having the nutrition equipment in the resident’s room.
Inaccurate MDS Coding for Hearing Status and Insulin Use
Penalty
Summary
The facility failed to ensure accurate MDS coding for 2 residents reviewed for MDS accuracy. For one resident, the face sheet listed chronic respiratory failure, high blood pressure, kidney failure, and atrial fibrillation, and the significant change MDS indicated intact cognition, adequate hearing, clear speech, and substantial assistance with ADLs. However, the resident stated through a whiteboard that she had been hard of hearing for years, and a nursing assistant confirmed she was hard of hearing and used a whiteboard to communicate. The resident’s care plan identified risk for impaired communication, but did not specifically identify her as hard of hearing, and the regional director of clinical reimbursement later confirmed the hearing coding in Section B of the MDS was incorrect. For the second resident, the face sheet listed pre-diabetes, and the quarterly MDS indicated intact cognition, clear speech, dependence for most ADLs, no walking, and insulin injections 7 days a week. However, the physician orders did not include insulin, the care plan did not indicate insulin use, and the resident stated he was not diabetic and had never used insulin. The regional director of clinical reimbursement stated the facility had hired a new MDS nurse in June who left in August, and that the facility had to make multiple MDS modifications after that nurse left, adding that the insulin entry on this resident’s MDS was not accurate.
Missing Care Plan for Antipsychotic Monitoring
Penalty
Summary
The facility failed to ensure the care plan included management and monitoring of an antipsychotic medication for one resident who was reviewed for antipsychotic use. The resident’s medical diagnosis form listed adjustment disorder with mixed anxiety and depressed mood, schizoaffective disorder, bipolar type, and PTSD. The significant change MDS assessment indicated intact cognition, no hallucinations or delusions, no physical, verbal, or other behavioral symptoms, no rejection of care, and that behavior was the same as the previous assessment. It also indicated the resident had trouble falling or staying asleep or sleeping too much for 2 to 6 days and took an antipsychotic. The resident’s CAA dated 6/26/25 was triggered for psychotropic drug use because the resident took an antipsychotic and an antidepressant. The CAA stated psychotropic drug use would be addressed in the care plan to avoid complications and minimize risks, and noted the resident could be at risk for sedation, memory loss, or falls due to psychotropic medications. Physician orders showed olanzapine 5 mg daily was ordered for sleep and anxiety related to schizoaffective disorder, then for delirium and sleep, and later continued for delirium and sleep. The care plan report lacked a specific care plan related to antipsychotic use. During interviews, staff and the consulting pharmacist stated psychotropic medications should have a care plan with target behaviors and side effect monitoring, and facility leadership stated an antipsychotic care plan was expected but was not present.
Care plans not updated to reflect current resident needs
Penalty
Summary
The facility failed to keep care plans revised and updated with current health status for 3 residents reviewed for care planning. The report states that comprehensive, person-centered care plans are to be developed within 7 days of the required MDS assessment and revised when resident conditions change, but the care plans for R4, R27, and R13 did not reflect current orders, assessments, and needs documented in the record. R4’s records showed diagnoses including CHF, DM2, CKD, and dependence on renal dialysis. Although the later care plan noted that the resident required ongoing dialysis and included some general interventions, the care plan and physician orders lacked specific dialysis-related information such as the dialysis company, contact information, the arm with the AV graft, and directions for assessing the graft site. During observation and interviews, R4 stated he had been to dialysis that afternoon and that nurses did not look at his dialysis site, while staff stated they were unsure where to find dialysis directions or contact information and described the care plan as generic rather than specific to his needs. R27’s assessments and orders showed moderate cognitive impairment, hemiplegia, apraxia, dysphagia, and a diet order requiring mechanical soft texture, thin liquids, and supervision with meals to cue alternating bites and sips and to stop eating if coughing occurred. However, the care plan still described R27 as independent with eating and only needing set-up help, and it did not reflect the need for supervision or the fact that dentures were missing. R13’s significant change MDS and provider order showed chronic respiratory failure and oxygen therapy at 1 L via nasal cannula, but the care plan did not include oxygen-related cares or treatments. Staff interviews confirmed that R27’s care plan had not been updated to match the current orders and that R13’s care plan did not indicate oxygen use.
Failure to Provide Ordered Meal Supervision and Cueing
Penalty
Summary
The facility failed to ensure ADL assistance was provided for a resident who required supervision and cueing during meals. R27 had moderate cognitive impairment, hemiplegia affecting the right dominant side after a cerebral infarction, apraxia, speech/language deficits, and dysphagia. Her records showed she used a wheelchair, had impairment on one side of her upper extremity, and had recent diet changes after losing dentures and having difficulty swallowing and chewing regular foods. The SLP downgraded her diet to mechanical soft with gravy and ordered supervision during meals to cue alternating bites and sips and to stop eating if she started coughing. During observation in the dining room, R27 was served foods including an omelet, hashbrowns, a donut, and cereal. Staff assisted only with putting sugar on the cereal and then walked away, and no nursing staff remained in the dining room to supervise her meal. The activity director was present but stated she did not have training in assisting residents with eating. Nursing assistant and kitchen staff stated there were no nurses or nursing assistants supervising R27, and the DON stated she did not know why the diet orders did not transfer to the meal ticket. The DON also stated the aides should be the staff providing supervision to residents requiring supervision during meals. R27’s care plan had been revised to state she was independent with eating and needed set-up help only, which was contrary to the assessment and diet orders indicating supervision was needed. On another observation, R27 sat with another resident and no staff were in the dining room assisting residents; R27 took food from the other resident’s plate. The SW intervened after the surveyor alerted her, and the food was removed. RN-C later stated a nurse or NA was responsible for providing supervision when ordered and verified that the supervision order should have been followed.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide ADL care to a resident who was dependent on staff for bathing. The resident had diagnoses including chronic respiratory failure, high blood pressure, kidney failure, and atrial fibrillation. The resident’s MDS indicated intact cognition, was continent of bowel and bladder, and required substantial to maximal assistance with ADLs, including bathing. The care plan identified a self-care deficit with bathing and noted that the resident’s preferences would be considered when providing care. A shower schedule posted at the nurses station indicated the resident was to receive showers on Wednesday and Saturday evenings. Although a progress note documented a shower as completed on one Wednesday evening, the resident repeatedly stated during interviews that she had not received showers as scheduled and that staff told her they did not have time. The resident reported itching in her groin area and stated she had not had a shower for nine days and was upset about not getting one because she liked her showers. Nursing assistants stated residents were scheduled for two showers so that if one was missed due to staffing, another would still be provided, and one NA stated showers were documented in the electronic POC. However, review of the POC showed documentation that the resident received a shower on one date despite her stating she did not, and documentation that she refused a shower on another date despite her stating she did not. The DON stated staff would be expected to provide showers as scheduled unless there was a specific reason such as the resident not being in the building or declining.
Failure to Carry Out Wound Care, Measure Edema, and Obtain Admission Weight
Penalty
Summary
The facility failed to implement wound care orders for two residents with venous ulcers. One resident had moderate cognitive impairment, venous insufficiency, cellulitis of the left lower extremity, heart failure, and multiple venous ulcers. After wound rounds, the provider updated treatment orders for the right shin and left lateral calf, but the progress note was uploaded without signatures or sign-off showing the orders were transcribed. The prior wound order remained active until several days after the new orders were sent, and the new wound treatments did not begin until after the ordered start date. During observation, the resident was sitting in a chair with legs not elevated, and nursing staff stated they were not aware of interventions related to the leg wounds or leg elevation. The RN confirmed the wound care orders were not transcribed after wound rounds and the new treatment was not started until later. A second resident with chronic venous hypertension and lymphedema also had deteriorating venous wounds on both lower legs. The provider updated the treatment plan to include cleansing, skin prep, calcium alginate, superabsorbent dressing, and wrapping daily and as needed, but the progress note was uploaded without signatures or sign-off showing the orders were transcribed. The prior wound order remained in place until several days after the new orders were sent, and the new daily dressing changes did not begin until after the ordered start date. During observation, the resident was sitting in a chair with legs not elevated, both legs wrapped in kerlix, and the resident stated dressings were often leaking and it was hard to find anyone to change them. Nursing staff confirmed the wound care orders were not started right away and that extra dressing changes were sometimes needed. The facility also failed to ensure provider-ordered thigh measurements were completed and documented for a resident with edema and possible lymphedema. The provider ordered daily thigh measurements for 7 days and then weekly, but the record showed only some measurements and no documentation of further measurements after the initial period. Nursing staff stated measurements were taken but not documented in the electronic record, and one nurse later found handwritten notes and planned to enter a late note. The DON acknowledged documentation was expected in the EMR and that lack of documentation was a problem, while the provider stated the measurements were important because without them nursing and providers could not detect changes in thigh circumference. The facility further failed to obtain a weight upon admission and follow ordered weight monitoring for a resident admitted with heart failure and other diagnoses. The admission record did not document a weight, despite orders to obtain a weight upon admission, the next day, weekly for two weeks, and then monthly. The only facility weight found was later in the stay, and the resident was subsequently hospitalized with reports of more than a 20-pound weight gain since the recent discharge and a bed weight at the facility of 426 pounds compared with 399 pounds at discharge. The record also showed ordered potassium medication was not administered because it was unavailable, and staff documented repeated notes that it was waiting for pharmacy delivery. The provider stated a documented admission weight should have been obtained and that potassium was critical for residents with heart failure.
Failure to Ensure Use and Documentation of a Palm Brace
Penalty
Summary
The facility failed to ensure a palm brace was used for a resident with hemiplegia following a cerebral infarction affecting the right dominant side, apraxia, and other speech-language deficits. The resident’s quarterly MDS indicated she used a wheelchair, had impairment on one side of her upper extremity, and did not reject care. Her care plan identified a functional maintenance plan for potential contracture and stated she refused to use the splint that was provided, with interventions including applying a palm brace and a restorative toileting program. However, the care plan did not include directions for staff on what to do when the resident refused the splint or when the splint should be applied. The resident’s orders, MAR, and TAR lacked information that she had a splint. Progress notes from the prior year stated she was discharged from therapy and was to wear a right resting hand splint overnight and during the day as desired by the resident, removing it for meals and hygiene. Later progress notes documented weakness in the right hand, and a PMR consultation noted muscle atrophy and deconditioning secondary to prior stroke, limited ROM to the right upper and lower extremities, no movement of the right upper extremity against gravity, and high risk for functional impairment in developing contractures if not receiving adequate therapy. The resident’s chart reviewed from May 2024 through September 2025 lacked documentation that she refused to use a right-hand splint. During observation and interview, the resident shook her head no when asked if staff did exercises for her right hand, her right hand was curled, her right arm was limp, and she was not wearing a brace. She was also observed in the dining room without a brace. Nursing assistants stated they documented refusals in the computer and that refusals should be documented by both aides and nurses, but they did not know whether the resident wore a brace. One NA stated the resident did not refuse care except occasionally toileting, while another stated the resident had a splint but thought she took it off sometimes and later could not locate it. The DOR/COTA stated the resident had not had OT or PT referrals for her hand, expected the splint to be applied if care planned, and said refusals should be communicated to therapy; the RN and LPNs similarly stated staff should offer the splint, document refusals, and contact therapy or the physician, but the record lacked such documentation.
Failure to Implement Dietician-Recommended Nutritional Supplement
Penalty
Summary
The facility failed to ensure a nutritional supplement was ordered and implemented per the dietician recommendation for a resident with severe protein-calorie malnutrition. The resident’s quarterly MDS indicated moderately impaired cognition, setup assistance for eating, no rejection of care, and a diagnosis of severe protein-calorie malnutrition. The care plan identified impaired nutrition and directed staff to provide and serve diet/supplements as ordered and monitor intake. The RD documented on 7/29/25 that the resident had weight fluctuations related to ETOH abuse and severe protein-calorie malnutrition, with fair intake records and potential for altered nutrition related to diagnosis and history, and recommended offering Glucerna or a similar HNS three times daily between meals. Despite the RD recommendation and later documentation from the NP noting supplements twice daily, the physician’s orders dated 9/17/25 did not include an order for a nutritional supplement. The resident stated on 9/16/25 that he had not received or been offered a supplement drink or any type of nutritional drink since admission. An LPN reviewing the EMR confirmed there was no order for nutritional supplement drinks and stated the nurse was expected to enter the dietician’s order into the EMR and communicate it to dietary. The RD stated the recommendation had been emailed to the previous DON for implementation and expected the order to be entered and the supplement provided, while the NP and RN-C stated they expected the emailed dietician recommendations to be implemented.
Improper G-J Tube Feeding Administration and Wrong-Port Medication Delivery
Penalty
Summary
The facility failed to follow physician orders for a resident with a G-J tube by not administering the tube feeding formula for the ordered 16 hours per day and by using the wrong tube port for medication administration. The resident had diagnoses including acute hemiplegia following cerebral infarction, protein-calorie malnutrition, metabolic encephalopathy, dysphagia, and aphasia, and the MDS indicated severely impaired cognitive decision-making skills, no speech, and tube feeding for 51% or more of calories. The care plan directed tube feeding for dysphagia and included monitoring of intake and lab work, with the head of bed elevated during and after feeding. Observation showed the Isosource 1.5 formula bag was not labeled with the date or time it was started, and at one point the tube feeding was not attached to the resident even though the pump bag still contained formula. Later, the same formula bag remained hanging without proper labeling, and the feeding was not started at the ordered time. The MAR reflected that the feeding should have been discontinued at 6:00 a.m., but the pump was still running later that morning. Staff stated the feeding should have been started and stopped according to the schedule, and the RD and NP stated that running the feeding outside the ordered time could result in the resident receiving too many or too few calories. During medication administration, an LPN stopped the tube feeding and flushed the port labeled J, then administered carvedilol and levetiracetam through the J port instead of the G port specified on the wall sign and in the order. The LPN acknowledged using the wrong tube and stated she was supposed to use the other tube. The pharmacist identified this as a medication error in route of administration, and the DON confirmed that giving medications through the J tube instead of the ordered G tube would be considered a medication error.
Failure to Provide Ordered CPAP Therapy
Penalty
Summary
The facility failed to ensure continuous positive airway pressure (CPAP) therapy was used according to physician orders for a resident with morbid obesity, heart failure, acute respiratory failure, chronic pain, and obstructive sleep apnea. The resident’s care plan included CPAP use, oxygen at 4 liters per nasal cannula, head of bed elevation, and monitoring for sleep apnea risk factors. Physician orders also directed daily and weekly cleaning of CPAP/BiPAP equipment and ordered replacement supplies for the hose, mask, filters, reservoirs, and other necessary items. During observation, the resident was found in bed with oxygen in place at 4 liters per nasal cannula, while the CPAP machine sat on the bedside table without a mask, tubing, or power cord. The resident stated he had not worn the CPAP since admission because the mask and tubing were old and thrown away, and the plug-in cord was lost. He stated that after his July hospitalization, he told staff he wanted to start using the CPAP again but needed supplies and a power cord. On a later observation, the CPAP machine was still present without the needed equipment, and the resident stated staff had not addressed replacing the cord, mask, or tubing since he first asked at the end of July. Staff interviews showed the issue had been reported but not resolved. An LPN stated she informed the RN/care coordinator about a month earlier, and the RN said she notified the DON and had heard the equipment came from a different company and replacement parts were difficult to obtain. The NP stated she was not aware the resident was not wearing the CPAP and said someone should have replaced the supplies or informed her if they were unavailable. The DON stated she was not aware the resident’s CPAP lacked the proper equipment, and confirmed it was important for the resident to wear the CPAP due to his diagnosis.
Missed Ordered Pain Medication
Penalty
Summary
The facility failed to ensure provider-ordered pain medication was administered for a resident with chronic pain. The resident was cognitively intact, used a manual wheelchair, and had diagnoses including diabetes, chronic pain, polyneuropathy, and morbid obesity. The care plan addressed acute and chronic pain, including comfort measures and evaluation for non-verbal indicators of pain. The resident had a standing order for buprenorphine 2 mg sublingual twice daily for chronic pain. The MAR showed missed doses of buprenorphine on multiple scheduled administrations, with documentation indicating the medication was not available or not on hand. Progress notes recorded that the medication was unavailable on several occasions. The resident’s pain assessments during this period documented repeated reports of significant pain, including pain ratings as high as 10/10 in the bilateral lower extremities, feet, and legs. A nurse practitioner noted the resident continued to report that his pain was not well managed. During interview, the resident stated he had not received pain medication all weekend and reported 10/10 pain in both feet and legs, saying the facility was out of the medication and that there was no follow-up with him regarding the delay. Nursing staff stated that medications were expected to be reordered before supply ran low, that pharmacy delivery was available, and that the provider should be notified if the medication was unavailable. The vice president of clinical services confirmed that a missed medication was considered a medication error and that missed medications and medication errors had occurred.
Dialysis Care Not Properly Assessed or Coordinated
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care and services for a resident with congestive heart failure, type 2 diabetes, chronic kidney disease, and dependence on renal dialysis. The resident’s physician orders lacked dialysis-related directions, including monitoring of the dialysis site and communication with the dialysis company. The care plan was also not specific to the resident’s dialysis needs and did not identify which arm contained the AV graft, the dialysis company name or contact information, or when the graft site should be assessed. The resident stated he had been to dialysis and that nurses did not look at his dialysis site, and he removed the dressings himself. Staff interviews showed they did not know where to find dialysis-specific directions, how the facility communicated with the dialysis provider, or where to locate the dialysis company’s phone number. The DON stated she would expect the care plan to contain specific dialysis information and some type of nurse-to-nurse communication with dialysis staff, but did not know if that was occurring. RN-C stated the care plan was vague and not specific to the resident’s needs, and that the resident should have daily AV graft assessments, with that information included in the care plan and physician orders. Review of the EMR showed no AV graft assessment on multiple dates when the resident received dialysis treatment, and two calls to DaVita dialysis were not returned. A dialysis policy was requested but not received.
Medication Error Rate Exceeded 5%
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, with 3 medication errors out of 35 opportunities for an error rate of 8.57% involving 2 residents. One resident had diagnoses including acute hemiplegia following cerebral infarction, protein-calorie malnutrition, metabolic encephalopathy, dysphagia, and aphasia, and received tube feeding and medications via a G-J tube. During medication administration, an LPN disconnected tube feeding from the J tube, flushed the J port, and administered crushed carvedilol and levetiracetam through the J tube instead of the ordered G tube, then restarted tube feeding through the J tube. A sign above the bed indicated medications were to be given through the G tube, and the LPN acknowledged she should have used the other tube. The DON stated this was considered a medication error, and the pharmacist stated the route given was a medication error. A second resident had mild cognitive impairment, diabetes, bipolar disorder, and parkinsonism, and was ordered Sinemet 25-100 mg three times daily at 8:00 a.m., 2:00 p.m., and 8:00 p.m. During morning medication administration, the LPN gave Sinemet late and later verified that it was administered late and that the timing of this medication was important. The LPN stated she was caring for 21 residents, had only 2 nurses available, and tried to prioritize medications due closer together while also responding to other staff and resident requests. The DON stated medications were expected to be given on time and that timing was important to avoid giving medications too close together and to prevent worsening symptoms.
Missed Antibiotic Doses After Therapeutic Substitution
Penalty
Summary
The facility failed to ensure antibiotics were administered as prescribed for one resident who had moderate cognitive impairment, chronic respiratory failure, cellulitis of the left lower extremity, and heart failure. The resident had a provider order for doxycycline hyclate 100 mg twice daily for 7 days for cellulitis and received a dose on the evening of 9/11/25, but the medication was then marked as not available the next morning and discontinued on the MAR. A pharmacy therapeutic interchange communication form dated 9/12/25 directed staff to discontinue doxycycline hyclate and replace it with doxycycline monohydrate 100 mg twice daily, and to verify and transcribe the new order into the resident record, but there was no nursing signature showing this was completed. A packing slip showed doxycycline monohydrate was sent to the facility on 9/12/25, yet the provider order for doxycycline monohydrate 100 mg twice daily was not entered until 9/14/25. The resident’s MAR showed two missed doses of doxycycline monohydrate on 9/12/25 and 9/13/25. During interview, RN-B confirmed the missed doses and stated that when antibiotics are ordered, staff may use the emergency kit until pharmacy delivers the medication, and that substitutions are communicated by pharmacy for staff to discontinue the prior order and transcribe the substitute order. The clinical pharmacist stated missed or delayed antibiotic doses would be significant, and the DON and RN-C stated nurses were expected to transcribe substituted orders when received and ensure there was no delay in treatment.
Failure to Timely Refer Resident for Dental Services After Missing Dentures
Penalty
Summary
The facility failed to timely refer a resident for dental services after the resident’s dentures were reported missing. The resident had moderate cognitive impairment, required supervision for eating, and had diagnoses including hemiplegia following a cerebral infarction, apraxia, speech-language deficits, dysphagia, and diabetes. The resident’s orders included a mechanical soft diet with gravy, soft foods, no breads, thin liquids, and supervision during meals to cue alternating bites and sips and to stop eating to clear the throat if coughing occurred. The resident’s speech therapy evaluation noted choking and difficulty swallowing, and also documented that the resident could not find the dentures and was having difficulty eating regular foods. The diet was downgraded to soft and bite-sized/mechanical soft because the resident did not have dentures and could not fully chew food. Progress notes later documented that the resident had a missing upper denture, a lower denture in the room that was not worn, and that the room had been searched, but there was no documented dental appointment or reason for delay in arranging one. During interviews and observations, staff and family reported that the dentures had been missing for at least 1 to 3 weeks, and the resident was observed without teeth and struggling with the modified diet. The resident pointed to the mouth, indicated needing help finding the teeth, and nodded yes when asked about trouble chewing. Staff stated the dentures had not yet been found, there was no plan yet for new dentures, and the dental appointment had not been set up. The facility’s Dental Services policy stated that if dentures are damaged or lost, residents will be referred for dental services within 3 days, and if the referral is not made in 3 days, documentation must explain how the resident is being helped to eat and drink adequately while awaiting services and the reason for the delay.
Failure to Provide Ordered Texture-Modified Diet
Penalty
Summary
The facility failed to provide a diet as ordered for a resident with a history of hemiplegia following cerebral infarction, apraxia, speech-language deficits, and dysphagia. The resident’s care plan and physician orders directed a downgraded texture diet of mechanical soft with gravy, soft foods with no breads, diabetic diet, thin liquids, and supervision during meals to cue alternating bites and sips and to stop eating if coughing occurred. Speech therapy had evaluated the resident after recent choking and difficulty swallowing, and the resident had also lost dentures, which contributed to the diet modification. Despite those orders, the resident’s progress notes and meal ticket continued to reflect a regular diet. On the morning of observation, the resident was in the dining room with foods including an omelet, hashbrowns, a donut, and cereal, and an unnamed staff member only assisted with sugar on the cereal before walking away. The resident was not supervised by nursing staff in the dining room, and the activity director was present but stated she was not an aide or nurse. During interviews, the cook and culinary director verified there were no nurses or nursing assistants in the dining room and stated the resident could have donuts. A nursing assistant stated she did not think the resident could have donuts because she did not have dentures and verified regular dry donuts were on the resident’s plate. The DON and culinary director later confirmed the meal ticket still showed a regular diet even though the diet had been downgraded, and the DON stated she did not know why the diet did not switch over in the kitchen. Speech therapy later stated donuts were considered bread and that the resident should not have had them.
Failure to Monitor Resident on Antibiotics
Penalty
Summary
The facility failed to ensure its antibiotic stewardship program was implemented for one resident who was receiving doxycycline monohydrate 100 mg twice daily for 7 days for cellulitis of the lower legs. The resident’s significant change MDS indicated moderate cognitive impairment, chronic respiratory failure, cellulitis of the left lower extremity, and heart failure. The medical record lacked documentation that monitoring was in place for the cellulitis infection, and the resident’s care plan identified risk for infection due to vascular ulcers on both lower extremities with interventions to monitor for signs and symptoms of infection. During interviews, an LPN stated that when residents were placed on antibiotics, additional orders for monitoring and vital signs each shift were usually entered, but there were no monitoring orders for this resident and the antibiotic order entry likely omitted them. The acting infection preventionist stated staff were expected to monitor for signs and symptoms of worsening infection and complete an assessment, but acknowledged staff had not been doing this. The DON and RN stated there should be an assessment or note documenting monitoring for worsening or improved infection when residents were on antibiotics, and RN stated they were aware infection monitoring while on antibiotics was lacking. The facility’s antibiotic stewardship policy stated the program’s purpose was to monitor antibiotic use in residents, but it lacked guidance on how nursing staff monitored residents on antibiotics for signs and symptoms of improving or worsening infection or a time-out period.
Failure to Offer and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that two residents, R6 and R35, were offered the pneumococcal vaccine, educated on the risks and benefits, and either administered the vaccine or documented as refusing it in accordance with CDC recommendations. R6’s record showed diagnoses including morbid obesity, heart failure, acute respiratory failure, chronic pain, and obstructive sleep apnea, and the resident had intact cognition with no behaviors or refusals of care. R6’s immunization record did not document an offer, refusal, or education regarding the pneumococcal vaccine, and during interview R6 stated no one had offered the vaccine since admission and that he would be interested in receiving it because of respiratory issues and multiple hospitalizations. R35’s record showed diagnoses including COPD, high blood pressure, obesity, and chronic pain syndrome, with intact cognition and no refusals of care. R35’s vaccination record showed Pneumovax 23 was given in 2012, but there was no documentation of any later offer, education on risks and benefits, or refusal of vaccination. The DON, who was also the infection preventionist, confirmed that R6 and R35 had not been offered the pneumococcal vaccine during the previous year, and stated that R35 had initially declined the vaccine in 2023 but was not offered further education or the vaccine in 2024. The facility’s pneumococcal vaccine policy required all residents to be offered pneumococcal vaccines and to receive documented education before vaccination.
Failure to Timely Assess and Manage Pain and Blood Glucose
Penalty
Summary
The facility failed to appropriately monitor and comprehensively assess complaints of pain and failed to assess or monitor blood glucose levels for a resident with multiple complex medical conditions, including multiple fractures, trauma, respiratory failure, and diabetes. Upon admission, the resident repeatedly reported severe pain rated as 9/10 on four separate assessments, but was not administered pain medication as ordered and waited approximately nine hours before receiving the prescribed narcotic pain medication. During this period, the resident was only given acetaminophen, which was ineffective, and no further interventions or escalation to the provider were documented. The resident ultimately called 911 due to unrelieved pain and was transported back to the hospital for pain management and assessment. Documentation and interviews revealed that the resident's vital signs were not reassessed after admission until two days later, and blood glucose monitoring was not initiated until two days after admission, despite orders for regular monitoring and the resident's insulin-dependent diabetes. Staff interviews confirmed that blood glucose checks and vital sign assessments were not performed as required by physician orders and facility protocols. The resident expressed concern about the lack of assessment and monitoring, questioning how staff would know if his condition deteriorated. Further investigation found that the facility's emergency medication kit (e-kit) was out of the prescribed pain medication, and the pharmacy did not deliver the medication promptly. The process for obtaining narcotic pain medications was delayed, and staff did not request a stat order or notify the provider in a timely manner. Facility policies required immediate interventions for pain and regular monitoring for diabetic residents, but these were not followed. The director of nursing acknowledged that immediate interventions and assessments should have occurred, and that the resident's blood glucose should have been checked on admission.
Failure to Administer Oxycodone per Physician Orders
Penalty
Summary
The facility failed to ensure that oxycodone hydrochloride (HCl), a narcotic pain medication, was administered according to physician orders for a resident admitted with multiple fractures and trauma. The resident's care plan lacked information related to pain management, and provider orders specified maximum dosing and frequency for oxycodone HCl. However, medication administration records and progress notes showed that the resident received oxycodone HCl more frequently than every four hours and in greater quantities than the maximum four doses per day as ordered. There were also instances where the resident received both 5 mg and 10 mg doses close together, resulting in a total dose that was not prescribed. Interviews with staff revealed that the facility ran out of medications in the emergency kit due to failure to reorder, leading to medication errors when the drugs were not available for administration. Staff also acknowledged that the narcotic count book did not contain proper dosing instructions, and orders were not consistently transcribed or recorded as required. Discrepancies were noted between the number of doses administered according to the medication administration record and the narcotic count book, with staff unable to account for the differences. Further, the pharmacy confirmed that the administration of both 5 mg and 10 mg doses together was a medication error, and the most current prescription for oxycodone HCl was not being followed by the facility. The director of nursing was unaware of the new order and acknowledged that errors occurred when doses were given more frequently than ordered and that these errors were not reported to the provider. The facility's policy required drug orders to be recorded and reviewed, but this was not consistently done.
Failure to Provide Sufficient Staffing and Timely Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff and oversight to meet the needs of all residents, resulting in multiple instances where residents did not receive timely care and assistance. Observations and interviews revealed that several residents, including those with significant mobility limitations, incontinence, and other complex medical conditions, experienced prolonged wait times for assistance with toileting, repositioning, and other activities of daily living (ADLs). For example, one resident with morbid obesity and reduced mobility waited over an hour to be assisted onto a bedpan, despite repeated requests and calls for help. Another resident reported being left in a wet pad for over two hours, with staff failing to respond to call lights in a timely manner. Call light response logs and resident interviews indicated a pattern of delayed responses, with numerous instances of call lights going unanswered for 20 minutes or more, and in some cases, up to several hours. Residents and staff reported that agency nursing assistants were often observed using cell phones while on duty, and there was a lack of accountability and supervision to ensure prompt response to resident needs. The facility's own policy required call lights to be answered within five minutes, but this standard was not met, as evidenced by both documented response times and resident grievances. Further review showed that the facility did not provide adequate orientation, training, or supervision for agency nursing assistants, and failed to ensure comprehensive care planning for residents with incontinence. The Director of Nursing and Assistant Director of Nursing acknowledged awareness of delayed call light responses but did not consistently review or act upon call light response data. The lack of effective communication and coordination among staff, as well as insufficient staffing levels and oversight, contributed to residents not receiving timely and appropriate care.
Failure to Ensure Nursing Assistant Competency and Orientation
Penalty
Summary
The facility failed to ensure that both employed and agency nursing assistants (NAs) received appropriate orientation, training, and supervision, as well as to verify and document their competency in providing resident care. Interviews with residents revealed concerns about agency staff lacking motivation, accountability, and knowledge of their job duties. Residents reported that agency NAs were unfamiliar with facility procedures, did not know how to use mechanical lifts, and sometimes asked residents for guidance on basic tasks and the location of supplies. Additionally, not all staff wore name tags, making it difficult for residents to distinguish between agency and employed staff. A review of the facility's orientation materials showed that the binder used for new employee and agency orientation was primarily focused on topics relevant to licensed nursing staff, with little job-specific information for NAs. There were no orientation checklists or documentation tools to ensure that NAs were trained in essential areas such as the use of mechanical lifts, location of supplies, resident preferences, transfer status, call light response times, or expectations regarding personal cell phone use. The assistant director of nursing (ADON) and director of nursing (DON) both confirmed that there was no documentation to verify that NAs had received or demonstrated required competencies, and that agency NAs did not have a specific orientation checklist. The only individualized resident care orientation provided to NAs was a single screenshot showing how to access the Kardex in the electronic medical record, and there was no follow-up to ensure agency NAs could access or use it. Employee files for two NAs showed missing or incomplete documentation of skill competencies and required in-service trainings. One NA had no skill competencies completed within the past year, while another had undated competency exams and incomplete Relias online training. The facility's own assessment and orientation policy described a comprehensive educational program and the use of checklists to ensure staff competency, but these practices were not reflected in the actual documentation or processes observed during the survey. The lack of proper orientation, training, and competency verification had the potential to affect all residents in the facility.
Failure to Employ Qualified Dietary Staff
Penalty
Summary
The facility failed to employ either a full-time registered dietician (RD) or a qualified dietary manager (DM) to oversee the food and nutrition service, potentially affecting all 44 residents who received food from the kitchen. Interviews revealed that the DM could not provide evidence of required certifications or qualifications, and her personnel file was incomplete. The DM stated she had a food safety certification and experience as a manager at another facility, but did not possess a certified dietary manager certificate or an associate's degree. The human resources director confirmed that the DM's personnel file was missing and that there were broader issues with incomplete employee files. The contracted RD reported working only 10 to 12 hours per week, typically on Mondays, and was not a full-time employee. The administrator acknowledged that the RD was a consultant and not full-time, and believed the DM was a certified dietary manager, though this could not be verified. The facility was unable to provide documentation of the DM's or RD's qualifications or certifications upon request, and the job description for the dietary manager position required at least a certified dietary manager or comparable certification, which was not substantiated by available records.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement and maintain an effective pest control program to eliminate mice, as evidenced by multiple documented sightings and the presence of mouse droppings in various areas, including the kitchen and dry storage. Pest control inspection reports over several months indicated repeated mouse activity, with staff often failing to log sightings or take consistent action. Observations revealed mouse droppings near traps, improperly stored food items, and unsanitary conditions such as spilled molasses, dried salsa, and unsecured bags of chips in the kitchen and storage areas. Staff interviews confirmed that doors to the outside were frequently propped open, which pest control personnel identified as a significant factor in allowing pests to enter the facility. The dumpster outside the kitchen was routinely left uncovered, and food waste was visible, further attracting pests. Housekeeping and dietary staff described inconsistent cleaning routines, with tables and floors often left with crumbs and food debris, especially overnight when housekeeping was not present. Nursing assistants were expected to clean tables after dinner, but observations showed food residue remained on surfaces into the morning. Staff also reported that residents sometimes kept food in their rooms without proper containers, and clutter in some rooms could conceal pest activity. Despite the facility's policy requiring all food to be stored in covered containers and for staff to report all pest sightings, there were lapses in both food storage and reporting. For example, a dead mouse found by an LPN was not logged, and the pest sighting log had not been updated for several months despite ongoing activity. Interviews with the administrator and maintenance staff revealed a lack of awareness of recent mouse sightings and inconsistent communication regarding pest control measures. The pest control company reduced its inspection frequency due to perceived decreased activity, but staff and pest control personnel acknowledged that mice were still present, particularly at night. The facility's own pest control policy outlined preventive measures such as keeping doors closed, using self-closing doors, and ensuring proper food storage, but these measures were not consistently followed. The combination of propped open doors, uncovered dumpsters, improper food storage, and inadequate reporting and cleaning contributed to the ongoing pest problem affecting all residents in the facility.
Deficient Food Storage, Labeling, and Sanitation Practices Identified
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and labeling practices. In the kitchen refrigerator, an opened sponge cake was found unlabeled and undated, and a container of dried milk was kept beyond its recommended use period. The kitchen freezer contained several food items, including gluten-free pasta shells stored on the floor, undated and unlabeled packages of waffles and egg omelets, and opened bags of chicken and chicken strips that were not properly sealed, labeled, or dated. In dry storage, an opened jug of molasses with residue on the outside and a jar of salsa with dried salsa and an unsecured lid were found. Multiple opened bags of tortilla chips were not properly closed, and scoops were stored inside a sugar bin, contrary to facility policy. The lids of sugar and flour bins were also found to be soiled with food debris. Additionally, the coffee machine had visible debris and buildup, and a salad brought from outside was found in the kitchenette refrigerator without a label or date. Interviews with the dietary manager and administrator confirmed awareness of the improper food storage and labeling practices, as well as the potential for pest attraction due to these lapses. Facility policies require that all food items be labeled, dated, and stored in clean, sealed containers, with scoops kept outside of food bins and all foods stored off the floor. The observed failures to follow these procedures were verified by both staff and management during the survey.
Failure to Ensure Resident Dignity and Access to Appropriate Clothing
Penalty
Summary
The facility failed to provide a dignified experience for two residents by not ensuring they had appropriate clothing and by allowing staff to speak to a resident in an undignified manner. One resident, with diagnoses including weakness, morbid obesity, and bipolar disorder, required assistance with dressing and reported being scolded by a nursing assistant after accidentally soiling her shirt. The resident stated she felt she was treated like a child and had reported the incident to a nurse, who was supposed to notify the assistant director of nursing (ADON). However, the ADON did not recall receiving the grievance form and had not followed up on the report until the resident brought it up again. Another resident, with chronic medical conditions and moderately impaired cognition, was observed without clothing except for a robe and slippers. The resident stated she had no other clothing at the facility, as her belongings remained at her previous group home and the facility no longer provided gowns. Staff interviews confirmed the resident's lack of clothing and indicated that attempts to retrieve her belongings had been unsuccessful. The social services staff and ADON acknowledged the dignity concern of the resident not having appropriate clothing for an extended period. Facility policy requires residents to be treated with dignity and respect, including being encouraged to dress in their preferred clothing and being spoken to respectfully at all times. Despite this, the facility did not ensure that the residents had access to appropriate clothing or that staff consistently interacted with residents in a dignified manner, resulting in a failure to honor the residents' rights to dignity and self-determination.
Failure to Notify Family of Resident's Change in Condition and Hospitalization
Penalty
Summary
The facility failed to provide timely notification to a family member regarding a resident's change in condition and subsequent hospitalization. The resident in question was severely cognitively impaired and had diagnoses including cerebral infarction, quadriplegia, hypertension, and seizure disorders. Progress notes indicated that the resident experienced increased coughing and bleeding from the mouth, which led to a nurse practitioner being updated and new medication ordered. The following day, the resident's condition changed further, and the nurse practitioner ordered a transfer to the hospital for evaluation. Despite these significant changes, there was no documentation in the progress notes that the resident's family was notified about the change in condition, new orders, or the hospital transfer. During interviews, a family member confirmed she was not informed by the facility and only learned of the hospitalization from a hospital physician. The DON acknowledged that the family should have been notified prior to the transfer and confirmed that this did not occur. The facility was unable to provide a policy regarding notification of change in condition and transfer.
Failure to Investigate Resident's Report of Missing Clothing
Penalty
Summary
A resident with diagnoses including weakness, adult failure to thrive, morbid obesity, and bipolar disorder with psychotic features reported missing clothing items to nursing staff. The resident, who required substantial assistance with dressing and was dependent on staff for lower body dressing, stated she informed a nurse about the missing items but did not recall the nurse's name and did not complete a formal grievance form. The resident reported that the nurse said she would look into the matter, but no further follow-up occurred, and the resident had not received any updates regarding her missing clothing. Interviews with social services, the assistant director of nursing, and the director of nursing revealed that none were aware of the missing clothing until the week of the survey. All agreed that a grievance form should have been completed by the nurse who received the report, in accordance with facility policy, which requires prompt investigation of complaints regarding resident property. The failure to document and investigate the resident's report of missing clothing resulted in the deficiency.
Inaccurate MDS Coding for Medication Administration
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident during their annual assessment. The assessment indicated the resident had limited upper extremity range of motion, was cognitively intact, and had diagnoses including renal insufficiency, amputation, diabetes, heart failure, and atrial fibrillation. The MDS section N0415 documented that the resident was taking an antidepressant and an antibiotic, but did not indicate that the resident was also receiving an anticoagulant, despite this being the case during the assessment period. During an interview, the DON confirmed that the resident did receive an anticoagulant during the MDS review period, but this was not reflected in the assessment. The DON acknowledged the importance of MDS accuracy for both payment and care planning. The facility's policy on MDS error correction outlines procedures for correcting both minor and major errors, depending on the impact on the resident's clinical status and care plan.
Failure to Provide Baseline Care Plan Summary Upon Admission
Penalty
Summary
The facility failed to provide a summary of the baseline care plan to a resident and/or the resident's representative within the required timeframe after admission. The resident, who was admitted with an infection and inflammatory reaction due to an internal joint prosthesis, was cognitively intact and receiving pain management, wound care, oxygen, and therapy services. Documentation in the electronic medical record did not show evidence that a baseline care plan was given to the resident. Interviews with the resident and staff confirmed that the resident did not recall receiving a care plan or participating in a care conference, and staff were unable to provide documentation that the care conference or baseline care plan had been completed or provided. Facility policy required that a baseline plan of care be developed within forty-eight hours of admission and that a written summary be provided to the resident or representative, with documentation of this provision in the medical record. However, staff interviews revealed that the initial care conference, where the baseline care plan is typically provided, may not have occurred within the required timeframe, and no documentation could be produced to show that the baseline care plan summary was given to the resident. This resulted in a failure to meet the resident's immediate needs as outlined by facility policy and regulatory requirements.
Failure to Develop and Maintain Comprehensive Care Plans for Residents with Pressure Ulcer and Respiratory Risks
Penalty
Summary
The facility failed to develop and maintain comprehensive care plans for two residents with significant medical needs. One resident, who had diagnoses including a right tibia fracture, type 2 diabetes, morbid obesity, and pulmonary embolism, was assessed as being at moderate risk for pressure ulcers according to multiple Braden Scale assessments. Despite this, the resident's care plan did not include a risk for skin breakdown or specific interventions to prevent pressure ulcers, even though the nurse practitioner had recommended a repositioning program and heel protectors. Nursing staff believed that repositioning was part of the care plan, but documentation did not reflect this, and the director of nursing confirmed the absence of a preventive care plan for skin breakdown. Another resident with morbid obesity, chronic pain, reduced mobility, and obstructive sleep apnea was observed using an oxygen concentrator and a non-invasive mechanical ventilator. The care plan for this resident did not address the risk or potential for respiratory system impairment, despite the presence of respiratory equipment and physician orders for a non-invasive ventilator. Additionally, there was no physician order for oxygen, even though the resident had been on oxygen since admission, and the care plan did not address the use of oxygen or other respiratory interventions. The LPN and DON both confirmed the lack of a respiratory care plan for this resident. Facility policy requires that comprehensive, person-centered care plans include measurable objectives, timeframes, and services to maintain residents' highest practicable well-being, and that care plans be revised as residents' conditions change. In both cases, the facility did not ensure that care plans reflected the residents' current needs and risks, as evidenced by the lack of documented interventions for pressure ulcer prevention and respiratory care.
Failure to Conduct Required Care Conferences for Residents
Penalty
Summary
The facility failed to ensure that care conferences were conducted as required for three residents reviewed for care planning. For one resident with moderate cognitive impairment and multiple diagnoses, a care conference was scheduled but canceled at the family's request. The family requested to reschedule, but the social services staff did not follow up, and the care conference was never rescheduled. The director of nursing acknowledged that the facility should accommodate care conferences to facilitate resident and family participation. Another resident, who was cognitively intact and admitted with a surgical wound and on a pain management program, did not have evidence of a care conference after admission, despite documentation indicating that one should have occurred. The resident reported not recalling any care conference involving the interdisciplinary team, and the social services staff confirmed that the resident did not meet with the full team to discuss care planning or rehabilitation goals. The director of nursing stated that care conferences should be scheduled shortly after admission and rescheduled promptly if missed. A third resident, also cognitively intact and with a history of amputation and other medical conditions, did not recall having a care conference. Social services staff indicated that care conferences were sometimes not conducted if the resident declined, and the interdisciplinary team did not always meet without the resident to review care areas. The director of nursing clarified that care conferences should occur every 92 days regardless of resident attendance. The facility's policy required care conferences to develop and review care plans with the interdisciplinary team, but this was not consistently followed.
Failure to Provide Routine Nail Care for Dependent Resident
Penalty
Summary
A resident who was severely cognitively impaired and diagnosed with cerebral infarction, quadriplegia, essential hypertension, and seizure disorders was found to be dependent on staff for all activities of daily living, including personal hygiene. The resident's care plan specified the need for total assistance with personal hygiene, and facility policy required regular cleaning and trimming of fingernails to prevent infection. Despite these directives, multiple observations over several days revealed that the resident's fingernails were about half an inch long and had black debris underneath. Staff interviews confirmed that the resident's nails had not been trimmed or cleaned as required, and there was uncertainty among staff regarding responsibility for nail care, especially since the resident was diabetic and required a nurse to perform this task. A family member also reported observing the resident's long and dirty fingernails and left a voicemail for the charge nurse requesting nail care, but the issue persisted in subsequent observations. Nursing assistants and an LPN acknowledged the condition of the resident's nails and described the process for nail care, but the care was not provided in a timely manner. The DON stated that nails should be cut on bath days or weekly, and recognized the risk of infection and dignity issues associated with untrimmed nails, particularly for residents with contractures. The facility's failure to provide routine nail care as outlined in the care plan and policy resulted in the resident having long, dirty fingernails over multiple days.
Failure to Transcribe and Implement Physician Orders for Compression Stockings and Wound Care
Penalty
Summary
The facility failed to properly transcribe and implement physician orders for a resident who required monitoring and care for edema and a surgical incision. The resident had multiple complex diagnoses, including infection and inflammatory reaction due to a joint prosthesis, heart failure, cellulitis, and respiratory failure. Physician orders included the use of compression stockings (ted hose) and specific wound care instructions, but these were not consistently transcribed into the treatment administration record (TAR) or medication administration record (MAR), resulting in a lack of documentation and implementation by nursing staff. Observations and interviews revealed that the resident was not wearing the prescribed ted stockings and was managing wound care independently, as staff were unaware of the current orders. The resident reported that staff never assisted with the ted stockings or wound care, and he had to perform these tasks himself. Documentation for wound care orders was either missing or not completed, and the order for ted stockings was not visible to nurses in their daily assignments due to improper transcription in the electronic health record system. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the orders for ted stockings and wound care were not properly processed or carried over into the nurses' daily assignments, making them inaccessible for routine care. The resident's care plan was not updated to reflect the need for ted stockings or address edema, and there were no reviews or updates to the wound management care plan after the initial entry. This resulted in the resident not receiving care as ordered and required by his condition.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
A deficiency occurred when the facility failed to implement interventions to prevent the development of new pressure ulcers for a resident with multiple risk factors. The resident had a history of right tibia fracture, type 2 diabetes, morbid obesity, and was incontinent of stool. Upon admission, the resident was assessed as cognitively intact and at moderate risk for pressure ulcers according to the Braden Scale, with subsequent assessments indicating high risk. Despite these risk factors and recommendations from wound care specialists, the resident's care plan did not include specific interventions for the prevention of skin breakdown. Observations and interviews revealed that the resident was not consistently repositioned according to the recommended schedule. The resident was observed lying in the same position for extended periods, and staff interviews confirmed that repositioning was not performed every two hours as required. Additionally, heel protectors were not consistently applied to both heels, and the resident's right heel was found resting on the bed without protection. The facility's own policy required individualized repositioning schedules and the use of support devices for residents at risk, but these measures were not fully implemented for this resident. Documentation showed that the resident developed new pressure ulcers, including an unstageable ulcer on the left heel and a stage 3 ulcer on the left gluteus, while under the facility's care. Wound care notes and staff interviews confirmed that the resident required assistance with mobility and repositioning, yet these interventions were not reliably provided. The director of nursing acknowledged the absence of a care plan for skin breakdown prevention and confirmed that the resident should have had heel protectors on both feet and been repositioned every 1-2 hours.
Failure to Assess and Supervise Safe Vaping Practices for Medical Marijuana
Penalty
Summary
The facility failed to comprehensively assess and ensure safe vaping practices for a resident with a medical marijuana card who was observed vaping THC in his room. The resident, who had diagnoses including malignant cancer of the bladder, chronic pain, anxiety, and insomnia, was dependent on staff for some activities of daily living and experienced constant pain. Despite the resident's use of medical marijuana being known to some staff, there was no documentation in the physician orders or care plan regarding the use or method of administration of medical marijuana, nor was there an assessment for safe vaping practices. Smoking assessments conducted at various intervals indicated the resident was a non-smoker, and the option for vaping was not selected in the electronic assessment tool, resulting in the absence of a safe vaping assessment. The facility's director of nursing (DON) and assistant director of nursing (ADON) were unaware that the resident was vaping, and the DON stated that while the resident was provided a locked box for marijuana supplies, the facility did not inquire about the method of ingestion or monitor the use. The facility's medical cannabis policy required physician support, documentation, and care plan updates for medical cannabis use, and specifically prohibited vaporizing or smoking cannabis within the facility or on its grounds. Despite these policies, the resident was observed vaping in bed, and documentation in the medical record by a physician assistant indicated prior awareness of the resident's use of a vape pen for THC. The facility did not assess the resident for safe self-administration of vaping, did not update the care plan to reflect the use of medical marijuana, and did not monitor or supervise the resident's vaping activities, resulting in a failure to prevent potential accident hazards related to vaping within the facility.
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Nursing homes near Saint Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Carondelet Village Care Center | 1.6 mi | ★★★★★ | 6 | 0 |
| Hayes Residence | 1.6 mi | ★★★★★ | 0 | 0 |
| Shirley Chapman Sholom Home East | 1.7 mi | ★★★★★ | 0 | 0 |
| Mn Veterans Home Minneapolis | 2.1 mi | ★★★★★ | 1 | 1 |
| Episcopal Church Home Of Minnesota | 3.5 mi | ★★★★★ | 17 | 1 |
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