Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North Ridge Health And Rehab during CMS and state inspections, most recent first.
Meals were served to multiple residents on hard plastic trays in the dining room, with the trays left under the plates, beverages, and silverware during the meal. Staff did not remove the trays or offer to do so, and one resident said he did not like eating from the tray. In a separate incident, an NA knocked once and entered a resident’s room without waiting for permission, and the resident stated staff just walk right in and that he did not feel he had adequate privacy.
Failure to Provide Bed-Hold Notice at Transfer: The facility did not document that written bed-hold information, including the duration of the bed hold and reserve bed payment details, was provided to residents or their representatives when residents were transferred to the hospital. Four residents had hospital transfers, but EMRs lacked evidence of signed bed-hold forms or follow-up documentation; one resident stated he was never offered a bed-hold form, and another record noted a POA signature without showing what information was provided.
Incomplete controlled substance reconciliation documentation: Controlled substances in two medication carts were counted at shift change, but the Narcotic Shift to Shift Signature forms had numerous blank signature spaces. RN staff stated the counts were documented on the forms, yet the nurse manager confirmed about half the signatures were missing on one form and could not verify that reconciliation had occurred based on the documentation. The DON stated shift-to-shift controlled medication reconciliation was expected, and the facility policy required a physical count by the oncoming and outgoing licensed nurse/designee.
Food was not served in a timely manner to keep meals at an appetizing temperature. Several cognitively intact residents reported that meals, including items like French fries, were consistently cold whether eaten in the dining room or in their rooms. During observation, the DM found food in the warmer above 140 F, but the last tray served in the memory care unit had dropped well below 140 F, and the DM stated food below 140 F was in the danger zone.
Failure to obtain consent for a psychotropic medication: A resident with severe cognitive impairment and diagnoses including dementia and insomnia was ordered trazodone for bedtime use, but the medical record lacked evidence that consent was obtained before the medication was used. RNs and the DON stated consent was expected for new psychotropic medications or when a resident was admitted on one, and the facility policy did not address consent for psychotropic use.
Failure to Assess Self-Administration of Medication: A cognitively intact resident with DM, heart disease, and kidney disease kept prescription nystatin ointment at bedside and used it as needed, but no SAM assessment was completed or documented. Staff and the DON confirmed the resident was never assessed for safe self-administration, no provider order or care plan update was obtained, and the discontinued medication remained in the room.
Call Lights Not Kept Within Reach: Two residents were observed with call lights wrapped around the bedrail or wall unit and out of sight and reach while they were in bed or seated in a wheelchair. One resident was cognitively intact with mobility and ADL impairments, and the other had impaired cognition and multiple chronic conditions. Staff, including an LPN, NAs, RNs, and the DON, confirmed the call lights were not within reach, despite the facility policy requiring them to be within easy reach when residents are in bed or confined to a chair.
Failure to Complete Quarterly Restraint Reassessments: A resident with quadriplegia, muscle weakness, and impaired mobility used a wheelchair seat belt and lap tray, and observations showed both devices in place while the resident was in a power wheelchair. Although the care plan addressed the seat belt and noted the resident could independently lock and release it, the EMR showed the last restraint quarterly assessment was completed months earlier, with no later reassessment documented. RN and DON interviews confirmed the quarterly reassessment was expected but had not been completed.
A resident with intact cognition and diagnoses including respiratory failure, COPD, and tracheostomy status received PRN lorazepam and PRN quetiapine with stop dates that allowed both psychotropic orders to remain active beyond the 14-day limit, without documented practitioner rationale or evaluation to support continued use. The facility also did not order or complete orthostatic BP monitoring for the resident’s antipsychotic use, and the RNCM and DON confirmed the 14-day requirements and the need for orthostatic monitoring.
Inaccurate MDS Coding for Falls and Medication Use: The facility failed to accurately code MDS assessments for three residents. One resident’s MDS omitted a recent fall with hip fracture despite documentation in the care plan, and two residents were coded as taking anticoagulants when MARs showed they were receiving aspirin, an antiplatelet, instead. The DON and MDS staff confirmed the coding errors after record review.
Failure to provide routine personal hygiene and grooming: A resident who was cognitively intact and needed staff help with personal hygiene was repeatedly observed with scruffy facial and neck hair, despite stating he preferred to be clean shaven. Staff identified shaving as part of personal hygiene and said it was typically done on bath days, while the DON stated resident grooming preferences should be honored whenever possible.
Failure to implement a fall intervention for a resident with repeated bed falls. A cognitively intact resident with arthritis and depression fell out of bed more than once while trying to reposition herself, and staff documented that a larger bed was intended after the first fall. However, observations showed the resident still had a standard bed, and RN, LPN, and maintenance interviews confirmed the larger bed had not been provided.
Incomplete Foley catheter orders were identified for a resident with moderate cognitive impairment and diagnoses including dementia, diabetes, atrial fibrillation, hypertension, and myelodysplastic syndrome. The resident’s order summary, TAR, and care plan all listed an indwelling Foley catheter for comfort, but none included the catheter size or balloon volume needed for replacement, and RN and DON interviews confirmed the missing details.
A resident with severe cognitive impairment, dependence for feeding, and a diagnosis of weight loss experienced significant unplanned weight loss while the care plan and MD orders conflicted on weight monitoring frequency. The resident lost 26.2 lbs over about 2 months, yet the nutrition note continued the current plan of care without new interventions or escalation, and staff acknowledged the interventions were not effective and the nutritional decline needed further evaluation.
Incomplete respiratory orders and oxygen not provided as ordered. The facility failed to ensure complete trach and O2 orders for two residents with trachs and respiratory conditions. One resident’s O2 was repeatedly set at 3 LPM instead of the ordered 5 LPM, and another resident received O2 without a current order for flow rate, delivery method, frequency, or parameters. The trach care orders for two residents did not identify the specific trach type or size, and RN-A, the RNCM, and the DON confirmed the missing order details.
Failure to Offer and Document Non-Pharmacological Pain Interventions: A resident with metastatic prostate cancer and neoplasm-related pain received frequent PRN hydromorphone and other PRN pain meds, but staff did not offer, implement, or document non-pharmacological pain interventions before or after administration. The resident stated massage had helped in the past but had not been offered, and staff interviews confirmed they were expected to document interventions and their effectiveness, yet no individualized non-pharmacological pain measures were identified in the care plan.
An LPN failed to verify the prescribed methadone dose for a resident with cancer-related pain and administered 20 mg instead of the ordered 50 mg morning dose because she removed tablets in the order packaged from a card containing multiple doses. She also entered an incorrect narcotic count in the controlled substance record and later corrected it after the error was identified. The DON and Nurse Manager stated nurses were expected to follow the five rights, verify medication directions, and accurately document controlled substance administration.
A resident with severe cognitive impairment, dementia, insomnia, and other diagnoses was prescribed trazodone for insomnia, and the consulting pharmacist recommended psychotropic consent and sleep monitoring. The resident’s record lacked evidence that consent was obtained or that sleep monitoring was completed, and RN and DON interviews confirmed the recommendations were not carried out timely.
A resident with severe cognitive impairment and multiple diagnoses, including HTN, CKD, dementia, diabetes, and anxiety, had an order for metoprolol ER with hold parameters for SBP and HR. The MARs showed BP monitoring but did not document HR monitoring or recording as ordered. RN-I, RN-J, and the DON confirmed the order and MAR did not prompt HR documentation, and the facility policy did not address medication parameters.
A resident with renal insufficiency, dialysis dependence, and anemia had a critical low Hgb reported, but the facility did not document completion of ordered weekly CBC labs, refusal of the draw, or follow-up with the provider. The resident said he wanted labs drawn on dialysis days, and staff noted the draw was not documented as done or declined, with no documented coordination with the dialysis unit.
Failure to Follow Dental Recommendations and Support Denture Use: The facility did not ensure two residents received needed dental follow-up and denture support. One cognitively intact resident had documented ill-fitting dentures, but the care plan lacked specific denture interventions, no follow-up was documented, and staff were not assisting with denture placement despite the resident wanting to wear them. Another resident had loose upper and lower dentures, dental screenings called for denture adhesive, but the EMR, care plan, and room lacked evidence that the adhesive was provided, and staff confirmed the recommendation was not reflected in the resident’s care.
Failure to change gloves and perform hand hygiene during incontinent care: An NA provided perineal care for a cognitively intact resident with cancer-related diagnoses, then used the same contaminated gloves to apply a clean brief, reposition the resident, remove soiled linens, and handle clean linens and environmental surfaces. The IP and DON stated staff were expected to change gloves and perform hand hygiene between dirty and clean care tasks, and the facility policy directed hand hygiene before and after bathroom care and resident personal hygiene.
Outdated Nurse Staffing Post: The facility failed to keep the nurse staffing post updated each shift, and surveyors repeatedly found staffing information posted with prior dates. Front desk staff, the staffing coordinator, and the DON gave differing descriptions of who was responsible for updates, while the facility policy required the number of RN, LPN/LVN, and CNA staff to be posted at the beginning of each shift in a prominent, accessible, and readable location.
A resident fell when a sling tore during a Hoyer transfer, and surveyors found the facility used a non-facility sling brand and relied on incomplete lift assessments that did not document proper sling size or resident measurements. The same issue affected two residents who used Hoyer lifts and three residents who used sit-to-stand lifts, because care plans, Kardex entries, and point-of-care tasks did not identify the correct sling or harness size, and staff based sizing mainly on weight rather than comprehensive assessment.
A resident who required hemodialysis three times weekly did not have a dialysis-related care plan. The resident's MDS and provider orders documented the need for dialysis and post-dialysis assessments, but the care plan lacked a focus area and interventions for dialysis treatment. Staff stated dialysis care planning should include pre- and post-dialysis weights, VS, bruit and thrill checks, shunt or port site assessment, pain assessment, and lung sound assessment, and the RN and DON acknowledged the care plan was missing.
Incomplete and inaccurate dialysis assessments: A resident receiving hemodialysis had missing and incorrect pre- and post-dialysis documentation, including absent current weights, vital signs, and access-site assessments. The care plan lacked dialysis-specific interventions, one dialysis day had no communication form, and staff documented findings such as "ports capped and clamped" and no bruit, which the RN, MD, and DON stated were not accurate for the resident’s access and did not reflect proper dialysis monitoring.
A resident with complex medical needs did not receive medications according to physician orders, with staff failing to separate doses of Oxycodone and Suboxone as required and administering medications outside the prescribed time window on numerous occasions. These actions resulted in multiple medication errors and noncompliance with care plan directives.
A resident with multiple complex medical conditions required repositioning every two hours per their care plan, but staff did not document when repositioning occurred. Interviews with nursing assistants and an RN confirmed that documentation of turning and repositioning was not performed, and no ADL documentation policy was provided when requested.
Two residents who required assistance with toileting experienced significant delays in staff response to call lights, resulting in prolonged periods of incontinence and discomfort. Despite care plans and facility policy requiring prompt assistance, call light logs and interviews confirmed that staff often took much longer than the expected 10-15 minutes to respond, especially for those needing two staff members for care. These delays led to residents remaining in soiled briefs, causing distress and a loss of dignity.
A resident with impaired cognition and respiratory diagnoses did not have oxygen saturation monitored every shift as ordered by the provider. Staff and leadership confirmed that checks were not consistently performed or documented, and there was no task on the treatment administration record to prompt this monitoring, contrary to facility policy and provider orders.
A resident with chronic kidney disease and heart failure received supplemental oxygen therapy on multiple occasions without a provider order or care plan documentation. Staff and provider notes referenced ongoing oxygen use, but no official order was present, and the facility's policy requiring a physician's order for oxygen administration was not followed.
A facility failed to accurately document a resident's advance directives, leading to a discrepancy in their code status. The resident, who wished to be full code, had their EMR banner and physician orders indicating DNR, contradicting their POLST form. Staff relied on the EMR banner, risking non-compliance with the resident's wishes. Additionally, the facility did not update the POA for another resident, leading to potential miscommunication in care decisions.
The facility's call system was deficient, lacking audible alerts and functioning pagers for staff, affecting all 250 residents. Observations showed no call light indicators above rooms, and staff relied on visual cues from kiosks without carrying communication devices. Only nurse managers and supervisors had pagers for alerts, and the facility's call light policy was not provided.
A LTC facility experienced a medication error rate of 22.58%, involving four residents. Errors included administering expired medication, incorrect mixing of potassium chloride, late administration of ondansetron, and missing medications due to unavailability. Staff failed to adhere to medication administration guidelines, leading to these deficiencies.
The facility failed to properly track and secure emergency kits containing controlled substances, such as lorazepam, which were not included in narcotic counts at shift changes and were not secured in the refrigerator. The DON acknowledged the oversight, noting that staff should have visually confirmed the kit's presence during narcotic counts, as per facility policy.
The facility failed to properly label and store insulin pens and other medications, affecting multiple residents. Insulin pens lacked expiration dates, and expired medications were found in medication carts and rooms. Additionally, medications and supplies for discharged residents were not disposed of properly. Temperature control issues in medication storage areas were also identified, with refrigerator temperatures frequently outside the safe range.
The facility failed to follow infection control practices during tracheal care for two residents and tube feeding for another. A respiratory therapist did not use proper PPE during tracheal suctioning, and a nurse did not maintain sterility of gloves. Additionally, staff did not sanitize hands between glove changes during care for a cognitively impaired resident. Tube feeding procedures were compromised by using undated nutritional supplements and not cleaning shared surfaces, leading to potential infection risks.
A resident with significant physical limitations and a tracheostomy was not provided with an appropriate call light in a LTC facility. Despite the care plan indicating the need for a reachable call light, the resident was unable to use the provided call light due to left-sided weakness and a restraint mitt on the right hand. A nurse acknowledged the oversight, noting the resident should have had a soft-touch call light, which was not provided upon readmission.
A resident's request for nausea medication before meals was not honored due to a transcription error, leading to improper scheduling of ondansetron. The medication was given at times that did not align with meal times, resulting in episodes of nausea and vomiting. The facility's policy did not adequately address order transcription, contributing to the oversight.
A facility failed to monitor and assess a resident's restraint use effectively, leading to the resident self-decannulating his tracheostomy tube multiple times. The resident used a restraint mitt to prevent pulling on medical devices, but the facility did not consistently follow the required schedule for releasing and repositioning the restraint. Staff interviews revealed a lack of clarity and documentation regarding the restraint's effectiveness and alternative interventions.
A resident experienced significant physical and cognitive decline after a stroke, including severe cognitive impairment and weight loss. Despite these changes, the facility failed to complete a Significant Change in Status Assessment (SCSA). Staff interviews confirmed the resident's increased need for assistance, and the Director of Nursing acknowledged the oversight.
A resident with severe cognitive impairment and multiple medical conditions was found to have a deficient care plan, lacking documentation of a pressure ulcer and personal preferences. The resident was often seen in hospital gowns, contrary to his preference, and the facility failed to use communication aids for his language barrier. Family members provided showers and laundry, which were not reflected in the care plan, highlighting a lack of communication and awareness among staff.
Two residents in a facility, both dependent on staff for ADLs, did not receive proper nail care. One resident with COPD, diabetes, and CKD had long, dirty nails despite a weekly care order. Another resident with multiple sclerosis and respiratory failure also had untrimmed nails and expressed dissatisfaction with staff assistance. Observations and interviews revealed lapses in care and documentation, contrary to the facility's nail care policy.
A resident with severe cognitive impairment and physical limitations was not comprehensively reassessed for activity interests and socialization needs after a stroke. Despite significant changes in her condition, the facility did not update her care plan or conduct a new activities assessment. Observations showed the resident spent time in a dark, quiet room, unable to engage in activities. Staff interviews confirmed the resident's previous activity level and the lack of reassessment post-hospitalization.
The facility failed to maintain accurate orders and ensure proper site care for two residents. One resident had outdated orders for fluid restriction and antibiotic monitoring, while staff were unaware of the current status. Another resident, with multiple diagnoses, had issues with tube feeding and catheter sites that were not properly documented or addressed. These deficiencies highlight a lack of adherence to policies and procedures for resident care and documentation.
A resident at risk for pressure ulcers was not provided with appropriate care, leading to the development and worsening of a stage 3 pressure ulcer. The facility failed to implement pressure-relieving devices and did not adhere to repositioning protocols, resulting in inadequate treatment and documentation of the wound. Despite hospital notes indicating a stage 3 ulcer, the facility continued to classify it as MASD, delaying necessary interventions.
A facility failed to implement a functional maintenance program for a resident with limited range of motion (ROM), leading to a deficiency. The resident's care plan required daily ROM exercises for the lower extremities, but these were not documented or performed. Nursing staff were unaware of the specific ROM tasks due to an oversight in task assignment, and the resident was not receiving physical therapy at the time.
A resident with multiple health conditions was observed using an electric heating pad without a provider order or documented approval. Facility staff were unaware of the resident's use of the heating pad, and there was no clear policy communicated regarding personal electrical devices. The Director of Nursing confirmed that heating pads should not be used without a provider order and regular skin checks, which were not conducted.
Two residents receiving tube feeding were observed lying flat in bed, increasing the risk of aspiration. The facility failed to maintain correct feeding rates and did not follow infection prevention practices, such as dating and changing supplies. The facility's policies lacked guidance on aspiration prevention and proper labeling, contributing to these deficiencies.
The facility failed to follow oxygen administration orders for two residents. One resident with COPD had their oxygen set higher than prescribed, risking over-oxygenation. Another resident had no active orders for oxygen use despite having equipment in their room. Staff confirmed these discrepancies, which violated the facility's policy requiring physician orders for oxygen administration.
Dignity and Privacy Failures During Dining and Room Entry
Penalty
Summary
The facility failed to provide a dignified dining experience for 7 residents when meals were served in the dining room on hard plastic trays instead of being removed from the trays. During lunch and breakfast observations in the 2W unit small dining room and the 2nd floor west main dining room, residents including those with intact cognition, impaired memory, and severely impaired daily decision making were observed eating meals that remained on the hard plastic serving trays with plates, silverware, beverages, and warming lids placed on the table. Staff did not ask or offer to remove the food items from the trays, and one resident stated he did not like the hard plastic serving trays and would not eat from one at home. Nursing staff stated this was the process used, and the RN unit manager and DON acknowledged the meals were served on the hard plastic trays and should have been taken off the trays to create a more homelike environment. The facility also failed to maintain privacy and dignity for one cognitively intact resident when staff entered the resident’s room without waiting for permission. During observation, an NA knocked once and entered the room without waiting for a response to tell the resident it was time for lunch. The resident stated staff just walk right in, expressed fear of changing clothes because of the lack of privacy, and said he did not feel he had adequate privacy in his room. Staff interviews confirmed that the expectation was to knock and wait for a response before entering resident rooms, and the DON stated this was required to maintain resident privacy.
Failure to Provide Written Bed-Hold Information at Hospital Transfer
Penalty
Summary
The facility failed to provide written information on the duration of bed-hold and reserve bed payment at the time of transfer for 4 of 4 residents reviewed for hospitalizations. The facility’s Bed Hold policy stated staff were to inform residents upon admission and prior to transfer for hospitalization, unless for an emergency, of the bed-hold policy, and a copy of the resident’s bed-hold or release record was to be filed in the medical record. R21 had intact cognition and diagnoses including diabetes, heart disease, kidney disease, and partial amputation of the left foot. After transfer to the hospital, R21’s EMR lacked evidence that bed holds were offered, signed, or followed up on, and the resident stated he had never been offered or signed a bed hold form and that no one from the facility reached out to him. R147 had intact cognition and diagnoses including chronic respiratory failure, quadriplegia, suctioning needs, and tracheostomy care; although transferred to the hospital twice, the EMR lacked evidence that the facility provided written bed-hold information to R147 and/or the resident representative at the time of transfer. R203 had moderate cognitive impairment and diagnoses including hypertension, peripheral vascular disease, kidney disease, hemodialysis, left below-the-knee amputation, and diabetes. His EMR showed multiple hospital transfers, but lacked evidence that bed holds were offered, signed, and followed up on, and he stated he had never been offered or signed a bed hold form when hospitalized. R260 was cognitively intact and able to express needs and wishes; after a fall and later change in condition with facial swelling and confusion, the resident was transferred to the hospital, and the progress note stated the bed hold was signed by the POA. However, the EMR lacked the signed bed hold from that transfer, and the DON acknowledged the documentation did not show what information was provided to the POA, including potential fees and the right to appeal.
Incomplete controlled substance reconciliation documentation
Penalty
Summary
Controlled substance reconciliation was not completed in accordance with the facility’s established policies and procedures on 2 of 8 medication carts reviewed. During observation and interview, the 2W far south medication cart and the 2W near south medication cart were both locked and contained separately locked narcotic boxes with numerous controlled substances inside. RN staff explained that narcotics and controlled substances were counted at each shift exchange and documented on Narcotic Shift to Shift Signature forms, but the forms reviewed had numerous blank signature spaces. On the far south form, 106 signatures were documented out of 132 possible spaces for 6/1/26 through 6/26/26, and on the near south form, only 41 signatures were documented out of 132 possible spaces for 6/1/26 through 6/22/26. The nurse manager/LPN confirmed that staff were expected to sign the controlled medication reconciliation form to show that reconciliation had occurred and acknowledged that approximately half of the signatures were missing on the 2W near south form. The nurse manager stated that, based on the documentation, he was unable to confirm that medication reconciliation had occurred. The DON stated that nursing staff were expected to complete controlled medication reconciliation at each shift change and document it on the narcotic shift change forms. The facility’s Controlled Substances policy stated that controlled substance records would be reconciled by a physical count of the remaining supply at each shift change by the oncoming and outgoing licensed nurse/designee.
Food Served at Unsafe Temperatures
Penalty
Summary
The facility failed to ensure food was served in a timely manner to preserve desired temperatures for 5 of 5 residents who voiced concerns about cold and unpalatable meals. Residents with intact cognition, including R3, R28, R156, R197, and R294, each reported that food was served cold, including items such as French fries, and that the issue had been brought to staff previously. R294 also stated the flavor was not always great. The residents ate in the main dining room, the dining room on 2W, or in their rooms, and they consistently described the food as cold regardless of where they ate. During observation and interview, dining staff and the dietary manager were seen serving meals from the 3 west dining room and then checking temperatures after all resident meals were plated. The remaining food in the warmer measured 164 F for turkey, 173.8 F for green beans, and 149.5 F for sweet potato, but after the meal cart was taken to the memory care unit and the last tray was delayed until it was ready to be served, the temperatures on that tray dropped to 103.5 F for turkey, 96.5 F for green beans, and 102.4 F for sweet potato. The dietary manager stated all food should have been above 140 F when served, whether in the dining room or resident rooms, and stated food below 140 F was in the danger zone and increased the potential for food-borne illnesses.
Failure to Obtain Consent for Psychotropic Medication
Penalty
Summary
The facility failed to obtain consent for the use of a psychotropic medication for one resident. R9’s admission MDS indicated severe cognitive impairment, dependence with ADLs, and diagnoses including edema, dementia, hypertension, insomnia, and encephalopathy. The resident’s Order Summary Report showed an order for trazodone 25 mg by mouth at bedtime for insomnia, but the medical record did not contain evidence that consent for trazodone was obtained before the medication was used. During interviews, RN-I stated nurses were expected to complete a consent form when a psychotropic medication was ordered and that verbal consent could be obtained initially but needed to be signed later. RN-H stated consent was expected when a resident was admitted on a psychotropic medication or when a new medication was added, and confirmed the record lacked evidence of consent for trazodone. The DON stated consent for psychotropic medications was expected when a new psychotropic medication was ordered or when a resident was admitted with one, and the facility’s Physician Medication Orders policy did not address obtaining consent for psychotropic medication use.
Failure to Assess Self-Administration of Medication
Penalty
Summary
The facility failed to assess whether a cognitively intact resident with diabetes, heart disease, and kidney disease was safe and clinically appropriate to self-administer medication when prescription nystatin ointment remained in the resident’s room. The resident stated the ointment had been kept on a rolling bedside table or nightstand since January 2026, that he applied it when he felt he needed it, and that staff were aware it was in his room. He also stated no one had talked with him about an assessment to determine his safety and competence to keep the prescription ointment in his room. Observation and interview confirmed a nearly empty tube of prescription nystatin ointment in the resident’s room, with the resident’s name and directions matching the physician order. Nursing staff stated residents should not keep prescription or OTC medications in their rooms unless an assessment was completed and documented in the EMR, and that if a resident was safe to self-administer, a provider order and care plan update were required. The DON verified the resident was never assessed for safe self-administration, the order and care plan were not updated, and the discontinued nystatin order should have resulted in the medication being removed from the room.
Call Lights Not Kept Within Reach
Penalty
Summary
The facility failed to accommodate resident needs by not ensuring call lights were accessible for two residents. One resident was cognitively intact and had diagnoses including neurogenic bladder, diabetes, and schizophrenia, with impairment on one side of the upper and lower extremities, use of a walker and wheelchair for mobility, and substantial assistance needed for dressing and hygiene. During observation, the resident was seated in a wheelchair in the room with the bedside table between the resident and the bed, and the call light was wrapped around the upper bedrail and out of reach. The resident stated it was too far away and was unable to move the wheelchair around the bed stand to reach it. An LPN and an NA entered the room and verified the call light was not within reach, and both stated it should be in reach. The second resident had impaired cognition and diagnoses including cardiomyopathy, heart disease, kidney disease, diabetes, and depression, and required assistance with hygiene. During multiple observations, the resident was in bed watching TV, but the call light was wrapped around the wall unit and out of the resident’s sight and reach. The resident stated that if help was needed, he would call out and that it takes all day to get attention, and later stated he did not use the call light because he could not reach it. An NA verified the call light was out of reach and stated it should have been within reach so the resident could call for help if needed. Other staff and the DON stated call lights were expected to be within reach of residents in their rooms, and the facility’s policy stated that when a resident is in bed or confined to a chair, the call light should be within easy reach.
Failure to Complete Quarterly Restraint Reassessments
Penalty
Summary
The facility failed to ensure ongoing assessment and evaluation of physical restraints for a resident who used a wheelchair lap tray and seat belt. The resident had intact cognition and diagnoses including quadriplegia, muscle weakness, lack of coordination, and abnormalities of gait and mobility. The quarterly MDS dated [DATE] identified that the resident did not use restraints, yet observations on 6/22/26 and 6/25/26 showed the resident seated and propelling in a power wheelchair with a secured seat belt and lap tray in place. The resident’s care plan dated 5/11/26 identified the seat belt use, noted the resident could lock and release it independently, and stated the resident had been educated on risks versus benefits and signed consent for use. The Physical Restraint Quarterly Assessment history showed the most recent assessment was completed on 2/17/26, and the EMR lacked evidence of any additional quarterly restraint assessments after that date. RN-A stated the nurse manager was responsible for reassessing continued need and ability to use the devices. The RNCM confirmed the assessment should have been completed after 2/17/26 and stated it had not triggered in the EMR system. The DON also confirmed another assessment should have been completed after 2/17/26 and stated quarterly assessments were expected to determine continued need, independent removal ability, and whether alternative interventions were needed.
Unnecessary Psychotropic Medication Use and Missing Orthostatic Monitoring
Penalty
Summary
The facility failed to ensure psychotropic medications were used in accordance with professional standards for one resident who had intact cognition and diagnoses including respiratory failure, COPD, and tracheostomy status. The resident’s physician orders included lorazepam 0.5 mg by mouth every six hours as needed for anxiety and quetiapine 37.5 mg by mouth twice daily as needed for generalized anxiety. Both PRN psychotropic orders were written with stop dates that allowed them to remain active for 30 days, and the medical record lacked documented clinical rationale or practitioner evaluation to support continued use beyond 14 days. The facility also failed to implement monitoring for potential adverse effects related to antipsychotic use. Although the resident received quetiapine, orthostatic blood pressure monitoring was not ordered or completed. The RNCM confirmed PRN psychotropic medications should have been limited to 14 days and stated the extended stop dates appeared to be a transcription error. The DON stated antipsychotic medications and PRN psychotropic medications required 14-day stop dates and that residents receiving antipsychotics needed orthostatic blood pressures completed because the medication could affect blood pressure.
Inaccurate MDS Coding for Falls and Medication Use
Penalty
Summary
The facility failed to ensure MDS assessments were accurately coded for 3 of 3 residents reviewed for MDS accuracy. For one resident, the readmission MDS dated 3/20/26 and the quarterly MDS dated 6/22/26 both indicated no falls or fractures in the applicable look-back periods, even though the care plan documented a fall with fractured hip on 3/9/26 and identified the resident as at risk for falls related to cognition, unsteady gait, and weakness. During interviews, the LPN manager and the DON confirmed the resident had fallen and fractured a hip on 3/9/26 and stated the MDS assessments were inaccurately coded. For two other residents, the MDS assessments indicated use of an anticoagulant rather than an antiplatelet medication. However, the MARs showed each resident received 81 mg aspirin daily during the look-back periods and did not receive an anticoagulant. An MDS coordinator, RN-G, RN-D, and the DON reviewed the records and confirmed aspirin had been given and that it was not an anticoagulant, and the MDS coordinator verified the MDS was coded incorrectly. The facility’s MDS Assessment Coordinator policy stated that each individual who completed a portion of the MDS must certify the accuracy of the assessment.
Failure to Provide Requested Shaving and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure routine personal hygiene and grooming, specifically shaving, was provided to a resident who was dependent on staff for personal care. The resident’s MDS assessment dated 3/6/26 indicated he was cognitively intact, required partial to moderate assistance with personal hygiene, and had not refused or rejected cares. His care plan, reviewed 6/24/26, indicated he required the assistance of one staff member for personal hygiene. During multiple observations from 6/22/26 through 6/24/26, the resident was noted to have scruffy facial and neck hair, approximately 3/4 of an inch long, and he stated he preferred to be clean shaven and did not like the scruff on his face. An electric razor was observed plugged into the wall and lying on the floor next to or near his bed during these observations. Nursing staff stated personal hygiene included shaving and that staff were responsible for completing these tasks, usually on bath days, and the DON stated resident preferences should be honored and that staff were expected to make every effort to keep residents clean shaven when desired.
Failure to Implement Fall Intervention for Resident With Repeated Bed Falls
Penalty
Summary
The facility failed to ensure fall interventions were implemented for a resident with repeated falls from bed. R6’s annual MDS indicated she was cognitively intact, independent with ADLs, and had diagnoses including arthritis and depression. After a fall on 5/14/26, R6 was found on the floor beside her bed after sliding or rolling out of bed, with no injuries observed. The fall report stated R6 believed her bed was too small and that she was given a new and bigger bed to reduce the risk of falling, and the care plan later documented that she had fallen multiple times, including on 7/8/25, 1/25/26, 2/10/26, and 5/14/26. A subsequent fall occurred on 6/22/26 when R6 was again found lying on the floor beside her bed after stating she had rolled out of bed while trying to reposition herself. During multiple observations on 6/23/26, R6’s bed appeared to be a standard bed size when compared with other beds on the unit. R6 stated she had fallen out of bed a couple of times when trying to reposition herself and felt her bed was too small, and she thought she was going to get a bigger bed but never did. Staff interviews showed the intervention had not been carried out as intended. RN-B stated R6 had a history of falls and was supposed to have a bigger bed, but it appeared she had not received one. LPN-A stated a larger bed had been ordered after the 5/14/26 fall and thought R6 had received it, but later learned she had not. The DM confirmed R6’s bed was the standard size and that she had not been provided a larger bed, explaining there had been a miscommunication between nursing and maintenance and the ticket had been closed because R6 already had the largest mattress size for her bed frame.
Incomplete Foley Catheter Orders
Penalty
Summary
Appropriate care for residents with an indwelling urinary catheter was not ensured for R246. R246’s admission MDS indicated moderate cognitive impairment, assistance with ADLs, and diagnoses including diabetes, atrial fibrillation, hypertension, dementia, and myelodysplastic syndrome. The resident’s Order Summary and TAR identified an order for an indwelling Foley catheter for comfort, but the order did not include the catheter size or balloon size needed for catheter replacement. R246’s care plan, initiated on 6/22/26, also identified the resident as having an indwelling Foley catheter, but it likewise lacked the catheter size and balloon size needed for replacement. During interviews, RN-I, RN-H, and the DON each stated catheter orders were expected to include the diagnosis, catheter size, and the amount of normal saline needed to inflate the balloon, and they verified that R246’s orders did not contain those specifics. The DON stated the orders appeared not to have been updated with the required information.
Failure to Address Significant Weight Loss and Inconsistent Weight Monitoring Orders
Penalty
Summary
The facility failed to ensure timely and effective interventions were implemented for significant, unplanned weight loss for one resident and failed to keep the care plan consistent with physician orders for weight monitoring. The resident had severe cognitive impairment, was dependent on staff for all ADLs including feeding, had a diagnosis of weight loss, and received a mechanically altered diet. The physician order directed monthly weights, while the care plan directed weekly weights. The resident also had orders for a house supplement shake twice daily and ProStat Advanced Wound Care Liquid daily. The resident’s weight decreased from 153.2 lbs to 127 lbs over about 2 months, a loss of 26.2 lbs (17.1%). A nutrition progress note documented the resident’s current weight as 127 lbs and noted a recent weight change within the last 30 days, but stated there was no notable change in oral intake and recommended continuation of the current plan of care. Despite the ongoing weight loss trend, no new interventions or escalation of nutritional interventions were implemented at that time. During interviews, the RD acknowledged the weight loss trend and stated current interventions were not effective, the LPN-Unit Manager stated staff followed physician orders when discrepancies existed and that the weight loss had not been escalated as requiring intervention change, and the DON acknowledged the resident continued to have ongoing nutritional decline and needed further evaluation of interventions.
Incomplete respiratory orders and oxygen not provided as ordered
Penalty
Summary
The facility failed to ensure respiratory care and services were provided according to professional standards of practice and physician orders for residents with tracheostomies and oxygen therapy. The report identified that tracheostomy orders for 2 residents did not include the specific type and size of tracheostomy tube. It also identified that one resident did not have a current physician order for oxygen therapy, including the prescribed flow rate and administration parameters, and another resident did not receive oxygen at the ordered flow rate. R14 had diagnoses including respiratory failure, tracheostomy status, and acute respiratory failure with hypoxia. His care plan directed staff to provide humidified oxygen as prescribed, monitor respiratory status, suction as needed, and maintain emergency tracheostomy equipment at bedside. Although the physician order called for oxygen at 5 LPM per tracheostomy collar continuously for hypoxia, observations over several days showed the oxygen set at 3 LPM instead of 5 LPM. During one observation, the oxygen tubing also contained condensation and was not labeled or dated to identify when it was last changed. R147 and R152 both had diagnoses including respiratory failure and tracheostomy status, and both required suctioning and tracheostomy care. Their physician orders for tracheostomy care stated only "Name of Trach Size of Trach every shift," but did not identify the specific type or size of tracheostomy tube. R152 also had no current physician order for oxygen therapy in the EMR, including no prescribed liter flow, delivery method, frequency, or parameters, yet observations showed oxygen set at varying flow rates over several days. RN-A, the RNCM, and the DON each confirmed the missing tracheostomy details and the absence of a complete oxygen order.
Failure to Offer and Document Non-Pharmacological Pain Interventions
Penalty
Summary
The facility failed to ensure non-pharmacological pain interventions were offered, implemented, and documented when administering PRN pain medication for a resident with metastatic prostate cancer and neoplasm-related pain. The resident’s diagnoses included malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and a pain assessment documented frequent pain during the previous five days. Physician orders included PRN hydromorphone, ibuprofen, methocarbamol, and baclofen for pain or muscle symptoms, and the June 2026 MAR showed the resident received PRN hydromorphone up to four times daily from 6/12/26 through 6/24/26, along with one dose each of PRN ibuprofen and methocarbamol. The EMR did not show non-pharmacological pain interventions were provided or documented before or after PRN pain medication administration. The hospice care plan addressed the resident’s terminal prognosis related to metastatic prostate cancer, but it did not identify individualized non-pharmacological pain interventions. During observations, the resident requested pain medication and staff administered scheduled pain medication and then PRN hydromorphone without offering or implementing non-pharmacological interventions. The resident stated massage had helped in the past but had not been offered since admission, and later stated pain remained poorly controlled despite receiving pain medication. Staff interviews confirmed expectations to document attempted interventions and their effectiveness, and the hospice RN case manager stated the facility had not communicated concerns that the resident continued to experience uncontrolled pain.
Incorrect Methadone Administration and Narcotic Record Documentation
Penalty
Summary
Licensed nursing staff failed to demonstrate competency in medication administration for a resident with malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain. The resident had physician orders for Methadone HCl 10 mg tablets totaling 50 mg every morning, 20 mg daily at midday, and 40 mg at bedtime. During a medication pass, an LPN entered the resident’s room to administer scheduled medications, and the resident questioned why only two pain pills were in the medication cup when five were expected. The LPN stated the cup contained the morning dose, but review of the methadone medication card showed the varying doses were packaged together in the same card, with bubbles containing two, four, or five 10 mg tablets. The LPN stated she removed tablets in the order packaged rather than verifying the prescribed dose before administration, and acknowledged she gave 20 mg instead of the ordered 50 mg morning dose. After the medication was given, the LPN documented the controlled substance incorrectly in the narcotic accountability record by recording an incorrect remaining tablet count, then corrected the documentation after the error was acknowledged. During the same observation, the LPN returned to the resident’s room with three additional methadone 10 mg tablets and stated hospice had been contacted and instructed her to administer the remaining tablets to complete the prescribed morning dose. The Nurse Manager and DON stated licensed nurses were expected to follow the five rights of medication administration, verify medication directions before administration, and accurately document controlled substance administration, and that nurses should have recognized that multiple methadone doses were packaged within the same medication card.
Failure to Act on Pharmacist Recommendations for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that recommendations from the consulting pharmacist were acted upon timely for 1 of 5 residents reviewed for unnecessary medication use, R9. R9’s admission MDS dated [DATE] indicated severe cognitive impairment, need for assistance with ADLs, and diagnoses of edema, dementia, hypertension, insomnia, and encephalopathy. A Pharmacy Consultation Report dated 5/19/26 stated the facility needed to obtain psychotropic consent for a new order of trazodone for insomnia and to monitor R9’s sleep while receiving trazodone. R9’s medical record lacked evidence that psychotropic consent was obtained for trazodone, and it also lacked evidence that the recommended sleep monitoring was completed. During interview, RN-H stated nurses obtained consent for a psychotropic medication when a resident was admitted or when a new psychotropic medication was ordered, and she verified the record lacked psychotropic consent for trazodone. RN-H also acknowledged sleep monitoring had not been initiated for R9. DON stated nurse managers were responsible for completing nursing department pharmacy recommendations and were expected to complete them within a week. A policy for follow up and review of consulting pharmacist recommendations was requested but not received.
Failure to Monitor Heart Rate for Metoprolol Order
Penalty
Summary
The facility failed to ensure adequate monitoring was completed for 1 of 5 residents reviewed for unnecessary medications. R255’s admission MDS indicated severe cognitive impairment, substantial assistance with ADLs, and diagnoses including hypertension, chronic kidney disease, dementia, diabetes, and anxiety. An order dated 5/12/26 directed metoprolol succinate ER 50 mg by mouth daily, to be held for SBP less than 100 or HR less than 60. R255’s MARs for May and June 2026 showed blood pressure monitoring, but did not indicate that heart rate was monitored and recorded as ordered. During interviews, RN-I stated staff were expected to check a resident’s BP and/or HR when medication orders had hold parameters and verified that R255’s metoprolol order required holding the medication if SBP was less than 100 or HR was less than 60. RN-I acknowledged the MAR failed to prompt staff to obtain R255’s HR before administration. RN-J stated that when a medication required HR and BP to be taken, the order should have triggered staff to check and record the reading, but R255’s order did not indicate the HR was to be recorded. The DON stated supplementary documentation was expected to be added when the order was entered to require both HR and BP to be recorded, and reviewed the order, stating the supplementary pulse was not selected so metoprolol could have been administered if R255’s HR was less than 60. The facility’s Physician Medication Orders policy, reviewed 10/2025, did not address medication parameters.
Failure to Coordinate Ordered CBC Draws for a Dialysis Resident
Penalty
Summary
The facility failed to coordinate ordered blood draws for a resident with renal insufficiency, dependence on dialysis, and anemia. The resident’s admission MDS indicated he was cognitively intact and able to communicate his wishes. On 6/8/26, the resident had a critical hemoglobin value of 6.9 reported to the facility, and the provider was updated. The record then lacked evidence of subsequent blood draws after 6/15/26, despite a weekly CBC being prepared for 6/22/26. During interview, the resident stated he felt good, denied nausea or vomiting, and reported being tired after dialysis. He stated his hemoglobin had been checked at dialysis and that he had asked for lab draws to be done on dialysis days because access was already being used, but the record lacked documentation that the lab work had been attempted and declined by the resident. The documentation also lacked evidence of follow-up with the dialysis facility to arrange labs during dialysis or follow-up with the provider when the ordered draw was not completed. The HUC, RN/UM, dialysis RN, and DON all identified that the lab draw was not documented as completed or refused and that there was no documented follow-up with the provider.
Failure to Follow Dental Recommendations and Support Denture Use
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for two residents with documented oral health needs. One resident was cognitively intact and required partial to moderate assistance with most ADLs. That resident had a dental note documenting that dentures did not fit properly and needed adjustment, and a later MDS oral/dental assessment again noted the dentures did not fit correctly and recommended evaluation for adjustment. The care plan addressed oral/dental health and mouth care, but it did not include specific interventions for denture use, management, or follow-up, and the EMR did not show dental follow-up after the December 2025 assessment. During observation, the resident was seen without dentures and stated the dentures frequently fell out, did not fit right, and staff had stopped helping with denture use, so the resident no longer wore them consistently. The resident also stated a desire to continue using the dentures and reported gum tenderness. Staff interviews confirmed oral care was provided, but staff were not assisting with denture placement or use and were unaware of current denture use. The HUC stated dental scheduling was variable and was not aware of when the resident last received follow-up for the dentures, and the RN and LPN also confirmed there was no current documentation or follow-up addressing the denture issue. A second resident had intact cognition, no behavior issues, and diagnoses including diabetes, heart disease, kidney disease, and partial amputation of the left foot. The resident’s EMR, including the care plan, physician orders, and progress notes, did not identify denture adhesive even though dental screening assessments stated to provide denture adhesive and noted the resident was concerned the dentures were loose. During observation and interview, the resident stated the upper and lower dentures did not fit properly, that the facility had said it would address the bottom dentures weeks earlier, and that the lower dentures fit so poorly the resident worried about losing them. No denture adhesive was present in the room or bathroom, and staff interviews confirmed the adhesive was not in the room and was not reflected in the care plan. The DON stated the facility did not have a reliable process to ensure dental recommendations were consistently followed, documented, and incorporated into the care plan.
Failure to Change Gloves and Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to implement infection prevention and control practices during incontinent care for R142, a cognitively intact resident with a BIMS score of 14 who had diagnoses including malignant neoplasm of the prostate with secondary malignant neoplasms of the bone, lung, and lymph nodes, and neoplasm-related pain. R142’s care plan indicated the resident had a self-care deficit related to cancer and required moderate assistance with most ADLs. During observation, Nursing Assistant (NA)-F provided incontinence care by removing the resident’s soiled brief and cleansing the perineal area while wearing gloves. Without removing the contaminated gloves, NA-F then applied a clean brief, repositioned the resident, removed soiled linens, placed clean sheets and pillowcases on the bed, and handled other clean linen and environmental surfaces while still wearing the same gloves. The Infection Preventionist and the DON both stated staff were expected to change gloves and perform hand hygiene between dirty and clean care tasks, and the facility’s Handwashing/Hand Hygiene policy directed staff to perform hand hygiene before and after bathroom care and resident personal hygiene.
Outdated Nurse Staffing Post
Penalty
Summary
The facility failed to ensure the nurse staffing post was updated each shift as required, resulting in outdated staffing information being posted over multiple days. Surveyors observed that on 6/22/26 at 10:02 a.m. the posted nurse staffing information was dated Friday, 6/19/26, on 6/24/26 at 7:53 a.m. it was dated 6/23/26, and on 6/25/26 at 7:50 a.m. it was dated 6/24/26. During interviews, front desk staff stated staffing updates were typically maintained by the staffing office, the staffing coordinator stated scheduling staff were responsible for weekday updates and the house manager was responsible on weekends, and the DON stated the expectation was that staff postings were updated each shift and that the house supervisor was responsible on weekends. The facility policy dated 10/2025 stated that at the beginning of each shift, the number of licensed nurses and unlicensed nursing personnel directly responsible for resident care would be posted in a prominent, accessible, and readable location.
Incorrect Sling Use and Incomplete Lift Assessments
Penalty
Summary
The facility failed to ensure safe mechanical lift transfers by using an incorrect sling brand and by not ensuring sling size and harness assessments were comprehensive for residents who required Hoyer and sit-to-stand lifts. For one resident with moderate cognitive impairment, hemiplegia/hemiparesis, and dependence for transfers, the facility’s lift and transfer evaluation selected a large sling based on a weight range even though the resident weighed 220 pounds and the facility’s own assessment guidance indicated a medium sling. The care plan, Kardex, and point-of-care tasks did not identify the sling size to use. During the incident, the resident’s sling tore during a transfer to bed, and the resident fell to the floor and hit his head. Survey review also found that the sling used was a Medline brand sling, not the facility’s Hoyer sling, and staff could not explain where it came from. The report also identified that the facility’s transfer assessments for two residents who used Hoyer lifts did not include the measurements or direct physical assessment needed to determine proper sling fit according to manufacturer guidance. For both residents, the assessments relied on weight ranges that did not match manufacturer instructions, and the records did not identify sling size on the care plan, Kardex, or point-of-care tasks at the time of the incident. Interviews with nursing leadership and product support representatives showed that weight was only a general reference and that resident measurements and body shape were more important for sizing, but those measurements were not documented in the facility assessments reviewed by surveyors. In addition, the facility failed to complete comprehensive harness assessments for three residents who used sit-to-stand lifts. For these residents, the records identified the transfer device but did not identify the harness size on the care plan, Kardex, or point-of-care tasks. One resident had recent changes in weight-bearing status and transfer method after a hospital visit and fracture-related restrictions, yet staff varied on whether to use a Hoyer or sit-to-stand lift. For the other residents, nursing staff completed transfer assessments by reviewing the care plan and weight rather than observing transfers or documenting measurements needed to ensure proper harness fit. The report states that the management team did not review residents who used sit-to-stand machines and that the assessments did not identify what size sling or harness staff were to use.
Failure to Include Dialysis Interventions in Care Plan
Penalty
Summary
The facility failed to comprehensively develop and implement a care plan for a resident who required in-center hemodialysis three days a week. R2's Medicare 5-Day MDS indicated admission with intact cognition, diagnoses including renal insufficiency, and a need for dialysis. Provider orders dated 1/27/26 directed dialysis three times weekly and required nurses to complete post-dialysis assessments on Tuesdays, Thursdays, and Saturdays, then were modified on 1/29/26 to Mondays, Wednesdays, and Fridays. R2's care plan reviewed on 4/30/26 did not include a focus area or interventions for dialysis treatment. During interviews, RN-A stated dialysis care planning should include pre-dialysis weights, vital signs, and assessment of the bruit and thrill, and post-dialysis weighing, assessment of the bruit and thrill, checking the shunt or port site for bleeding and pain, and lung sound assessment. LPN-A stated nursing staff were expected to obtain vital signs before and after dialysis and assess for the bruit and thrill, and that dialysis interventions should be on the care plan. RN-D and the DON both acknowledged that R2 did not have a dialysis-related care plan, despite the facility policy stating individualized care plans must include measurable objectives, time frames, and specialized services based on the MDS and physician orders.
Incomplete and inaccurate dialysis assessments
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care for a resident who required hemodialysis three times weekly. The resident’s record showed a diagnosis of renal insufficiency and provider orders for dialysis with nursing post-dialysis assessments. The care plan reviewed lacked a focus area and interventions for dialysis treatment, and the medical record did not contain Dialysis Communication documentation for one dialysis date that should have included pre-dialysis and post-dialysis nursing assessments. Document review showed multiple dialysis assessment forms were incomplete or inaccurate. One form recorded the same pre-dialysis and post-dialysis weight and used pre-dialysis vital signs as post-dialysis data. Another lacked an actual pre-dialysis weight and assessment and instead used data obtained earlier. A different form used a weight from two days prior rather than a current pre-dialysis weight. Another form recorded the same pre-dialysis and post-dialysis weights and did not include actual post-dialysis weights or vital signs. One assessment also documented, "Ports capped and clamped," and indicated the bruit was not present. During interviews, nursing staff and the medical director stated pre-dialysis and post-dialysis assessments should include current weights, vital signs, assessment of the dialysis access site, and checking for bruit and thrill. Staff stated the documentation on the forms was not accurate, that "ports capped and clamped" did not fit the resident’s dialysis access, and that a missing bruit would be concerning and should have been reported. The DON acknowledged the resident did not have pre/post dialysis assessments completed on one dialysis day and that several assessments were not accurate because they did not contain current weights or vital signs.
Failure to Prevent Significant Medication Errors and Adhere to Medication Administration Times
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by the administration of medications not in accordance with physician orders and prescribed timing requirements. Specifically, a resident with multiple complex diagnoses, including acute and subacute infective endocarditis, pneumonitis, a tibia fracture, cognitive communication deficit, and fibromyalgia, had physician orders for Oxycodone and Suboxone that required specific intervals between doses. The staff did not consistently separate Oxycodone doses by the required four hours or separate Oxycodone and Suboxone doses by the required two hours, resulting in at least 12 documented instances where these instructions were not followed. Additionally, the facility did not ensure that medications were administered within the required window of one hour before or after the scheduled administration time. Over the course of a month, there were 360 documented instances where medications were given outside of this window. These included a wide range of medications such as antibiotics, pain medications, and other routine prescriptions, with administration times often delayed by more than an hour from the scheduled time. The resident's care plan included directives for staff to administer medications as ordered and to promptly address pain management needs, including evaluating the effectiveness of interventions and compliance with dosing schedules. Despite these care plan interventions, the facility's staff failed to adhere to the prescribed medication administration protocols, leading to multiple medication errors and deviations from physician orders.
Failure to Document Resident Repositioning as Required by Care Plan
Penalty
Summary
The facility failed to accurately document the turning and repositioning of a resident whose care plan required repositioning every two hours. The resident, who had multiple complex medical diagnoses including acute and subacute infective endocarditis, pneumonitis, a displaced bicondylar fracture, COPD, dysphagia, and peripheral vascular disease, was care planned to be repositioned at least every two hours to facilitate lung secretion movement and drainage. Despite this, interviews with multiple nursing assistants revealed that while they reported repositioning residents every two hours, they did not document these actions. The registered nurse also confirmed that the facility staff did not document when residents were rounded on or repositioned. Additionally, when the facility's policy for activities of daily living (ADL) documentation was requested, none was provided. The lack of documentation was consistent across all interviewed staff, and there was no evidence in the resident's records to confirm that the required repositioning was performed as per the care plan. This failure to maintain accurate and complete medical records is not in accordance with accepted professional standards.
Failure to Promote Dignity Due to Delayed Response to Toileting Assistance
Penalty
Summary
The facility failed to promote dignity for two residents who required assistance with toileting, as staff did not respond in a timely manner to their requests for help with toileting and hygiene. One resident, who had intact cognition, a history of urinary catheter use, bowel incontinence, and was fully dependent on staff for transfers, experienced significant delays in call light response, with logs showing response times ranging from 15 to 77 minutes. The resident's care plan required prompt response to all requests for assistance, but interviews and documentation revealed that the resident often waited extended periods, resulting in sitting in urine and feces, which caused distress and feelings of lost dignity. Family members and the resident reported long waits and expressed concerns about safety and emotional well-being due to these delays. Another resident, with severe cognitive impairment and incontinence, also experienced delayed responses to call lights, with logs indicating response times between 15 and 63 minutes. This resident required substantial assistance for activities of daily living and care in pairs. The resident reported discomfort and embarrassment from waiting to be changed after incontinence episodes. Staff interviews confirmed that delays occurred, particularly for residents needing two staff members for care, and acknowledged that these delays could result in residents remaining in soiled briefs for extended periods. Staff, including nursing assistants and the RN, acknowledged that while the facility had enough staff to answer call lights, the need for two staff members to assist certain residents contributed to longer wait times. The facility's policy required call lights to be answered as soon as possible, and the expectation was a response within 10-15 minutes. However, documentation and interviews confirmed that this standard was not consistently met, leading to residents experiencing incontinence and loss of dignity while waiting for assistance.
Failure to Monitor Oxygen Saturation per Provider Orders
Penalty
Summary
The facility failed to implement resident-directed care and treatment consistent with provider orders and professional standards for a resident with moderately impaired cognition and diagnoses including acute respiratory failure with hypoxia and COPD. The resident had a provider order for continuous oxygen at 2 liters per minute by nasal cannula, with instructions to maintain oxygen saturations above 90% and to check oxygen saturation every shift. The care plan also directed staff to administer oxygen according to the provider order. However, review of the electronic health record showed that oxygen saturation was not checked every shift as required, with documentation indicating checks occurred only sporadically over a two-month period. Interviews with the resident, LPN, NP, and DON confirmed that staff were not consistently monitoring oxygen saturation as ordered, and there was no task on the treatment administration record to prompt staff to perform these checks. The facility's policy on oxygen administration required assessment of oxygen saturation when a resident was receiving oxygen therapy, but this was not followed. The lack of consistent monitoring and documentation was acknowledged by staff and leadership during interviews.
Failure to Obtain Provider Order for Supplemental Oxygen Administration
Penalty
Summary
A resident with diagnoses including chronic kidney disease and heart failure was found to have received supplemental oxygen therapy on multiple occasions over a period of several months without a corresponding provider order or care plan documentation. The resident's medical records, including the provider order list and care plan, lacked any information regarding the use or monitoring of supplemental oxygen, despite documentation showing the resident used oxygen via nasal cannula on numerous days in May, June, and July. Nursing notes and provider visit notes repeatedly referenced the resident's use of oxygen at varying flow rates, but none of these notes included an official order for oxygen therapy. Interviews with facility staff, including an LPN, RN, nurse practitioner, and the DON, confirmed that the resident had been receiving supplemental oxygen without a provider order prior to a specific date in July. The facility's own policy required a physician's order for oxygen administration, which was not followed in this case. Observations on the day of the survey confirmed the resident was using oxygen, and staff acknowledged the absence of a provider order for this therapy.
Failure to Accurately Document Advance Directives and POA
Penalty
Summary
The facility failed to ensure a resident's advance directives were accurately and consistently documented across various records, leading to a discrepancy in the resident's code status. The resident, who was cognitively intact and had multiple diagnoses including end-stage renal disease and congestive heart failure, had expressed a desire to change their code status to full code, indicating they wanted cardiopulmonary resuscitation (CPR) in the event of a cardiac arrest. However, the electronic medical record (EMR) banner and physician orders still indicated a do-not-resuscitate (DNR) status, which contradicted the resident's wishes as documented in the Provider Order for Life-Sustaining Treatment (POLST) form. The inconsistency arose because the POLST form, which directed CPR, was not signed by the provider and was not dated, leading to confusion among staff about the resident's true code status. Interviews with various staff members revealed that they relied on the EMR banner to determine code status, which at the time indicated DNR. This reliance on the EMR banner, coupled with the lack of a signed and dated POLST, meant that the resident's wishes for CPR might not have been honored in an emergency situation. Additionally, the facility failed to ensure that the power of attorney (POA) for another resident was correctly identified in the electronic health record. This oversight meant that staff would have contacted the wrong individual for care decisions, as the emergency contact list was not updated to reflect the correct POA. This failure to update the contact information could have led to inappropriate decision-making regarding the resident's care, as the staff were not aware of the correct person to contact for decisions.
Removal Plan
- Corrected R43's code status on the EMR banner/provider order to CPR
- Completed a facility-wide audit to ensure there were no other code status discrepancies
- Reviewed related policies and procedures
- Provided education for all staff involved in ensuring advance directives were honored
- Provided education on CPR and POLST policies/procedures and their respective roles in the process
Deficient Call System in Facility
Penalty
Summary
The facility failed to ensure a complete wireless call system, affecting all 250 residents. Observations revealed that there were no call light indicators above resident rooms on the East side in hallways 500, 600, or 700. Instead, scrolling kiosks displayed the room and bed number of the resident who activated their call light. However, these kiosks did not provide an audible tone, and staff did not carry pagers or communication devices to alert them to call light activations. Nursing assistants and registered nurses confirmed that they relied on visual cues from the kiosks, and if they were in a resident's room, they had to either yell for help or turn on the call light themselves. Interviews with staff, including nursing assistants, registered nurses, the acting administrator, and the director of campus plant operations, confirmed the lack of an audible alert system and the absence of pagers for most staff. Only nurse managers and supervisors carried pagers, which alerted them if a call light was on for more than ten minutes. The facility's call light policy and procedure were requested but not provided, indicating a potential gap in documentation and protocol adherence. The deficiency was further compounded by the fact that the maintenance person who knew how to reprogram the pagers was no longer employed at the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 22.58% with seven errors out of 31 opportunities. This involved four residents who were observed during medication passes. One resident received expired calcium carbonate, as the LPN administering the medication did not check the expiration date. Another resident was given potassium chloride mixed with pudding instead of being dissolved in water or juice as per the medication's instructions, leading to inconsistent administration practices among staff. A third resident, who required ondansetron 30 minutes before dialysis, received the medication late due to a delay in administration by the RN. This resident was already at the dialysis unit when the medication was administered, contrary to the prescribed timing. Additionally, a fourth resident did not receive several medications, including gabapentin and ezetimibe, due to them being unavailable, and the LPN did not administer other medications due to a low blood pressure reading without documented parameters to hold the medications. The Director of Nursing and the consultant pharmacist both indicated that medications should be administered as ordered, with missing medications promptly addressed by contacting the pharmacy. The facility's medication administration guidelines emphasize verifying the correct medication, dose, route, rate, time, and resident, as well as checking expiration dates and following manufacturer guidelines, which were not adhered to in these instances.
Failure to Secure and Track Emergency Kits with Controlled Substances
Penalty
Summary
The facility failed to ensure proper tracking and security of emergency kits containing controlled substances, which could potentially lead to theft and diversion of medications. During a tour of the medication room, it was observed that an insulin kit containing lorazepam, a controlled substance, was not included in the narcotic count at shift changes and was not secured in the refrigerator. The Director of Nursing (DON) acknowledged that the emergency kit did not need to be counted at shift changes due to a security tab that only the pharmacy could replace. However, the DON admitted that staff should have visually confirmed the presence of the kit during narcotic counts, as it was not secured. The facility's policy requires controlled substances to be stored in a locked container and counted at the end of each shift, with any discrepancies reported to the DON. This policy was not followed, leading to the deficiency.
Medication Management Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of insulin pens and other medications, affecting multiple residents. During various tours, it was observed that insulin pens for several residents were not dated with an expiration date after being opened. Staff members, including registered nurses and licensed practical nurses, incorrectly believed that the manufacturer's expiration date was sufficient for determining the usability of the insulin pens. Additionally, there was a lack of reference materials on medication carts to guide staff on the appropriate duration for which insulin pens could be used after opening. The facility also failed to remove and dispose of outdated medications properly. During inspections of medication carts and rooms, expired medications were found, including famotidine and Geri-Dryl, as well as insulin pens without open or expiration dates. Furthermore, medications and supplies belonging to discharged residents were not disposed of appropriately, with some items remaining in the medication room long after the residents had left the facility. Temperature control issues were identified in the medication storage areas, with refrigerator temperatures frequently falling outside the safe range. This was confirmed by temperature logs and staff verification. The director of nursing and consultant pharmacist acknowledged the importance of maintaining proper storage conditions to ensure medication viability. However, the facility's policies did not adequately address the labeling of insulin pens or the management of medication refrigerator temperatures, contributing to the deficiencies observed.
Infection Control Deficiencies in Tracheal and Tube Feeding Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during tracheal care for two residents. One resident, with a tracheostomy, was observed being suctioned by a respiratory therapist who did not wear a gown or eye protection, despite the resident being on enhanced barrier precautions (EBP) due to an indwelling medical device. The therapist admitted to not applying additional personal protective equipment (PPE) due to moving quickly. Another resident with a tracheostomy was also on EBP, and during suctioning, the respiratory therapist used sterile gloves but contaminated them by touching non-sterile items in the room before completing the suctioning procedure. The director of respiratory therapy and the infection preventionist confirmed that tracheal suctioning should be a sterile procedure, and the therapist should have maintained sterility of the gloves. The facility also failed to ensure proper hand hygiene during care for a resident who was severely cognitively impaired and on hospice care. During a brief change, a nursing assistant and a registered nurse were observed changing gloves multiple times without sanitizing their hands in between. They acknowledged the importance of hand sanitization between glove changes to prevent infection but did not have hand sanitizer readily available in the room and chose to continue with the care without sanitizing their hands. Additionally, the facility did not follow clean procedures when administering tube feedings for a resident with a gastrostomy tube. An open bottle of nutritional supplement was found without a date or time, and a used tube feeding bag was undated. A registered nurse used the undated supplement and did not clean the overbed table used for tube feeding supplies, which belonged to the resident's roommate. The resident's tube site was red and painful, but the nurse did not document or report this condition promptly. The facility's policy did not address the need for dating and timing tube feeding bottles, contributing to the oversight.
Inadequate Call Light Accommodation for Resident with Physical Limitations
Penalty
Summary
The facility failed to provide a call light that accommodated the needs of a resident with significant physical limitations. The resident, who had a functional limitation in the range of motion of both upper extremities and was dependent on staff for most activities of daily living, was observed with a call light that was not suitable for his condition. The resident had a tracheostomy and communication problems, and his care plan indicated the call light should be within reach. However, the care plan did not specify the type of call light needed, and the resident was unable to use the provided call light due to his physical limitations, including left-sided weakness and the use of a restraint mitt on his right hand. During multiple observations, the resident was seen with a call light that had a small red button, which he confirmed he could not use. A registered nurse acknowledged the oversight and stated that the resident should have been provided with a soft-touch call light, which he previously used before being readmitted to the facility. The facility's policy on reasonable accommodation of needs required assessing and accommodating individual resident needs, but this was not adequately implemented for the resident in question.
Failure to Administer Nausea Medication as Requested
Penalty
Summary
The facility failed to ensure that a resident's family request for pretreatment of nausea before meals was honored, impacting the resident's self-determination. The resident, who was severely cognitively impaired and under hospice care, had a care plan that included managing symptoms such as nausea and vomiting. Despite an order for ondansetron to be administered before meals and at bedtime, the medication was scheduled and given at 4:00 p.m. and 8:00 p.m., which did not align with the intended therapeutic schedule. This discrepancy was noted by the resident's family, who observed that the resident experienced nausea and vomiting when the medication was not administered as requested. The issue was further compounded by a transcription error in the medication order, which was supposed to be administered four times a day but was only ordered for two times a day. The registered nurse and the director of nursing acknowledged the error, noting that the medication schedule did not provide the desired therapeutic effects. The consulting pharmacist confirmed that the current order was insufficient to cover all meals, as the half-life of the medication would not last until the next meal. The facility's policy on medication orders did not address the transcription of orders, contributing to the oversight.
Failure to Monitor and Assess Restraint Use Effectively
Penalty
Summary
The facility failed to ensure ongoing monitoring and assessments of a resident's condition during restraint use, which led to adverse outcomes. The resident, identified as R190, had a tracheostomy and was using a restraint mitt to prevent pulling on his tracheostomy tube and catheter. Despite the restraint, R190 was able to self-decannulate his tracheostomy tube on multiple occasions, indicating that the restraint was ineffective. The facility did not complete comprehensive assessments or reassessments to determine if the least restrictive device was used or if the restraint was effective. R190's care plan and informed consent for restraint use indicated that the restraint mitt was to be used with a release and reposition schedule of every two hours. However, documentation and interviews revealed that staff did not consistently follow this schedule, and there was a lack of documentation on how often the restraint was removed or when skin assessments were conducted. The facility's failure to document and monitor the restraint use properly contributed to the resident's ability to remove his tracheostomy tube, which posed a significant risk to his health. Interviews with staff, including RN-L and RN-J, highlighted a lack of clarity and consistency in the application and monitoring of the restraint mitt. Staff were unsure of the interventions attempted to address the medical symptoms leading to the need for restraint use, and there was no evidence of reassessment for less restrictive alternatives. The director of nursing acknowledged that the facility's policy required reassessment of restraint necessity every month, but this was not documented or followed, leading to the continued use of an ineffective restraint.
Failure to Complete SCSA After Resident's Stroke
Penalty
Summary
The facility failed to initiate and complete a Significant Change in Status Assessment (SCSA) for a resident, identified as R42, following a significant physical and cognitive decline after a stroke. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, an SCSA is required when a resident experiences a major decline that affects multiple areas of health status and necessitates an interdisciplinary review and care plan revision. R42's quarterly Minimum Data Set (MDS) indicated severe cognitive impairment, significant weight loss, a mechanically altered diet, and impairments in extremities, contrasting with a previous MDS that showed no such impairments. Despite these changes, the facility did not complete an SCSA. Interviews with staff and family members revealed that R42 had become mostly non-verbal and required assistance with daily activities such as eating and transferring, which she previously managed independently. The MDS nurse acknowledged that an SCSA should have been completed due to changes in R42's mobility, transfer status, and eating assistance needs. The Director of Nursing confirmed that an SCSA should have been initiated upon R42's return from the hospital, which would have triggered other comprehensive assessments. The facility's policy on MDS was requested but not provided, indicating a lack of documentation to support the assessment process.
Failure to Maintain Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and maintain a comprehensive care plan for a resident, identified as R86, which led to inadequate care provision. R86, who has severely impaired cognition due to vascular dementia, type 1 diabetes, chronic kidney disease, and hypertension, was found to have a stage 2 pressure ulcer. The care plan did not include this pressure ulcer or additional interventions to prevent its worsening. Furthermore, the care plan lacked documentation of R86's preference for laundry to be done by his daughter, preference for male caregivers, and the use of a walker or wheelchair when ambulating. Observations and interviews revealed that R86 was often seen wearing hospital gowns instead of street clothes, which was not his preference. The family member expressed concerns about the language barrier, as R86 primarily speaks Somali, and the facility's failure to use communication aids or interpreters. The family member also noted that the facility had not communicated the need for clothes for R86, despite previous notifications. Additionally, the family member stated that they provide showers and laundry services for R86, which were not reflected in the care plan. Staff interviews indicated a lack of awareness and communication regarding R86's needs and preferences. The registered nurse and nursing assistant acknowledged the absence of clothes for R86 and the lack of communication aids. The director of nursing emphasized the importance of having up-to-date care plans, but the facility's policy on comprehensive care plans was not adhered to, resulting in the deficiency.
Failure to Provide Adequate Nail Care for Residents
Penalty
Summary
The facility failed to ensure proper nail care for two residents who were dependent on staff for activities of daily living (ADLs). Resident R21, with intact cognition and diagnoses including COPD, diabetes, and CKD, required moderate assistance with bathing, dressing, and toileting. Despite having a provider order for weekly nail care, observations revealed R21's fingernails were long and dirty. Nursing staff confirmed the nails were not properly maintained, and there was no documentation of care refusal, indicating a lapse in following care plans and documentation protocols. Similarly, Resident R28, diagnosed with multiple sclerosis and respiratory failure, was dependent on staff for personal hygiene and required extensive assistance with bathing. Observations showed R28's fingernails were excessively long and dirty, and the resident expressed dissatisfaction with the lack of assistance in trimming them. Despite claims from a nursing assistant that R28 refused nail care, the resident denied such refusals, and there was no documentation to support the claim. This indicates a failure in communication and documentation, as well as a lack of adherence to the facility's nail care policy.
Failure to Reassess Resident's Activity Needs Post-Stroke
Penalty
Summary
The facility failed to comprehensively reassess a resident, identified as R42, for activity interests and socialization needs following a hospitalization for a stroke. R42, who had severe cognitive impairment and required substantial assistance with daily activities, was hospitalized for a stroke that resulted in right-sided weakness. Despite these significant changes in condition, the facility did not update R42's care plan or conduct a comprehensive activities assessment post-hospitalization to address her new limitations and socialization needs. Observations revealed that R42 spent most of her time in a dark, quiet room, appearing restless and unable to use the television remote. Staff interviews indicated that R42 was previously active and enjoyed going outside but was no longer able to do so independently after her stroke. The activities aide confirmed that R42 had not been comprehensively reassessed for activities since November, prior to her hospitalization, and no one-to-one visits had been initiated to engage her in activities suitable for her current condition. The facility's policy required staff to evaluate residents' physical and mental capacity to participate in activities, noting any limitations or needs. However, this was not done for R42 after her stroke, as confirmed by the director of nursing, who acknowledged that a comprehensive activities assessment should have been completed. The lack of reassessment and updated interventions left R42 without adequate socialization opportunities, as she was no longer able to participate in her preferred activities.
Deficiencies in Order Accuracy and Site Care
Penalty
Summary
The facility failed to ensure that orders were current and accurate for a resident, R90, who was reviewed for orders. R90 had multiple diagnoses, including intestinal malabsorption, gastrostomy tube status, malnutrition, diabetes mellitus, heart failure, anxiety, and depression. Despite being cognitively intact and independent with activities of daily living, R90's care plan did not address a fluid restriction or antibiotic monitoring, even though the Order Summary Report indicated active orders for both. Interviews with staff revealed confusion and lack of awareness regarding R90's current orders, with some staff members unsure about the fluid restriction and antibiotic monitoring status. The director of nursing confirmed that staff should understand what they are documenting when signing off on tasks in the medication and treatment records. The facility also failed to ensure proper site care for R4, who was reviewed for tube feeding. R4 was moderately cognitively impaired with diagnoses including epilepsy, traumatic brain injury, quadriplegia, diabetes, and sepsis. R4's care plan included goals for tube feeding and catheter care, but interventions did not include dressing changes or assessment of the catheter insertion site. Observations and interviews revealed that R4 had noticeable issues with the tube feeding and suprapubic catheter sites, including redness, moisture, and crusting, which were not properly documented or addressed in the skin assessments. The facility's policies for suprapubic catheter care and enteral nutrition did not adequately address the necessary skin assessments and documentation. The deficiencies in the facility's care for R90 and R4 highlight a lack of adherence to established policies and procedures for maintaining accurate and current orders, as well as ensuring proper site care and documentation. The failure to document and address changes in skin condition and site care for R4, along with the confusion surrounding R90's orders, indicate a need for improved communication and understanding among staff regarding resident care and documentation requirements.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident identified as R4. R4 was moderately cognitively impaired and at risk of developing pressure ulcers upon re-admission, with no unhealed pressure ulcers noted at that time. However, hospital notes later identified a stage 3 pressure ulcer on R4's coccyx, which the facility failed to document and address in a timely manner. The facility did not implement the recommended pressure-relieving devices for R4's chair and bed, and there was a lack of documentation regarding the identification and treatment of the pressure ulcer. Observations revealed that R4 was consistently positioned on their back with the head of the bed elevated, contrary to the care plan's instructions for repositioning every two hours to relieve pressure. Interviews with staff indicated a lack of adherence to repositioning protocols, with R4 often being returned to the same position after care. The facility's care plan and wound documentation were not updated to reflect the presence of a pressure ulcer, and the necessary interventions, such as a pressure-relieving mattress and wound nurse consultation, were not implemented promptly. The facility's failure to identify and document R4's pressure ulcer led to inadequate treatment and worsening of the wound. Despite hospital documentation of a stage 3 pressure ulcer, the facility continued to classify the wound as moisture-associated skin damage (MASD) and did not update the care plan or involve a wound nurse. The facility's policy required daily monitoring and provider contact if a pressure ulcer showed no progression, but these protocols were not followed, contributing to the deficiency.
Failure to Implement Functional Maintenance Program for ROM
Penalty
Summary
The facility failed to implement a nursing functional maintenance program to prevent a decline in range of motion (ROM) for a resident identified as R190. R190's admission Minimum Data Set indicated functional limitations in the range of motion of both upper extremities, and the resident was dependent on staff for most activities of daily living. The care plan and Functional Maintenance Program (FMP) required nursing staff to perform bilateral lower extremity ankle and knee ROM exercises daily. However, the medical record did not show evidence that these exercises were completed since the FMP's initiation. Interviews with nursing assistants and registered nurses revealed a lack of awareness and execution of the ROM exercises for R190. Nursing assistants relied on electronic health records to determine tasks, but no ROM tasks were listed for R190. Additionally, the registered nurse responsible for R190 was unsure of the specific ROM exercises required and deferred to therapy for guidance. The director of rehabilitation confirmed that R190 was not currently receiving physical therapy, and the nurse manager admitted to an oversight in not adding the ROM exercises as a task for nursing assistants to document, which was the standard procedure.
Resident's Use of Heating Pad Without Proper Oversight
Penalty
Summary
The facility failed to ensure that a resident, identified as R90, was free from potential injury due to the use of an electric heating pad. R90, who had multiple diagnoses including intestinal malabsorption, diabetes mellitus, and heart failure, was observed using an electric heating pad on several occasions without a provider order or documented approval for heat therapy. The resident's care plan did not include the use of a heating pad, and there were no changes in the resident's skin condition noted in weekly assessments. Despite this, R90 was repeatedly observed lying on a heating pad that was plugged into the wall. Interviews with facility staff revealed a lack of awareness and understanding regarding the policy for personal electrical devices brought in by residents. Nursing assistants and registered nurses were unaware of any residents using heating pads, and there was no clear policy communicated to them. The Director of Nursing confirmed that electrical heating pads should not be brought in from home without a provider order and that staff should conduct regular skin checks. The facility's policy on electrical safety discouraged the use of heating pads and required inspection of such devices, which was not adhered to in this case.
Failure to Prevent Aspiration and Ensure Infection Control in Tube Feeding
Penalty
Summary
The facility failed to ensure appropriate interventions were taken to reduce the risk of aspiration for two residents who were using tube feeding. Both residents were observed to be positioned flat in bed while their feeding was running, which is against the recommended practice of keeping the head of the bed elevated to prevent aspiration. Additionally, the facility did not follow infection prevention practices, as evidenced by undated syringes, tubing, and feeding solution containers, which were not changed or documented as required. One resident, who was moderately cognitively impaired and received a significant portion of their nutrition via tube feeding, was observed multiple times with their feeding running at an incorrect rate of 50 ml/hour instead of the ordered 60 ml/hour. The registered nurse confirmed the discrepancy and adjusted the rate accordingly. However, the failure to maintain the correct feeding rate and to date and change supplies daily posed a risk of infection and inadequate nutrition. Another resident, who was severely cognitively impaired and dependent on staff for activities of daily living, was also observed lying flat in bed with the tube feeding running. The nursing assistant did not pause the feeding before lowering the bed, as the nurse was busy, which could lead to aspiration. The facility's policies did not adequately address aspiration prevention or the labeling and dating of supplies, contributing to these deficiencies.
Deficiencies in Oxygen Administration for Residents
Penalty
Summary
The facility failed to ensure proper oxygen administration for two residents, leading to deficiencies in respiratory care. For one resident with chronic obstructive pulmonary disease (COPD) and respiratory failure, the facility did not adhere to the prescribed oxygen flow rate. The resident's medical records indicated an order for oxygen at 3.5 liters per minute to maintain oxygen saturation levels above 90%. However, observations revealed that the oxygen was set to five liters per minute on multiple occasions, which was confirmed by a registered nurse. This discrepancy posed a risk of over-oxygenation, particularly given the resident's COPD condition. Another resident, who had a history of acute respiratory failure and other respiratory conditions, had access to oxygen equipment in their room but lacked a current provider order for oxygen administration. Despite the presence of an oxygen concentrator and portable oxygen, the resident's medical records did not contain active orders for oxygen use. Interviews with nursing staff confirmed the absence of such orders, even though the resident used oxygen as needed. The facility's policy required verification of a physician's order before administering oxygen, which was not followed in this case.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near New Hope
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Woodlake Healthcare And Rehabilitation Center | 0.5 mi | ★★★★★ | 8 | 0 |
| Mission Nursing Home | 2.8 mi | ★★★★★ | 11 | 0 |
| The Terrace At Crystal Llc | 2.8 mi | — | 65 | 4 |
| Maranatha Care Center | 2.8 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Ambassador | 3.1 mi | ★★★★★ | 2 | 0 |
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