Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pathstone Living during CMS and state inspections, most recent first.
Two residents with diabetes received long‑acting insulin at widely varying times across the morning shift rather than at a consistent daily time, despite orders for daily dosing and internal policies and pharmacist guidance that long‑acting insulin should be given at approximately the same time each day. For one resident using a Dexcom CGM, staff relied on CGM readings without consistently confirming low values by fingerstick, did not follow the facility’s hypoglycemia protocol for 15‑minute BG rechecks, and allowed the resident to leave for outside appointments shortly after a documented low BG and glucagon administration without documented monitoring to ensure BG had returned to safe levels. Surveyors also observed this resident eating most of a meal before any BG was obtained, delayed insulin administration until after the meal, and noted that a dislodged CGM sensor had gone unnoticed, while staff interviews revealed uncertainty about CGM use and order transcription that created broad administration windows for insulin.
A facility failed to provide enough nursing staff to meet resident needs for timely incontinence care, hydration, meal assistance, and call light response. Residents reported waiting 20 minutes to 2 hours for help, and call light logs showed repeated delays over 20, 50, 60, and even 90 minutes. Staff confirmed that residents were not always toileted before meals because of insufficient staffing, and leadership acknowledged high resident acuity and prolonged wait times.
The facility failed to ensure staff had the competency to assess and document wounds accurately, resulting in a coccyx wound being documented as a pressure injury when staff later said it was moisture-related, and a buttocks condition being repeatedly misidentified as a pressure ulcer despite provider notes showing incontinence associated dermatitis. The facility also did not include a resident’s colostomy in the care plan, and staff reported the bag often leaked and was not applied correctly. In addition, a resident’s hand splint was applied incorrectly, and an RN’s orientation packet was incomplete and not turned in to leadership.
A dietary assistant was observed serving beverages after touching her face and eyeglasses, and another dietary assistant handled a resident’s food with bare hands, wiped her hands on her clothing, touched her face and nose, and continued plating and serving food without hand hygiene. The CD stated staff were expected to wash hands after touching their face or clothing, and that there was no documentation of face-to-face hand hygiene competency for one dietary assistant.
Administration failed to maintain effective oversight across several areas, including resident funds, wound assessment/documentation, staffing response times, staff competency validation, and QAPI follow-through. A resident’s missing money was not properly secured, documented, reported, or investigated, while nursing staff documented pressure ulcers that the provider said were not present and relied only on printed wound materials for training. The facility also had long call light response times, incomplete competency tracking for nursing staff, and verbal-only follow-up on identified quality issues.
Failure to Use QAPI to Identify and Correct Survey Deficiencies: The facility failed to use its QAPI process to identify and address multiple survey findings, including notification to provider, vulnerable adult reporting, bed holds and transfer forms, inaccurate MDS assessments, care plan issues, wound assessment problems, splint/ROM concerns, staffing posting content, and dining practices. The ED stated most of the survey team’s concerns were not known to QAPI until brought up during survey, and follow-up was largely verbal rather than formally tracked to ensure sustained improvement.
A facility failed to maintain infection control for resident water mugs and urinary drainage bags. Multiple residents reported they were not getting clean mugs daily, staff gave inconsistent accounts of who was responsible for exchanging them, and leadership stated there was no current process or policy in place. In addition, three residents with indwelling or suprapubic catheters were observed with drainage bags hooked to wastebaskets or garbage cans with the bottoms resting on the floor, and staff acknowledged the bags should not have been on the floor.
Unsanitary resident room and kitchen food prep area. A resident with hemiplegia, dementia, and highly impaired vision was observed in a room with an overfilled commode, a full wastebasket with a soiled brief, open wipes, and cluttered items around the room. The nurse manager stated staff were expected to empty commodes, remove trash, and pick up rooms before leaving. In the kitchen, debris-covered cords and an outlet above clean plates and food prep areas were observed, and the CD and ED confirmed the area was dirty and not on a routine cleaning schedule.
The facility failed to timely assess and document a resident’s new forearm skin injury after PT, and nursing staff also misclassified wounds for two other residents. One resident’s coccyx area was documented as a pressure injury even though staff described it as moisture-related, while another resident’s buttock skin condition was repeatedly charted as pressure injuries despite provider notes identifying incontinence associated dermatitis. The facility also failed to complete a new comprehensive assessment for newly identified toe wounds on a resident with diabetes after the foot was injured by a wheeled table.
Failure to provide daily fresh drinking water to multiple residents. Residents with care plans calling for adequate hydration, water at bedside, and routine fluid offers reported that staff did not pass water daily and instead provided it only when asked. Interviews with NAs, RNs, LPNs, dietary staff, and management confirmed there was no current process for routinely offering or refilling resident water mugs, despite expectations that residents should receive water daily and not have to request it.
Failure to Notify Provider of Choking and Skin Injuries A resident with impaired cognition choked at dinner and required the Heimlich maneuver, but the provider was not notified. The resident’s emergency contact was informed, and staff later acknowledged the missed provider notification. Two other residents had newly identified skin injuries, including multiple toe wounds and a right forearm skin tear after an accident with a motorized wheelchair, but provider notification was incomplete or delayed. Staff interviews and record review showed the injuries were treated and documented, yet the provider was not promptly informed of all new wounds.
A facility failed to timely report an allegation that a resident’s cash was missing and did not complete a formal investigation when staff were aware the resident repeatedly accused a staff member of taking his money. The resident had dementia, impaired vision, and impaired cognition, and staff messages showed the issue was known before the State Agency report was made. The facility also failed to immediately report a choking incident involving another resident who required supervision for all meals but was left alone and choked while eating after the care plan was not followed.
Failure to Protect Resident Funds and Follow Meal Supervision Care Plan: A resident with dementia and severe visual impairment had large amounts of cash kept in his room, but staff did not secure the money in the facility safe, did not maintain documentation or a ledger, and did not complete a full investigation after he accused a staff member of taking his funds. In a separate incident, another resident who required supervision and assist with meals choked while eating alone, and staff and leadership acknowledged the care plan was not followed and the event was not immediately investigated or reported.
A facility failed to ensure that two residents or their representatives received required bed hold notices and written transfer notices when they were sent to the ER and hospitalized overnight. One resident had CHF, CKD, and a urinary catheter, while the other had hemiplegia, dementia, diabetes, chronic pain, and impaired vision. Staff documented calls to family and verbal bed hold discussions, but no signed bed hold forms or written transfer notices were found in the EMR, and the nurse manager could not locate the required paperwork.
Inaccurate MDS coding occurred for one resident with conflicting buttock skin documentation and for another resident receiving dialysis. Nursing notes described the buttock area as pressure injuries with varying stages, while the provider consistently documented incontinence associated dermatitis and stated the resident did not have pressure wounds. The MDS nurse coded pressure ulcer findings based on nursing assessments. For the other resident, the 5-day MDS failed to indicate dialysis while a resident even though the resident received dialysis three times weekly and had ESRD.
A resident with a colostomy and cancer diagnoses did not have ostomy care included in the care plan, despite physician orders for specific bag-change steps and family concerns that the bag was often applied incorrectly and leaked stool. The CAA also did not identify the ostomy, and staff interviews showed inconsistent training and awareness about the resident’s ostomy care, including whether all nurses used the family-supplied binders and whether the skin prep was allowed to dry before the next step.
A resident with severely impaired cognition, Alzheimer’s disease, and a care plan requiring one-helper supervision for all meals was left unsupervised while eating. He choked on dessert and juice after an NA stepped away to answer other call lights and assist another resident. Family members had posted signs in the room reminding staff to supervise him from start to finish with each meal, and staff interviews confirmed he was supposed to be supervised during all meals.
Failure to provide timely incontinence care for a resident dependent on staff for toileting and hygiene. The resident had severe cognitive impairment, was always incontinent of urine and frequently incontinent of bowel, and had a care plan calling for checks every 2 hours and toileting before meals. Staff initially missed a saturated brief with bowel movement before lunch, and the resident was only changed after prompting.
Failure to provide ROM and proper hand splint application. A resident with left-sided hemiplegia after a stroke had orders for PT/OT and a resting hand splint, but EMR documentation showed ROM was completed only twice in 30 days and the splint task only 12 times. During observations, staff applied the splint incorrectly, with the palmar support not placed in the palm or placed under clenched fingers. The OT corrected the splint, and staff interviews showed confusion about who was responsible for ROM and splint care.
Daily staffing information was not posted in a clear, readable format for residents, staff, and visitors. The posting was a multi-page UKG headcount report in very small font and was not easily recognizable among other documents; it also lacked census information and current staffing adjustments by shift. The ED stated the posting had always been generated this way and that she was not aware of the regulatory requirements.
The facility failed to maintain an effective infection control program, with incomplete documentation and analysis of resident infections. The infection preventionist struggled to access reports and did not include essential data such as signs and symptoms or transmission-based precautions. Additionally, a resident with a nephrostomy tube did not receive proper Enhanced Barrier Precautions (EBP), as a nursing assistant entered the room without wearing the required PPE, despite being aware of the EBP policy.
The facility failed to effectively implement an antibiotic review process, impacting the monitoring of antibiotic use and resistance. The ADON, responsible for tracking infections and antibiotic use, faced challenges in accessing culture results and did not report on MDRO or prophylactic use at meetings. A review showed that many UTIs treated with antibiotics lacked culture results, and not all physicians followed infection testing criteria. The DON confirmed the lack of analysis and monitoring in the antibiotic stewardship program.
A resident with chronic conditions expressed dissatisfaction with the facility's food, which did not align with his cultural preferences. Despite the facility's policy on culturally competent care, the resident's care plan lacked cultural considerations, and staff interviews revealed uncertainty about responsibility for addressing these needs.
The facility failed to ensure cleanliness of ceiling vents in the 3400 wing, affecting three residents. Observations showed vents covered with a black substance due to dust and dirt buildup. The maintenance director admitted that vent cleaning was on a monthly checklist but was only done quarterly. The facility's policy required items to be free of visible soil, yet the vents were visibly dirty.
A resident with a history of cardiovascular issues experienced chest pain, but the facility staff failed to promptly assess and notify the physician, delaying treatment. Despite the resident's symptoms and family member's concerns, staff waited for physician rounds. The resident was eventually sent to the hospital, diagnosed with an acute anterior STEMI, and passed away after complications.
The facility failed to ensure proper infection control practices, including ongoing surveillance, correct PPE usage, and proper storage of PPE. Staff were observed doffing PPE incorrectly, and a meal tray was placed on the floor, posing an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility.
The facility failed to implement a process for antibiotic review, lacking formal tracking and monitoring for residents on antibiotics. The DON and ADON confirmed that while symptoms were monitored and reported, there was no system to track antibiotic use, cultures, or ensure proper prescriptions.
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours. A resident reported missing cash, and while a police report was filed, the facility did not notify the state agency as required by their policies. The resident later found the cash, but the incident should have been reported within the required timeframe.
The facility failed to ensure accurate MDS assessments for two residents. One resident receiving hospice services was not correctly documented, and another resident with pressure ulcers had an MDS assessment indicating no such injuries. These inaccuracies were confirmed by the MDS coordinators and the DON.
The facility failed to provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents, with staff confirming that copies of the care plan were only provided if requested, contrary to the facility's policy.
A resident with moderately intact cognition and specific activity preferences was not offered individualized activities by the facility. Despite documented interests in playing cards, listening to music, and attending religious services, the resident and his family member reported no activities were offered. Staff confirmed the lack of engagement, and the facility did not adhere to its Activity Programs policy.
A resident receiving hospice services experienced missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. The facility's director of nursing confirmed the communication issues, and a policy on hospice services was not provided.
A facility failed to implement a ROM program and properly apply a wrist brace and edema glove for a resident with hemiplegia and hemiparesis. Staff inconsistencies and improper application led to the resident's fingers curling and the splint losing its form, indicating a lack of proper care.
A facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment. The resident was observed smoking across the street with the interim director of nursing (IDON) supervising, but the cigarette butt was improperly disposed of and later found inside the facility. The facility lacked a designated receptacle for cigarette disposal, and the IDON admitted to not knowing where the cigarette butt was disposed of, leading to a deficiency in managing the resident's smoking habits and ensuring safety.
The facility failed to maintain a sanitary environment in the kitchen's food preparation and drying areas, with vents, wire mesh, and a printer cord covered in debris. This was confirmed by the cook, maintenance director, and culinary director.
A resident with diabetes received both detemir and glargine insulin simultaneously over six days due to a lapse in the visibility of a hold order, leading to hypoglycemia and hospitalization. Nurses administered both insulins without questioning the orders, and significant changes in the resident's condition were observed.
A resident with a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness experienced a significant decline in condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness. Despite multiple reports from nursing assistants, the licensed nursing staff failed to perform a comprehensive assessment, document observations, or notify a physician. The resident was found in severe respiratory distress and later died from acute respiratory failure.
Inconsistent Insulin Administration and Inadequate Hypoglycemia Management
Penalty
Summary
The deficiency involves the facility’s failure to administer long‑acting insulin at consistent times, failure to appropriately respond to abnormal blood glucose (BG) levels, and failure to monitor and follow up after hypoglycemia interventions for residents with diabetes. One resident with type 2 diabetes mellitus, diabetic retinopathy, and use of a Dexcom continuous glucose monitor (CGM) had a care plan and physician orders directing daily glargine insulin, sliding‑scale Novolog, hypoglycemia treatment, and specific notification parameters for BG values. However, the MAR showed glargine ordered as "every day shift" with an administration window of 6:30 a.m.–1:00 p.m., and actual administration times varied widely from early morning to early afternoon. On multiple days, glargine was given at different times (e.g., between about 9:00 a.m. and 2:45 p.m.), and on some days it was not administered at all with no explanation. Facility staff, including a nursing assistant who transcribed orders and nurses who confirmed them, acknowledged that the order was entered as a broad shift‑range rather than a specific time and that this could affect BG control. The same resident experienced multiple episodes of low BG where staff did not follow the facility’s hypoglycemia protocol or the physician’s orders. On one occasion, the Dexcom alarmed for a low reading in the dining room, and a family member obtained orange juice and notified staff. An LPN reported difficulty locating glucose tablets, did not clearly recall whether a manual fingerstick was obtained, and administered glucagon from the emergency kit based on the CGM reading. Documentation showed BG readings of 54 and 57, administration of orange juice and glucagon, and then the resident leaving the facility for appointments, with instructions to the family member to recheck BG later. There was no comprehensive assessment documented for signs/symptoms of hypoglycemia and no documented monitoring to ensure BG returned to safe levels after glucagon; the next recorded BG was not until several hours later. The van driver and clinic nurse reported they were not informed of the low BG event, and the physician later stated the BG should have been manually checked and that such low levels could lead to coma or death. Additional documentation for this resident showed repeated low BG readings (e.g., in the 50s, 60s, and low 70s) where interventions such as orange juice were given but follow‑up BG checks were delayed or incompletely documented, contrary to the facility’s diabetes and hypoglycemia protocols that called for rechecking every 15 minutes until BG was at least 70 mg/dL and the resident was without symptoms. The Dexcom order initially lacked clear instructions on how to change the sensor, verify readings with fingersticks, or set alarm parameters, and staff reported relying on internet videos to learn sensor changes. During surveyor observation, the resident’s Dexcom displayed a message to start a new sensor, and the resident ate most of his breakfast before any BG was obtained; a TMA later took a manual BG of 153 and then an LPN administered both long‑acting and short‑acting insulin after the meal. Family reported that the Dexcom sensor had fallen off the previous day and staff had not noticed. A second resident with type 2 diabetes and multiple diabetic complications also had glargine ordered daily, but MAR review showed long‑acting insulin administered at widely varying morning times, from just before 7:00 a.m. to after noon, despite staff and the consulting pharmacist stating that long‑acting insulin should be given at approximately the same time each day and BG should be checked before meals and insulin administration. The facility’s own Diabetes‑Clinical Protocol and Insulin Administration policies required assessment of diabetic residents, incorporation of orders and reporting parameters into the MAR and care plan, consistent monitoring of BG, and specific hypoglycemia treatment steps including 15‑minute rechecks and continued monitoring after glucagon. Standing orders for CGM use required setting alarms, verifying initial readings with fingersticks, and performing fingersticks when readings were <100 or >400 or when accuracy was in question. Interviews with nursing staff, the clinical manager, and the pharmacist confirmed that long‑acting insulin should not be administered at random times across a broad shift window and that BG should be checked before meals and insulin dosing. Despite these policies and professional expectations, the facility did not ensure consistent timing of long‑acting insulin for two residents, did not consistently verify or respond to abnormal BG readings according to protocol, and did not document timely reassessment after hypoglycemia interventions for one resident.
Insufficient Staffing Caused Delayed Resident Assistance
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs for timely incontinence care, hydration, meal assistance, and call light response. Surveyors found that 7 residents reviewed for staffing concerns experienced prolonged waits for assistance, and the deficient practice had the potential to affect all 61 residents in the facility. The facility’s own assessment stated that a high percentage of residents required one- to two-person assistance for dressing, bathing, transfers, and toileting, and the facility policy required call lights to be answered immediately and requests completed within five minutes if possible. Residents and family members described repeated delays in staff response. One resident’s family member stated the resident had reported waiting up to two hours for staff to respond to a call light and that the resident was supposed to be checked and changed every two hours but was not. Another resident stated staff sometimes took one to one-and-one-half hours to answer the call light. Other residents reported waits of 20 minutes to one hour, and one resident stated the facility was short staffed and that a recent weekend delay caused him to miss breakfast. Surveyors also observed one resident’s call light illuminated continuously for about 50 minutes while the resident remained seated in the room. Call light logs documented frequent prolonged response times for multiple residents, including waits of 20 to 30 minutes, 31 to 40 minutes, 41 to 50 minutes, and several responses greater than 50 minutes, 60 minutes, 90 minutes, and even 3 hours. Staff interviews confirmed that residents were not always toileted before meals because of insufficient staffing and the number of residents needing two-person transfers. Staff also stated that treatments were sometimes not completed because of insufficient staffing, and that residents consistently waited longer than 20 minutes for assistance. Leadership acknowledged long call light wait times, high resident acuity, and staffing challenges, while also stating that average response times were being monitored and that outlier waits over 20 minutes were not routinely monitored.
Wound Documentation, Care Planning, and Staff Competency Failures
Penalty
Summary
The facility failed to ensure nursing staff had the competencies needed to care for residents according to their assessments and care plans. For one resident with severe cognitive impairment, dependence for toileting hygiene, bathing, dressing, hygiene, and transfers, and incontinence of urine and bowel, an LPN documented a new coccyx wound as a stage 1 pressure injury with a Mepilex dressing, but later stated she had been told the resident had a slit on the coccyx and that she had not received specific training on differentiating wound types or on checking blanchability. The LPN confirmed the area had been inaccurately documented as pressure-related, and the RN manager stated the area was small and not pressure-related and that the documentation discrepancy reflected nursing staff training needs. For another resident with intact cognition, dependence for ADLs, a urinary catheter, occasional bowel incontinence, and pressure-ulcer risk, nursing wound assessments repeatedly changed the description of the buttocks condition from unstageable pressure injury to stage 2 pressure injury, while provider wound assessments consistently identified the problem as incontinence associated dermatitis of the bilateral buttocks. The RN manager stated the variable measurements occurred because some nurses measured red areas and others measured open areas, and later acknowledged the resident’s buttocks condition had been incorrectly identified and that the resident never had a pressure ulcer. The ADON stated nurses had only been given a folder of resources, with no in-person wound care training, and that there were no nurses designated as wound nurses or consistently performing wound assessments. The facility also failed to develop a comprehensive care plan for a resident with a colostomy. The resident’s MDS identified an ostomy/colostomy and dependence or supervision for ADLs, but the CAA did not identify the ostomy and the care plan did not include colostomy care, skin observations, family tips for an effective seal, or reporting problems. The resident’s family member stated the colostomy bag was often not placed correctly, separated from the skin, and leaked stool, and said she had trained staff herself because they were not drying skin prep properly. Staff stated the family had posted instructions in the room and in the EMR, but the RN manager acknowledged ostomy care should have been on the care plan and that she could not verify that all staff who changed the bag had been trained. The facility further failed to ensure a hand splint was properly applied for a resident with substantial dependence for ADLs and orders to wear a resting hand splint in the wheelchair, at bedtime, and in the morning. During observation, the splint’s palmar padding was not positioned in the palm, and an OT removed and reapplied it after opening the resident’s fingers and sliding the support into the palm. A nursing assistant later applied the splint incorrectly by placing the palm protector under clenched fingers and wrapping it around the fist, stating no one had shown her the proper way and that she had not noticed instructions in the room. The RN manager stated she had trained NAs on splint placement but had not documented who had been trained, and an RN who had recently started stated her orientation packet was incomplete and had not been turned in to leadership.
Hand Hygiene and Food Handling Lapses During Meal Service
Penalty
Summary
The facility failed to ensure dietary staff followed basic infection control practices, specifically hand hygiene, while serving residents in the dining room. During lunch service, a dining assistant was observed filling beverages for residents after touching her face and eyeglasses, then placing a cup of juice in front of a resident and handling a cup of milk by the rim where the resident would place his lips. The culinary director later stated the dining assistant would be reminded to wash her hands and not touch her face while serving residents, and also stated there was no documentation that the dining assistant had received face-to-face training or competencies regarding hand hygiene, only online modules. A second dining assistant was observed handling food with bare hands when separating two pieces of bread on a resident’s plate before serving it to R55. The dining assistant confirmed bare hands were used and stated gloves were expected to be worn when handling food. After being informed that R55’s food had been handled with bare hands, the nursing assistant returned the plated food to the kitchen. The same dining assistant was later observed wiping her bare hands on her clothing, touching her face and nose without washing her hands, and then handling plated food and trays for residents without hand hygiene. During follow-up interview, she stated it was not common practice to disinfect or wash hands when entering the kitchen from the dining room and confirmed that R55’s food was not remade after it had been handled with bare hands.
Administration Failed to Oversee Funds, Wound Care, Staffing, Competency, and QAPI
Penalty
Summary
Administration failed to exercise effective oversight over multiple ongoing deficient practices across departments, despite knowledge of concerns through staffing data, QAPI activities, staff reports, and prior monitoring. The report states these issues were not corrected in a timely or effective manner and continued across the facility, affecting all 61 residents. The deficiencies included missing resident funds, inaccurate wound assessment and documentation, inadequate staffing response times, insufficient staff competency validation, and ineffective QAPI follow-through. Regarding resident funds, the facility failed to protect personal property from misappropriation, failed to secure and account for a resident’s money, failed to report the allegation, and failed to conduct a comprehensive documented investigation. A resident repeatedly expressed concern that money was missing, and staff also raised concerns. The ED/administrator acknowledged the resident had reported missing money, that the allegation should have been reported to the state agency, and that no formal or comprehensive investigation was completed. The ED stated there was no documentation of the money, no chronological money ledger, no two-person verification process, and no assessment to determine whether other residents’ funds may have been at risk. The ED also stated the accused staff member should not have been responsible for securing the funds and that the resident’s money should have been secured in the facility safe, which was not accessible because the access code was unknown. The facility also failed to ensure timely and accurate skin assessment and wound documentation. One resident’s skin injury did not have a timely assessment and documentation, two residents had inaccurate wound assessments for pressure wounds, and one resident’s newly identified toe wounds did not receive an accurate, new, comprehensive assessment. Nursing staff documented pressure ulcers on one resident’s buttocks even though the provider consistently identified the condition as incontinence associated dermatitis and stated the resident did not have pressure wounds. The ADON stated nurses had only been given a folder of printed wound resources from a wound care company, with no in-person training or specialized courses, and there were no nurses designated as wound nurses or with special training. The report also states the facility failed to provide sufficient staffing to ensure residents received care and assistance in a timely manner, with average call light response times of eight minutes and long call lights not being monitored as outliers. In addition, the facility failed to ensure nursing staff had the specific competencies and skill sets needed for resident care, as orientation and competency validation were not consistently completed or tracked, annual hands-on competency assessments were not conducted, and leadership relied largely on verbal follow-up rather than formal monitoring.
Failure to Use QAPI to Identify and Correct Survey Deficiencies
Penalty
Summary
The facility failed to conduct ongoing QAPI and QA activities and failed to develop and implement action plans to correct quality deficiencies identified during the survey that it was aware of or should have been aware of. Review of QAPI meeting minutes since the last survey showed monthly discussions of topics such as hospitalizations/ED visits, risk management, wounds, weight trends, pain, unmet needs, falls, medication errors, and behaviors, with some months having no meeting. During interview, the ED stated the QAPI team was not aware of most of the survey team’s findings until they were brought to her attention during the survey. The ED stated the team had not previously identified concerns related to notification to provider, vulnerable adult reporting, bed holds and transfer forms, inaccurate MDS assessments, missing care plan items, care plan implementation, inaccurate or untimely wound assessments, incorrect splint application, lack of ROM, staff competency concerns, required nurse staffing posting content, water pitcher service, or unsanitary dining practices. The ED also stated she was unsure of any specific audits being completed, did not specifically monitor whether projects were completed, and relied mainly on verbal follow-up through morning meetings and individual check-ins rather than formal tracking to ensure improvements were realized and sustained. The facility QAPI policy stated the plan included tracking and measuring performance, identifying and prioritizing deficiencies, analyzing underlying causes, developing corrective actions, and monitoring and evaluating effectiveness.
Infection Control Failures With Resident Water Mugs and Urinary Drainage Bags
Penalty
Summary
The facility failed to provide an infection prevention and control program when resident water mugs were not sanitized or replaced on a daily basis for 7 of 7 residents reviewed. Residents and family members reported that clean mugs were not being provided consistently, and multiple staff members stated they did not know of a current process for washing or exchanging the mugs. On observation, residents had insulated or thermal mugs at the bedside, and several residents stated they did not know whether the mugs had ever been washed or said they did not receive a clean mug daily. The dietary director and nursing leadership also stated there was no current process in place to ensure residents received a clean mug and fresh water daily, and the facility did not have a policy for clean water mugs. R30 had no cognitive impairment, used a wheelchair, and was independent with eating but dependent for toileting hygiene and transfers. R30 stated fresh water was brought only when requested or by a family member, and an insulated mug was observed on the bedside table. R10 had diagnoses including spinal stenosis, diabetes, and chronic kidney disease, was independent with eating and drinking, and had three thermal cups with lids on the overbed table; R10 did not know if they had ever been washed. R4 had hemiplegia, diabetes, congestive heart failure, and dementia, and was observed with a large thermal water mug on the overbed table; R4 stated he never received a clean water mug, and a family member stated R4 reported the water smelled bad and they thought it might be bacteria from a dirty mug. During resident council interviews, five of six residents stated they were not provided a clean water mug daily. R7 stated he got a clean mug sometimes but not daily, R39 stated he never got a clean mug that he was aware of, R54 did not know if he ever got a clean mug, and R17 stated he received a clean water mug occasionally but not every day. Staff interviews showed inconsistent understanding of responsibility for mug exchange, with some staff believing day shift or evening shift handled it and others stating they had never seen it done. On the short-term care unit and long-term care unit kitchenettes, no extra or clean water mugs were available for nursing staff to use. The facility also failed to ensure basic infection control practices were followed when urinary drainage bags for 3 of 3 residents were observed resting on the floor. R13 had urinary retention and an indwelling catheter, and R43 had urinary retention and a suprapubic catheter; both had orders for catheter output every shift and care plans addressing catheter care. R3 had urinary retention, UTI, and chronic kidney disease, with orders for foley catheter care every shift. In each resident’s room, the drainage bag was hooked to a wastebasket or garbage can with the bottom resting on the floor. Staff and the infection prevention nurse acknowledged the bags should not be on the floor and stated the practice could contribute to infection concerns, while the facility policy stated catheter tubing and drainage bags were to be kept off the floor.
Unsanitary resident room and kitchen food prep area
Penalty
Summary
The facility failed to provide a comfortable and sanitary environment for one resident who had diagnoses including hemiplegia following stroke, diabetes, chronic pain, and dementia. The resident’s quarterly MDS indicated intact cognition, clear speech, highly impaired vision, adequate hearing, and substantial assistance or dependence for ADLs, and the care plan noted left-sided hemiplegia, need for assist of two staff with a Hoyer, preference for a commode, and impaired visual function with legal blindness. During observation in the resident’s room, an extra wide commode was found with the waste bucket filled to the rim of the seat with toilet paper, the odor of BM permeated the room, wet wipes were left open on the commode arm, the overbed table with food and drinks was touching the commode, a pillow was on the floor, items were piled in the corner, and the wastebasket beside the dresser was full with a soiled brief hanging over the side. During interview, the nurse manager observed the room and stated it was not okay to leave a commode like that. She stated staff were expected to remove and/or empty a commode right away, take trash out when they left the room, and pick up the room before exiting. She also stated newer staff had issues with time management and that nursing report included reminders about removing trash, closing wet wipe packages, and cleaning commodes. The resident stated he was not aware of the cleanliness of his room because of limited eyesight, thought staff did a good job keeping it clean, and expected staff to keep the room clean because he could not do it himself. The facility also failed to maintain a clean and sanitary kitchen food preparation and service area. During the kitchen tour, an electrical outlet and extension cord above the food service area were observed with gray, fuzzy debris present, and the cord extended down from the ceiling to a printer. The debris-covered cords were located directly above clean plates, near the steam table, and adjacent to a food preparation area. The culinary director and environmental director both confirmed the cords were dirty, covered in debris and lint, required cleaning, and were not on a routine cleaning schedule. The culinary director stated debris could fall onto uncovered plates during meal plating, and the environmental director stated debris-covered cords would not be expected over a food preparation area due to the risk of debris falling onto plates or food being prepared.
Inaccurate and Delayed Wound Assessment and Documentation
Penalty
Summary
The facility failed to ensure timely assessment and documentation of a skin injury for a resident who used a wheelchair and required substantial assistance with ADLs. The resident sustained a right forearm injury while working with PT and using a motorized wheelchair/scooter when the arm became caught on a bathroom counter or sink. Nursing staff applied bacitracin and a dressing, and the injury was added to the TAR, but the record lacked a skin assessment and wound documentation for the injury until several days later. Staff interviews confirmed that a comprehensive skin assessment and provider notification were expected on the date of the injury, but neither was documented at that time. The facility also failed to ensure accurate wound assessments for two residents with skin breakdown. One resident had severe cognitive impairment, was dependent for care, and was incontinent of urine and bowel. A new coccyx skin concern was identified by nursing staff and documented as a stage 1 pressure injury with measurements of 0.5 cm by 0.5 cm, with Mepilex applied and provider notification sent. During interview, the LPN stated the area was actually a slit related to moisture, not a pressure injury, and acknowledged she had not been trained to differentiate wound types or assess blanching. The RN manager confirmed the area was not pressure-related and that she did not assess the resident’s coccyx. The provider later documented the area as an open area and ordered Triad, while nursing documentation had already labeled it as pressure-related. For another resident with intact cognition, dependence for ADLs, a urinary catheter, and bowel incontinence, nursing documentation repeatedly identified bilateral buttock skin problems as pressure injuries, including stage 1, stage 2, and suspected deep tissue injury, with highly variable measurements across assessments. However, provider wound notes consistently described the buttocks condition as incontinence associated dermatitis, not pressure injury. Interviews with the RN manager, ADON, and provider confirmed that nursing staff had incorrectly identified the buttock condition as pressure-related and that the facility did not have nurses with specialized wound training or consistent wound assessors. The facility also failed to complete an accurate, new comprehensive assessment for newly identified toe wounds on another resident with diabetes and heart failure. The resident developed new left foot toe wounds after the foot was run over by a wheeled table, but the wound assessment documented the new toe findings as present on admission and unchanged, and only one of the new toe wounds was communicated to the provider.
Failure to Provide Daily Fresh Drinking Water
Penalty
Summary
The facility failed to provide fresh drinking water to 7 of 7 residents reviewed for hydration needs. The deficiency involved residents who had care plans directing staff to ensure adequate fluid intake, offer fluids, and keep water at bedside for easy access, yet multiple residents reported that they had to ask for water rather than being offered it routinely. Survey observations from 12/8/25 through 12/11/25 did not show staff passing water to resident rooms. R10 had diagnoses including spinal stenosis, diabetes, and chronic kidney disease, was cognitively intact, and could eat and drink independently. Her care plans directed staff to offer fluids, keep water at bedside, refill her water cup every day after lunch, and encourage adequate hydration, including due to diuretic use. During interview, R10 stated she was not offered fresh water daily and had to ask for it, or her daughter had to get it for her. R4 had diagnoses including hemiplegia following stroke, diabetes, congestive heart failure, and dementia, with highly impaired vision and need for substantial assistance with most ADLs. His care plan directed staff to ensure adequate fluid intake and keep water at bedside. He stated he had to ask staff for drinking water, which staff obtained from his bathroom. R30, who had no cognitive impairment and was independent with eating, stated fresh water was brought only when she requested it or when her family member brought it, and she reported staff had never offered her water. Other residents in resident council also stated they had to ask for fresh water, and staff interviews confirmed there was no current process for passing water daily, with staff generally providing water only when residents requested it.
Failure to Notify Provider of Resident Choking and New Skin Injuries
Penalty
Summary
The facility failed to notify the provider of a choking episode for one resident. The resident had moderately impaired cognition, used a walker and wheelchair, was independent with eating, and had diagnoses including heart failure and fracture. The resident’s care plan indicated eating assistance for set up and clean up, but the resident was ordered a regular diet with regular texture and thin liquids. A progress note documented that the resident choked at the dinner table, raised a hand and pointed at the throat, and staff performed the Heimlich maneuver until the resident started coughing and worked through the episode. The emergency contact was notified, but the executive director stated the provider was not notified of the choking incident. The facility also failed to notify the provider of newly identified skin injuries for one resident with diabetes and heart failure. The resident used a wheelchair and required substantial to maximal assistance with bathing and partial to moderate assistance with toileting and dressing. Skin assessments documented multiple toe wounds on the left foot, including shearing to the second, fourth, and fifth toes and a larger wound to the left great toe. A provider notification documented only a small blister at the tip of the fourth left toe that had popped a few days earlier, and no documentation of other new wounds was included in that notification. Staff interviews indicated the new wounds should have been separately assessed and reported, but no provider notification was documented for all of the newly identified toe wounds. The facility further failed to notify the provider promptly about a skin injury to another resident’s right forearm. The resident had diabetes and arthritis, used a wheelchair, and required extensive assistance with care. The resident sustained three skin tears on the right forearm after the arm became caught under a bathroom counter while using a motorized wheelchair during therapy. The wound was cleaned and dressed, and later notes referenced ongoing dressing changes, but the record lacked documentation that the provider had been notified of the arm injury until several days later. Staff interviews confirmed there was no assessment or documentation of the injury on the date it occurred, and the nurse manager stated the provider would be expected to be notified when a resident sustained a skin injury requiring treatment.
Failure to Timely Report Missing Money Allegation and Choking Incident
Penalty
Summary
The facility failed to ensure allegations of missing money were reported timely to the State Agency for one resident who had a history of dementia, impaired vision, impaired cognition, and dependence for many activities of daily living. The resident kept cash in a locked drawer in his room, and multiple staff members documented that he repeatedly expressed concern that money was missing. Staff messages show that the administrator, ADON, LPN, and others were aware of the resident’s accusations that a staff member may have taken his money, that he wanted police contacted, and that he believed a large amount of cash was unaccounted for. The administrator acknowledged the issue was known, but the facility did not immediately report the allegation to the State Agency when it was raised. Interviews and record review showed the facility did not complete a formal internal investigation when the allegation was made. The executive director stated there was no documentation of the money, no chronological money ledger, no two-person verification process, and no formal or comprehensive investigation. She also stated she did not interview staff or residents, did not conduct a room audit, did not interview the resident in a documented manner, and did not consult the financial POA about the missing money. Staff reported that the resident’s money had been handled based on verbal communication only, and the resident’s cash had been kept in his room with access by staff who could unlock the drawer. The executive director later confirmed that after receiving the allegation, it should have been reported to the State Agency. The facility also failed to report a choking incident involving another resident when the resident’s care plan was not followed. That resident had severely impaired cognition, required substantial assistance with eating and oral hygiene, and was dependent for showering, dressing, and toileting hygiene. The care plan required supervision and one-helper assistance for meals, yet the resident choked on dessert and juice while unsupervised. Staff interviews confirmed the resident was left alone during the meal because the aide stepped away to assist another resident, despite knowing the resident required supervision for all meals. The nurse and administrator later stated that the lack of supervision and failure to follow the care plan should have been reported immediately to the State Agency, but the report was not filed until the following day.
Failure to Protect Resident Funds and Follow Meal Supervision Care Plan
Penalty
Summary
The facility failed to ensure actions were taken to prevent further misappropriation of funds for a resident with dementia, severe visual impairment, and impaired cognition, and failed to fully investigate the allegation or protect other residents. The resident’s records showed he required substantial assistance with many activities of daily living, used a manual wheelchair, and had diagnoses including non-Alzheimer’s dementia, depression, end stage renal disease with dialysis, muscle weakness, difficulty walking, and essential tremor. Staff communications showed repeated concerns about the resident’s money, including reports that he kept large amounts of cash in a drawer in his room, that he was accusing a staff member of taking money, and that staff were aware he was blind, forgetful, and having difficulty understanding and responding to questions. The resident’s money was kept in his room in a locked drawer and blue bag, and staff acknowledged that multiple employees and service providers had access to the area and that the resident was often out of his room or off-site. Staff also acknowledged that the resident could not reliably count his money or identify denominations because of his visual impairment. The executive director stated the resident’s money should have been secured in the facility safe, but instead the handling of the funds was based on verbal communication only, there was no chronological money ledger, no two-person verification process, and no documentation of the money. The executive director further stated she did not notify or consult the financial POA about the missing money and that no formal or comprehensive investigation was completed. The facility also failed to fully investigate the resident’s allegation of missing money or determine whether other residents had concerns about missing valuables. Staff interviews showed that concerns were raised to leadership, including messages from an LPN and the ADON, but the executive director stated she did not interview staff or residents, did not conduct a room audit, and did not complete a documented interview with the resident. The resident later stated money was missing and identified the staff member he believed took it. The report also identified a separate deficiency involving another resident who choked while eating unsupervised despite a care plan requiring supervision and assist of one helper for meals; staff and leadership acknowledged the resident was supposed to be supervised, that the choking occurred while he was eating alone, and that the incident was not immediately investigated or reported.
Failure to Provide Bed Hold and Transfer Notices
Penalty
Summary
The facility failed to ensure that the resident and/or legal representative received a bed hold notice and written notice of transfer for 2 residents who were transferred to the hospital for overnight stays. One resident had diagnoses including congestive heart failure, chronic kidney disease, and urinary retention, had an indwelling urinary catheter, did not walk, and required substantial assistance or was dependent for most ADLs. The resident’s progress notes showed staff notified a family member about low blood pressure and the provider’s recommendation to send the resident to the ER, and later documented that the resident was transferred to the hospital and that messages were left regarding bed hold. The resident was readmitted several days later after hospitalization for a catheter-associated UTI. The resident stated during interview that he had recently been admitted to the hospital for a UTI and did not recall signing a bed hold or receiving a written notice of transfer form. The resident did not know whether someone else had done that on his behalf. The nurse manager reviewed the EMR and did not find a bed hold or written notice of transfer for the hospitalization, and also could not locate the facility folder where such forms were kept at the nurses’ station. The nurse manager stated the bed hold and written notice could have been explained and given to the resident before hospitalization because he was his own person. The second resident had diagnoses including hemiplegia following stroke, diabetes, chronic pain, and dementia, and required substantial assistance or was dependent for help with ADLs. The resident did not walk and had highly impaired vision. Progress notes showed the provider recommended sending the resident to the ER for further evaluation after the resident’s right upper quadrant was very distended, and the family member was called and informed. The note documented that the family member gave a verbal bed hold, the resident was sent to the ER, and later returned from the hospital. The family member stated she gave a verbal bed hold but did not sign a bed hold form or receive a written notice of transfer form, and the nurse manager found no such documentation in the EMR.
Inaccurate MDS Coding for Skin Breakdown and Dialysis
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for a resident whose records showed conflicting documentation about buttock skin breakdown. The resident’s face sheet listed diagnoses including an unstageable pressure ulcer of the back, buttock, and hip, and irritant contact dermatitis due to incontinence. The significant change MDS indicated intact cognition, clear speech, substantial to dependent assistance with ADLs, no walking, a urinary catheter, occasional bowel incontinence, and risk for pressure ulcers with an unhealed pressure ulcer and two unstageable pressure injuries described as deep tissue injury not present on admission. The resident’s CAA and care plan documented suspected deep tissue injuries to the bilateral buttocks and multiple skin-related care plan entries referencing pressure injury, pressure ulcer, and SDTI. Nursing wound assessments by the RN/nurse manager documented varying pressure injury stages and locations on the buttocks, including unstageable, no stage, and stage 2. In contrast, provider wound assessments consistently identified the buttocks problem as incontinence associated dermatitis, bilateral, and never described it as a pressure injury or ulcer. During interview, the RN/nurse manager stated she realized the resident’s buttock skin had been incorrectly identified and that the resident never had a pressure ulcer, while the MDS nurse stated she coded the MDS based on nursing skin assessments and believed the resident could have both pressure ulcer and dermatitis. The facility also failed to accurately code dialysis on another resident’s MDS. The resident had end stage renal disease with dialysis, was receiving dialysis three times weekly, and the care plan identified risk for complications related to dialysis. The 5-day MDS indicated dialysis on admission but did not indicate dialysis while a resident. The MDS coordinator later stated this was an oversight and that the resident’s dialysis while in the facility should have been marked on the assessment. The executive director stated MDS assessments were expected to be accurate.
Failure to Include Colostomy Care in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with a colostomy. The resident’s face sheet listed diagnoses of malignant neoplasm of the rectum, rectosigmoid junction, and anus. The annual MDS indicated intact cognition, clear speech, and that the resident had an ostomy and required supervision or dependence for ADLs. The resident’s physician orders and TAR included colostomy bag changes twice weekly with specific steps for cleansing, skin protection, drying the area, applying ostomy powder, a moldable ring, a new ostomy bag, and elastic barrier strips. The resident’s CAA did not identify an ostomy or colostomy, and the care plan reviewed on 12/9/25 did not include the resident’s colostomy, ostomy care, skin observations, family member tips for an effective seal, or reporting problems. During interviews, the resident’s family member stated the colostomy bag was often not placed correctly, separated from the skin, and leaked stool, and that staff did not let the skin prep dry before proceeding. The family member also stated she had trained nursing staff herself and had posted handwritten instructions in the resident’s room for staff to review. Staff interviews confirmed inconsistent knowledge and training related to the resident’s ostomy care. An LPN stated the bag came off quite a bit and was not sure whether all nursing staff used the binders supplied by the family member. The nurse manager stated she had reviewed the family member’s instructions with an LPN so that the LPN could teach other nurses, but she did not track who had been trained. The nurse manager acknowledged ostomy care should have been on the care plan, and later stated there was nothing in the care plan pertaining to the colostomy and that it should have been added when the resident came from short-term stay. The MDS nurse stated ostomy care should have automatically pulled to the care plan, and the ADON acknowledged that nurse managers were responsible for ensuring staff were trained on ostomy care.
Failure to Supervise Resident During Meals
Penalty
Summary
The facility failed to ensure a resident received the assistance and supervision with meals that were identified in the care plan. The resident had severely impaired cognition on the MDS, used a wheelchair, and required substantial to maximal assistance for eating and oral hygiene, with diagnoses including Alzheimer’s disease, depression, and pressure ulcers. The care plan directed supervision/touch assistance of one helper for eating, and physician orders specified a regular diet with soft and bite-sized texture and thin liquids. Facility policy stated residents unable to perform ADLs independently would receive the services necessary to maintain good nutrition and appropriate support with dining. On 12/7/25, the resident choked on dessert and juice while unsupervised during a meal, and the chart note stated he was supposed to have one-helper assistance and supervision for all meals. Family members reported they had repeatedly posted signs in the resident’s room reminding staff to supervise him from start to finish with each meal and were concerned the facility would leave him unsupervised. Staff interviews confirmed the resident was left alone while eating, that he was supposed to be supervised for all meals, and that the assigned NA left him unattended to answer other call lights and assist another resident, after which the choking episode occurred.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide incontinence care for one resident who was dependent on staff for assistance with ADLs. The resident had severe cognitive impairment, was dependent on staff for toileting hygiene, shower/bath, lower body dressing, personal hygiene, and transfers, used a wheelchair, and was always incontinent of urine and frequently incontinent of bowel. The resident’s care area assessment and care plan directed staff to anticipate toileting needs, check the resident every 2 hours, assist with toileting as needed, and provide toileting before meals and at bedtime, with assistance from two staff and use of a mechanical lift for transfers. On observation, the resident was found lying in bed with a noticeable odor in the room. A nursing assistant initially stated the brief was dry and not soiled, but upon rechecking found it saturated with urine and containing bowel movement, then provided cleansing and a brief change. The nursing assistant confirmed the resident required staff assistance with toileting hygiene and stated the resident had last received toileting care at about 10:00 a.m. Later the same day, the resident stated staff had not checked the brief before lunch until someone prompted them to do so, and the nursing assistant confirmed the brief had not been checked or changed as expected prior to lunch. The nursing assistant, nurse manager, and interim DON stated staff were expected to check and change the resident’s brief every 2 hours and before meals, and that residents were not to be transferred to meals wearing urine-soaked or soiled briefs.
Failure to Provide ROM and Proper Hand Splint Application
Penalty
Summary
The facility failed to provide services to maintain and/or prevent loss of range of motion (ROM) for a resident with left-sided hemiplegia following a stroke, and also failed to ensure a hand splint was properly applied for palmar protection. The resident’s records showed he had intact cognition, required substantial assistance or was dependent for most ADLs, did not walk, and had provider orders for PT/OT evaluation and treatment every shift as well as a resting hand splint when in the wheelchair, at bedtime, and in the morning. His care plan identified a restorative nursing program, ROM exercises, and a left hand splint with gentle finger stretching before application. Documentation in the EMR showed the ROM task had been completed only twice in the prior 30 days, and the hand splint task had been completed only 12 times in the prior 30 days. A family member stated the resident no longer received therapy or ROM to his joints and said staff had “given up” on the splint. During observation, the resident was seen in his wheelchair with the left hand splint on, but the palmar padding was not positioned in the palm. An OT later confirmed the splint had not been positioned correctly and removed it, then replaced it by opening the resident’s fingers and sliding the palmar support into the palm. Further observations showed an NA applying the splint without opening the resident’s fingers, placing the palmar protector under clenched fingers and wrapping the strap around the fist. Another OT and the DON later observed the splint on the bed and reapplied it correctly. The NA stated no one had shown her how to apply the splint and that she had not noticed the visual instructions posted on the closet door. The RN manager verified ROM had been documented only twice in 30 days and stated she had not been aware of that. Multiple staff members stated they believed ROM instructions were for therapy staff, while the ADON stated it was the NA’s responsibility to perform ROM and the nurse managers’ responsibility to monitor it.
Daily staffing posting not posted in a clear, readable format
Penalty
Summary
The facility failed to ensure required nursing staffing information was posted in a clear, readable, and accessible format for residents, staff, and visitors. During observation and interview, the executive director escorted the surveyor to a Plexiglas sign holder on the first floor near other resident information and a fish tank, where the Daily Staffing Posting was located. The posting was a four-page, electronically generated UKG document titled Daily Headcount, printed in an estimated seven-point font with six columns and 35 rows, and it was not readily recognizable among the other documents displayed. Only some dates were visible because other dates had been cut off, and the document did not include census information or up-to-date staffing adjustments by shift. The executive director stated the posting had always been generated automatically with a week of dates at a time and that census had never been included, nor staffing adjustments identified by shift. The executive director also stated she had not been aware of the regulatory requirements related to the Daily Staffing Posting. The facility policy required daily posting of staffing data within two hours of each shift start, including resident census, shift information, staff categories, actual hours worked, and total staffing numbers in a prominent location and in a clear and readable format.
Inadequate Infection Control and EBP Implementation
Penalty
Summary
The facility failed to ensure that its infection control program included ongoing surveillance, trending, and analysis of resident infections. The Assistant Director of Nursing (ADON-B), who also served as the infection preventionist, was responsible for tracking and documenting infections and antibiotic use. However, ADON-B experienced difficulties accessing reports and did not include essential information such as signs and symptoms, treatment, or the implementation of transmission-based precautions in the documentation. The facility's monthly resident infection statistics revealed incomplete documentation, with missing data on signs and symptoms, bacteria, outcomes, and whether infections were healthcare-associated. ADON-B acknowledged the challenges in accessing culture and x-ray reports and the lack of adherence to McGeer's criteria by physicians for ordering tests before treating infections. The facility's infection surveillance policy required the infection preventionist to conduct ongoing surveillance for healthcare-associated infections and other significant infections. However, the surveillance flow sheet lacked critical information, and ADON-B did not print out monthly or quarterly reports for infection analysis. Consequently, ADON-B was unable to report on the facility's current or past infection rates during infection control meetings and quality assurance and performance improvement meetings. The Director of Nursing (DON) confirmed that infection surveillance was incomplete and acknowledged the need for improvement in the process. Additionally, the facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a nephrostomy tube, which posed a risk of infection. Despite the presence of a PPE cart and a sign indicating the need for gloves and gown, a nursing assistant (NA-A) entered the resident's room without donning the required PPE. NA-A admitted to being aware of the EBP requirement but did not think it was necessary if not directly handling the tube. The facility had conducted multiple trainings on EBP and created a pocket guide to assist staff, but compliance with the policy was inconsistent. The DON expected staff to adhere to the EBP sign on the door, but the deficiency in implementing EBP was evident in this instance.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an effective process for antibiotic review, which is crucial for determining appropriate indications, dosage, duration, and trends of antibiotic use and resistance. During an interview, the Assistant Director of Nursing (ADON), who also serves as the infection preventionist, revealed that while infections and antibiotic use were tracked and documented using a software program, there was difficulty in accessing and printing reports. A review of the facility's monthly antibiotic use data from May 2024 to February 2025 showed that 34 out of 37 urinary tract infections treated with antibiotics lacked culture results and analysis of antibiotic treatment. Additionally, six UTIs were documented as suspected without proper diagnosis, and five residents were on prophylactic antibiotics. The ADON indicated challenges in accessing culture results and noted that not all physicians adhered to the McGeer criteria for infection testing. Furthermore, the ADON did not report on multi-drug resistant organisms (MDRO), prophylactic use, or antibiotic use at infection control or quality assurance performance improvement (QAPI) meetings. The Director of Nursing (DON) confirmed that the antibiotic stewardship program lacked proper analysis and monitoring. The facility's Antibiotic Stewardship policy, last reviewed in October 2024, outlined the need for culture and sensitivity results to be communicated to prescribers to guide antibiotic therapy decisions, but this was not effectively implemented. The Prevention and Control Program policy also emphasized the inclusion of culture reports and antibiotic usage reviews in surveillance activities, which was not adequately followed.
Failure to Include Cultural Aspects in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan included cultural aspects, specifically related to food preferences, for a resident with chronic kidney disease, heart failure, and diabetes. The resident, who was moderately cognitively impaired, expressed dissatisfaction with the food provided, stating it was not prepared in a manner consistent with his cultural preferences. Despite the culinary team offering options within religious and cultural preferences, the resident reported a poor appetite and did not consume the offered supplements. The care plan, developed by a registered nurse, did not address the resident's cultural needs, and the nursing assistant's task sheet and kardex also lacked this information. Interviews with facility staff, including the director of nursing and a licensed social worker, revealed a lack of clarity regarding responsibility for incorporating cultural preferences into care plans. The facility's policy on comprehensive person-centered care plans emphasized culturally competent services, yet this was not reflected in the resident's care plan. The facility assessment indicated a commitment to person-centered care, including cultural and religious aspects, but this was not implemented in practice for the resident in question.
Failure to Maintain Clean Ceiling Vents
Penalty
Summary
The facility failed to maintain cleanliness in the 3400 wing, specifically regarding the ceiling vents in the rooms of three residents. Observations revealed that the vents were covered with a black substance, which was identified as dust and dirt buildup. The maintenance director acknowledged that the vents were dirty and needed cleaning, attributing the buildup to moisture causing dirt to stick. The maintenance director also admitted that although vent cleaning was on a monthly checklist, it was only performed quarterly, contrary to the facility's expectations. Interviews with residents and staff confirmed the presence of the black substance on the vents. One resident expressed uncertainty about whether the substance was dirt or mold. The facility's policy on maintenance of plumbing, HVAC, and related systems indicated that items should be free of visible soil, yet the vents were visibly dirty. The administrator confirmed that vents were expected to be cleaned regularly by maintenance and housekeeping staff, especially before new residents moved in, at resident discharge, and when visibly dirty.
Failure to Address Sudden Change in Condition Leads to Resident's Death
Penalty
Summary
The facility failed to recognize and respond appropriately to a sudden change in condition for a resident, leading to a delay in treatment. The resident, who had a history of cardiovascular issues including non-ST elevation myocardial infarction, atrial fibrillation, and nonrheumatic aortic stenosis, experienced chest pain. Despite the resident's history and the care plan's directive to monitor for cardiac complications, the nursing staff did not conduct a comprehensive assessment or continuous monitoring of the resident's condition. On the morning of the incident, the resident reported chest pain to the nursing staff. However, the staff did not immediately notify the physician or take urgent action. Instead, they planned to wait for the physician's rounds later that morning. The resident's condition included symptoms such as pitting edema, wheezing, and nausea, which were not adequately addressed. The nursing staff's inaction persisted despite the resident's family member expressing concern and urging them to contact the physician. The delay in response resulted in the resident being sent to the emergency room only after the family member insisted on immediate action. Upon arrival at the hospital, the resident was diagnosed with an acute anterior STEMI and underwent a surgical procedure. Unfortunately, the resident suffered complications and passed away later that day. The facility's failure to promptly address the resident's chest pain and notify the physician contributed to the delay in receiving necessary emergency care.
Removal Plan
- re-education on change of condition with nurse management team
- posters of signs/symptoms of cardiac episodes posted at nurses stations and reviewed with all staff
- quiz for each nurse to take asking what do nurses do when a change of condition occurs, what is considered a change of condition
- review of like residents and no one else was at-risk
- nurse meeting scheduled to reiterate presented education
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure the infection control program included ongoing surveillance, trending, and analysis of resident infections. Staff were observed doffing personal protective equipment (PPE) incorrectly for one resident and PPE was stored improperly on the floor for multiple residents placed on enhanced barrier precautions (EBP). Additionally, a meal tray was placed on the floor for one resident, which posed an infection control risk. These deficiencies had the potential to affect all 56 residents in the facility. During observations, it was noted that plastic gowns were stored directly on the floor inside resident rooms, and there was no place to dispose of the gowns before leaving the rooms. Staff confirmed that PPE was donned inside the resident rooms, and it was suggested that mounting the gowns and gloves on the wall would be more efficient. The assistant director of nursing (ADON) and the director of nursing (DON) acknowledged that the current placement of PPE was an infection control risk and that there was no garbage or place to dispose of the gowns readily available next to the door for staff to doff PPE before exiting the rooms. The facility also failed to conduct ongoing infection surveillance. The ADON, who was responsible for infection surveillance, confirmed that tracking of infections was not currently taking place and was not aware of the last infection surveillance. The DON stated that discussions were held at daily meetings about residents showing signs of infection and on antibiotics, but ongoing surveillance had not been completed. The ADON verified that a monthly analysis of illnesses and infections was important to rule out any trends or patterns and that the facility was not currently tracking infection data. Additionally, staff were observed improperly doffing PPE, and a meal tray was placed on the floor, which the ADON acknowledged as an infection control breach.
Failure to Implement Antibiotic Review Process
Penalty
Summary
The facility failed to implement a process for antibiotic review to determine appropriate indications, dosage, duration, and trends of antibiotic use and resistance. This deficiency was identified during an interview with the DON and ADON, who confirmed that while the nursing staff monitored symptoms and reported potential infections to providers, there was no formal tracking or monitoring process for residents placed on antibiotics. The ADON, who was responsible for the infection control program, acknowledged that although he had completed education on infection control and antibiotic stewardship, the facility had not yet implemented a tracking system for antibiotic use. The DON and ADON verified that the facility did not have a formal process to track antibiotics for cultures, source, location of infection, or symptoms when placed on antibiotics. The health unit coordinator received culture results via fax and alerted the nursing staff, who would then contact the doctor if a change in the antibiotic was needed. However, the ADON confirmed that he did not review or track culture results to ensure proper antibiotics were prescribed and did not maintain a tracking log. The facility's Prevention and Control Program policy indicated that antibiotic usage reviews should be included in surveillance activities, but this was not being followed.
Failure to Report Allegation of Misappropriation of Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property to the state agency within 24 hours as required by their policies and procedures. A resident, who was cognitively intact and independent with most activities of daily living, reported that approximately $70 in cash was stolen from his room. The facility staff were informed of the missing money, and a police report was filed. However, the facility did not report the incident to the state agency within the required timeframe, relying instead on law enforcement to file a report with the Minnesota Adult Abuse Reporting Center (MAARC). The resident's care plan indicated a behavior problem of paranoia related to dementia, which may have influenced the staff's perception of the validity of the report. Despite the resident later finding the cash in his underwear drawer, the facility's regional nurse consultant acknowledged that the incident should have been reported to the state agency within 24 hours. The facility's policy clearly states that any suspected theft or misappropriation of resident property must be reported to the appropriate agencies within 24 hours, which was not adhered to in this case.
Inaccurate MDS Assessments for Hospice and Pressure Ulcers
Penalty
Summary
The facility failed to ensure the accurate identification of resident status in the Minimum Data Set (MDS) assessment for two residents. Resident R52, who was admitted with diagnoses including malignant neoplasms and heart failure, was receiving hospice services. However, the MDS assessment did not reflect this, as section O, K1 under special treatments and programs did not include hospice care services. This discrepancy was confirmed by the MDS coordinator, who acknowledged that the section was not coded correctly despite the resident's indication of receiving hospice services and a provider order for hospice evaluation. Similarly, Resident R21, with diagnoses of hemiplegia, hemiparesis, and diabetes mellitus type 2, had an MDS assessment that incorrectly indicated no pressure ulcers or deep tissue injuries. However, a skin assessment revealed a small open shallow area on the left buttock and a pressure ulcer on the left heel. The MDS coordinator confirmed the inaccuracy and admitted that the MDS would have been submitted incorrectly. The director of nursing also acknowledged that the MDS should have been completed accurately. The facility's policy requires an RN to be responsible for the accuracy of the resident assessment, which was not adhered to in these cases.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to offer or provide a summary of the baseline care plan to newly admitted residents and/or their representatives. This deficiency was identified for three residents who were newly admitted. One resident, who was cognitively intact, stated that she never received a copy of her care plan and would like to have one. The social worker confirmed that copies of the care plan were only provided if requested, and the Director of Nursing confirmed that a copy of the baseline care plan was not being offered to the resident or a family member. Another resident's family member also did not recall receiving a copy of the baseline care plan. A registered nurse stated that it was not current facility practice to provide the resident or resident representative a copy of the baseline care plan. The facility's policy and procedure for baseline care plans, dated March 2022, included the requirement to develop a baseline plan of care within 48 hours of admission and to provide a written summary of the baseline care plan to the resident and/or representative. This summary should include the stated goals and objectives of the resident, a summary of the resident's medications and dietary instructions, any services and treatments to be administered by the facility, and any updated information based on the comprehensive care plan. The provision of the summary to the resident and/or representative should be documented in the medical record. However, the facility did not adhere to this policy, resulting in the deficiency noted in the report.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to ensure individualized activities were provided for a resident (R29) who had moderately intact cognition and expressed interest in various activities. Despite the resident's care plan and baseline care plan indicating his preferences for activities such as playing cards, listening to music, and attending religious services, the facility did not offer these activities to him. The resident and his family member both reported that he had not been offered any activities, and the activity calendar posted in his room was not utilized to engage him in the listed activities. The activity coordinators (AC-A and AC-B) and nursing assistant (NA-F) confirmed that they had not offered R29 any activities based on his interests. AC-A stated that the resident's activity preferences were documented, but there was no follow-up to ensure he participated in these activities. AC-C mentioned that staff might have assumed the resident did not want to participate in activities because he had company, but this assumption was not verified with the resident. The director of nursing (DON) confirmed that residents were expected to be offered activities based on their interests and assessments, which did not occur in this case. The facility's Activity Programs policy outlined the importance of providing individualized and group activities based on residents' preferences and needs. However, the facility did not adhere to this policy for R29, as there was no documentation of his participation in activities, and staff did not actively engage him in the activities he enjoyed. This failure to provide individualized activities led to the deficiency identified in the report.
Lack of Coordination with Hospice Services
Penalty
Summary
The facility failed to ensure services were coordinated with the hospice agency for a resident receiving hospice services. The resident required substantial to maximum staff assistance with all activities of daily living and had intact cognition. The resident's care plan indicated the need for coordination with hospice services, but there were discrepancies in the hospice visit schedule. The hospice agency's plan of care indicated visits from a registered nurse and a home health aide, but the facility's hospice binder did not have updated visit dates beyond a certain point. The resident reported missed visits and lack of communication from the hospice agency, leading to confusion and unmet care needs. Interviews with the resident, hospice staff, and the facility's director of nursing confirmed the lack of communication and coordination. The resident expressed frustration over not being informed about visit schedules and having to refuse care from facility staff because hospice was supposed to provide it. The hospice staff admitted to not notifying the resident or the facility in advance of visits, and the director of nursing acknowledged the communication issues. A policy on hospice services was requested but not provided by the facility.
Failure to Implement ROM Program and Properly Apply Splint and Edema Glove
Penalty
Summary
The facility failed to ensure a range of motion (ROM) program for a resident with limited upper extremity mobility, leading to improper application of a wrist brace and edema glove. The resident, who had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, was observed with a hand splint and edema glove incorrectly applied. The resident reported that staff did not perform ROM exercises and often applied the brace incorrectly, causing it to move out of place. Observations confirmed that the splint was not providing the intended support, and the resident's fingers were curled, indicating a lack of proper ROM exercises and splint application. Interviews with staff revealed inconsistencies in the implementation of the resident's care plan. Nursing assistants indicated they did not perform PROM on the resident's left hand due to discomfort and lack of clear instructions. The occupational therapist confirmed that the splint was not in the correct position and had lost its form, making it ineffective in preventing contractures. The therapist also noted that the resident's fingers were tight and required further therapy to regain flexibility. The resident's care plan and provider orders specified the need for ROM exercises and proper application of the splint and edema glove, but these were not consistently followed. The director of nursing acknowledged that the PROM should be performed by nursing assistants and that the hand splint should be applied correctly. However, the facility's documentation and staff interviews indicated a failure to adhere to the care plan, resulting in the resident's condition worsening. The facility's policy emphasized the importance of maintaining ROM and preventing contractures, but the lack of proper implementation and monitoring led to the deficiency observed by the surveyors.
Improper Cigarette Disposal and Supervision
Penalty
Summary
The facility failed to properly assess and manage the disposal of cigarettes for a resident with severe cognitive impairment and multiple health conditions, including aphasia, hemiplegia, and tobacco use. The resident's care plan indicated that he required supervision while smoking and that the facility would store his lighter and cigarettes. However, during an observation, the resident was seen smoking across the street with the interim director of nursing (IDON) supervising. The resident disposed of the cigarette butt improperly, and it was later found inside the facility, indicating a lapse in supervision and proper disposal procedures. The IDON admitted to not knowing where the cigarette butt was disposed of and confirmed that the facility did not have a designated receptacle for cigarette disposal. The director of nursing (DON) also acknowledged the lack of a proper plan or designated area for cigarette disposal, despite the facility's policy requiring metal containers with self-closing covers in smoking areas. The IDON, who was recently hired and still unfamiliar with the facility layout, confirmed that the facility allowed the resident to smoke off-property but did not have a well-thought-out plan for cigarette disposal. Further observations revealed multiple cigarette butts on the ground where the resident commonly smoked, and the DON stated that education would be provided to nursing staff and the resident regarding proper cigarette disposal. The facility's smoking policy emphasized the need for safe smoking practices and designated smoking areas, but the lack of a proper receptacle and supervision led to the deficiency in managing the resident's smoking habits and ensuring safety within the facility.
Unsanitary Conditions in Kitchen Areas
Penalty
Summary
The facility failed to provide a sanitary environment in the kitchen's food preparation and drying areas, potentially affecting all 56 residents. During an initial tour, a vent above the pots and pans dishwashing area was observed to have dark, fuzzy material. Additionally, wire mesh and a printer cord above the food serving area were covered in gray, fuzzy debris. These observations were confirmed by the cook and maintenance director, who acknowledged that the areas were dirty and needed cleaning. The culinary director also confirmed that there should not be any dirt or debris in these areas.
Failure to Administer Insulin Per Physician Orders
Penalty
Summary
The facility failed to ensure insulin was administered per physician orders for a resident (R1) with diabetes, leading to significant medication errors. R1, who was cognitively intact and required insulin daily, had physician orders to switch from detemir insulin to glargine insulin once the detemir was used up. However, due to a lapse in the visibility of the hold order for glargine insulin, R1 received both types of long-acting insulin simultaneously over a six-day period. This resulted in R1 experiencing hypoglycemia and being transported to the hospital after showing symptoms such as increased confusion and agitation. Licensed Practical Nurse (LPN)-A and Registered Nurse (RN)-A both administered the insulins without questioning the orders, despite knowing that both were long-acting insulins. The Director of Nursing (DON) acknowledged that the facility was transitioning from detemir to glargine insulin, and the hold order for glargine was not easily visible. Family members and staff observed significant changes in R1's condition, including increased confusion, agitation, and physical symptoms like being pale and clammy. The facility's Insulin Administration Policy required verification of insulin type, dosage, strength, and method of administration before administration, which was not adhered to in this case.
Failure to Assess and Respond to Change in Condition
Penalty
Summary
The facility failed to comprehensively assess, implement interventions, and provide timely notification for a change in condition to a provider for a resident who was found unresponsive, which delayed care and resulted in death from acute respiratory distress. The resident had a history of Parkinson's Disease, renal insufficiency, neurogenic bladder, seizure disorder, and muscle weakness. Despite several nursing assistants reporting the resident's deteriorating condition, including decreased appetite, facial pallor, blue lips, increased fatigue, lethargy, and decreased responsiveness, the licensed nursing staff did not perform a comprehensive assessment or monitor the resident adequately. On the day of the incident, multiple staff members observed and reported significant changes in the resident's condition, such as very dark urine, red eyes, and lethargy. However, the licensed practical nurse (LPN) and registered nurses (RNs) involved did not take appropriate actions, such as conducting a full set of vital signs, documenting the observations, or notifying a physician. The resident's condition continued to deteriorate throughout the day and evening, with no significant interventions or assessments performed by the nursing staff. By the time the night shift staff assessed the resident, the resident was found to be in severe respiratory distress with critically low oxygen saturation and pulse rates. Emergency Medical Services (EMS) were called, but the resident was not provided with oxygen or other necessary interventions before their arrival. The resident was transported to the hospital, where they were diagnosed with acute respiratory failure and subsequently passed away. The facility's failure to follow protocols for assessing and responding to changes in the resident's condition directly contributed to the resident's death.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mankato
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Care & Rehabilitation Center | 1.1 mi | ★★★★★ | 5 | 0 |
| Laurels Peak Care & Rehabilitation Center | 1.7 mi | ★★★★★ | 19 | 0 |
| Oaklawn Care & Rehabilitation Center | 2.1 mi | ★★★★★ | 2 | 0 |
| Benedictine Living Community Of St. Peter | 13.3 mi | ★★★★★ | 8 | 0 |
| Whispering Creek | 16.1 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.