Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Providence Place during CMS and state inspections, most recent first.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors: Two residents with substance use and mental health histories continued to drink and display alcohol-related behaviors, including slurred speech, odor of alcohol, and repeated intoxication. One resident had dementia, anxiety, and depression; the other had TBI, depression, psychotic disorder, and substance use disorder. Despite existing care plan interventions, staff interviews and records showed ongoing alcohol use, limited monitoring of triggers and target behaviors, and a resident-to-resident altercation on the smoking patio that involved yelling, physical contact, and police response.
Food Storage and Refrigerator Sanitation Deficiencies: Surveyors found raw meat and other food items stored improperly in the kitchen walk-in refrigerator, including undated and unlabeled meat, a leaking package of raw meat, and turkey past its use-by date. In the walk-in freezer, surveyors observed soup with ice on top, unlabeled brats stored in a personal belongings bag, frost-damaged egg noodles, and food buildup under the shelving. On a unit refrigerator, an uncovered energy drink, undated pitchers of juice, and red liquid residue were observed.
Failure to Deliver Resident Mail on Saturdays: Residents reported during Resident Council that mail delivered by the post office on Saturdays was not given to them until Monday. The DON stated mail should be delivered the same day it arrived and that timely mail delivery was a resident right, but she could not identify a specific staff member responsible for overseeing the process. The Admin also stated all staff were responsible for delivering mail, including on weekends, and that mail should be delivered the same day it arrived.
The facility failed to document resident-specific non-pharmacological interventions before PRN pain meds were given to four residents. Records showed repeated PRN acetaminophen, oxycodone, and hydromorphone use without evidence that comfort measures such as ice, heat, massage, music, or repositioning were offered or tried first, and staff confirmed these interventions were not routinely provided unless requested. The facility also continued daily nystatin powder for a resident whose groin redness had resolved, despite a pharmacist review recommending discontinuation when healing was complete.
The facility failed to maintain accurate and complete immunization records for 3 residents when the EMR showed a second influenza vaccine for each resident, even though the April clinic was actually a COVID-19 vaccination clinic. The DON/IP stated the entries were incorrect and acknowledged that staff would use MIIC to verify which vaccine each resident received, but the facility could not provide a policy addressing accurate medical records.
The facility failed to identify and use EBP for residents with tunneled CVC dialysis access sites and for a resident with open gluteal wounds. Staff observed no EBP signage, PPE bins, or gowns during care, and staff confirmed these residents were not on EBP. The facility also failed to keep oxygen tubing and a nasal cannula off the floor for a resident on oxygen therapy, and an LPN reapplied the contaminated equipment directly without cleaning or replacement.
Resident dignity was not maintained during personal care when a resident with severe cognitive impairment was left exposed during wound and incontinent care and a housekeeper entered the room, and when another resident was uncovered during incontinent care while the Administrator, an LPN, and an RN entered without waiting for permission. Dignity was also affected when two residents waited an excessive time for call light response and experienced bowel or bladder accidents while waiting; one resident reported a bowel accident on the floor, and another reported sitting in a soiled brief. Call light logs showed waits of 38 minutes, 53 minutes, and 58 minutes.
A resident with intact cognition, DM, depression, and malnutrition was supposed to receive larger protein portions because he reported increased hunger, and this was reflected in the meal ticket and care plan. During observation, he was served a smaller chicken portion than other residents, and both an RN and the dietary manager confirmed the serving did not match the ordered larger portion; staff also stated the facility had been giving the same standard chicken portions to residents ordered larger protein servings.
A resident remained in the facility after Medicare Part A coverage ended, but the SNFABN was not provided. Record review showed the resident’s Medicare-covered stay had ended, a NOMNC had been issued, and the SNF Beneficiary Protection Notification Review form stated no SNFABN was given because the resident was dropped to a non-skilled level. The assistant administrator confirmed the SNFABN appeared not to have been completed.
A resident’s care plan contained conflicting and inconsistent information about toileting, transfers, mobility, and ambulation after a hospitalization, with entries showing independence, supervision, wheelchair use, walker use, and toileting assistance needs that did not match staff reports of the resident’s current condition. In a separate issue, a resident with stroke-related paralysis, diabetes, and depression did not have care conferences documented for the quarterly and significant change MDS cycle, and staff confirmed only an admission care conference was on record.
Failure to provide routine nail care for a dependent resident. A resident with dementia, severe glaucoma, hemiplegia, and hospice services was dependent on staff for personal hygiene, and the care plan directed staff to check, trim, and clean nails on bath day and as needed. However, the TAR and progress notes did not show nail care was provided or refused, and repeated observations found long, jagged fingernails with dark debris underneath. Staff interviews confirmed the resident required extensive assistance, and an RN and the DON/ADON acknowledged nail care was expected on shower days and as needed.
The facility failed to follow provider orders for two residents. One resident with diabetes had scheduled Aspart insulin doses documented as given on multiple mornings even though BG readings were below the hold parameter, and staff and leadership acknowledged the orders were not being followed. Another resident with severe cognitive impairment and gluteal wounds did not receive ordered daily wound care on multiple days, and when care was provided, the nurse did not use the ordered Medi honey on either wound.
A facility failed to include resident-specific CPAP/BiPAP settings in the orders for two residents using non-invasive ventilation, even though staff were assisting with mask placement and machine use and the records lacked documented pressure settings. The facility also failed to reinstate oxygen-related orders after a resident returned from the hospital; the MAR/TAR had no active oxygen or saturation-monitoring orders, while staff still described the resident as needing oxygen at 2 LPM and oxygen tubing was observed on the floor with the tank left on.
A resident with bipolar II disorder, PTSD, depression, and anxiety had ongoing room clutter, urine odor, and food trays left in the room, but the care plan lacked specific trauma-informed interventions and there was no evidence of a behavioral contract, structured behavioral monitoring, or coordination with outside mental health providers. Staff reported uncertainty about the resident’s trauma history and relied on repeated attempts to address the room conditions, while observations showed severe clutter, food debris, and sanitation concerns.
A resident with intact cognition, diabetes, depression, and a below-the-knee amputation was observed wearing mismatched shoes after receiving a prosthetic. He stated the uneven shoe heights caused hip pain and that he had told staff and the social worker about the problem, but no one helped him obtain matching shoes. Multiple staff members, including the NA, RN, and SSD, had noticed the issue, and the DON was unsure whether the prosthetic company had been contacted about shoe wear recommendations.
A resident with intact cognition and diagnoses including anxiety, atrial fibrillation, and peptic ulcer had multiple CP medication review concerns that were not addressed timely, including meloxicam instructions to give with food or milk, Jardiance being ordered for DM2 without DM listed in the diagnoses, and buspirone and Eliquis being tied to inappropriate diagnoses; the same concerns reappeared in a later review while the MAR still listed the same indications. Another resident had a nystatin powder order without an end date, and the CP recommended discontinuation but did not include a response timeframe; the facility also lacked a clear procedure for follow-up time frames on nonurgent MRR recommendations.
Food Served at Improper Temperature: A resident received a meal tray with chicken, potatoes, and vegetables that were served well below the expected serving temperature. Staff stated the food sat on the tray cart too long before delivery, and the resident said the chicken was cooked but not warm enough. The D-MGR acknowledged the facility struggled to keep food at desirable temperatures for residents who ate in their rooms.
Surveyors found that the facility failed to ensure two residents’ pain regimens were free from unnecessary drugs by not documenting clear indications for PRN opioid use and not recording attempts or offers of non-pharmacological interventions before administering PRN pain medications. Both residents had care plans and pain assessments indicating chronic pain that interfered with daily activities, and both reported that repositioning, ice packs, and rest helped relieve their pain in addition to PRN medications. However, medication administration records and progress notes for multiple PRN doses of acetaminophen, hydromorphone, and oxycodone lacked documentation of pain location, associated symptoms, and any non-pharmacological measures tried prior to giving the medications, including instances where opioids were given for mild pain or when pain was documented as 0/10. Interviews with an LPN, an RN, the DON, a nurse practitioner, and a pharmacist, as well as the facility’s Pain Management Program policy, all described expectations to use non-opioids first when appropriate, reserve opioids for more severe pain, and document pain assessments and non-pharmacological interventions, which were not reflected in the records reviewed.
A resident with dysphagia, cognitive impairment, and a history of choking incidents did not have speech therapy recommendations or physician orders for safe swallowing—such as upright positioning, crushing medications, and specific eating techniques—incorporated into their care plan. Despite staff and family being aware of the swallowing difficulties and receiving education, the care plan was not updated to reflect these critical interventions.
Two residents with behavioral health and substance use needs did not receive individualized care plans that incorporated recommendations from psychological services to support sobriety. Staff were unaware of or did not implement suggested interventions, resulting in ongoing substance use, unaddressed mental health needs, and repeated unsupervised departures from the facility that led to hospitalizations.
The facility did not adequately assess or address the supervision needs of residents with cognitive impairment and substance use disorders when they left the facility, resulting in multiple incidents where residents were missing for extended periods, returned intoxicated, or required hospitalization. Care plans lacked individualized interventions for community safety, and staff were unable to articulate or implement a systematic process for evaluating or mitigating risks for these residents.
A facility failed to accurately document a resident's advance directives, resulting in a mismatch between the POLST and EHR. The resident's POLST indicated a DNR status, but the EHR and physician orders showed a full code status. Staff interviews revealed reliance on the EHR for code status decisions, risking CPR against the resident's wishes. The HUC was responsible for updating records, but audits were not completed due to staffing issues.
The facility failed to provide routine personal hygiene care for several residents dependent on staff for ADLs. One resident with multiple medical conditions had long, soiled fingernails despite expressing a desire for them to be cleaned. Another resident with cognitive impairment was observed with unwanted chin hair, and staff interviews revealed inconsistencies in addressing personal hygiene. A third resident was observed in soiled clothing with long nails, and staff failed to address hygiene needs despite visible signs. Facility policies on bathing and nail care were not consistently followed.
Two residents in the facility experienced deficiencies in care related to skin conditions. One resident had dry, cracked skin on her feet that was not addressed despite her requests, and staff failed to follow care plan directives for skin observation. Another resident had a deep tissue injury and unreported skin concerns on her foot and thigh, with inconsistent documentation and lack of staff awareness. The facility's Skin Management Program Policy was not consistently followed, leading to inadequate monitoring and intervention for these residents.
A resident with a history of falls and impaired cognition experienced multiple falls due to the facility's failure to implement planned interventions. The care plan required auto-lock brakes on the wheelchair and keeping it at the bedside, but observations showed these were not consistently followed. Staff interviews revealed a lack of awareness and adherence to the care plan, contributing to the resident's repeated falls.
A resident with severe cognitive impairment and significant weight loss did not receive prescribed nutritional supplements as ordered. Despite being on a fortified diet, the facility failed to provide the necessary magic cup supplement twice daily. Observations and staff interviews revealed inconsistencies in supplement administration, with supplements remaining in the refrigerator and not being distributed. The DON expected staff to administer supplements or document refusals, but this was not consistently done.
The facility failed to implement enhanced barrier precautions (EBP) and proper hand hygiene for two residents, one with a feeding tube and another with a wound. Staff were observed providing care without necessary PPE and not performing hand hygiene between tasks, despite clear signage and facility policies. The infection preventionist confirmed the need for EBP and ongoing education efforts.
The facility failed to post complaint investigations and plans of correction for 2024 and 2025 in accessible areas. The survey results binder was placed too high for wheelchair users to reach, as confirmed by multiple residents and staff. Additionally, the binder lacked results of complaint surveys for 2024 and January 2025. The facility's policy on posting survey results was not provided.
The facility failed to protect resident privacy by leaving care sheets with sensitive information unattended on medication carts. Staff members, including an LPN and an RN, acknowledged the issue, and the DON confirmed the need for better privacy practices. The facility's privacy policy was not provided.
The facility failed to provide a dignified dining experience for residents needing assistance during mealtime on a dementia unit. Nursing assistants used the term 'feeders' in the presence of residents, which was acknowledged as inappropriate by staff, including an LPN and the DON. The facility's guidelines emphasize promoting dignity, which was not upheld in this instance.
A contracted therapy staff member at an LTC facility took unauthorized photos of a resident with cognitive impairments and shared them via text message, violating facility policy. The resident, diagnosed with paranoid schizophrenia and schizoaffective disorder, was vulnerable to abuse due to his condition. Facility leadership acknowledged the inappropriateness of the action, which breached policies protecting residents from mental abuse.
The facility failed to investigate allegations of staff-to-resident abuse involving a COTA and two residents. One resident reported a consensual relationship with the COTA, but only therapy staff were interviewed, and no facility floor staff were questioned. Text messages from the COTA to the resident included pictures of another resident, which were not addressed. The facility's policy lacked guidance on investigation procedures, contributing to the deficiency.
The facility failed to provide routine bathing, nail care, and shaving assistance for four residents who were dependent on staff for these activities of daily living. Residents were found with unkempt hair, long dirty fingernails, and overgrown facial hair, despite care plans indicating regular assistance. Staff interviews revealed inconsistencies in following care plans and documenting refusals of care.
The facility failed to ensure routine dental needs were evaluated and addressed timely for four residents, resulting in unaddressed broken dentures, missing teeth, and lack of dental appointments. Residents expressed a desire for dental care, but the facility did not take necessary follow-up actions.
The facility failed to offer or provide the pneumococcal vaccine to two residents and did not engage in shared clinical decision-making for the pneumococcal vaccine for two additional residents. The infection preventionist acknowledged awareness of the new CDC guidance but had not implemented it due to time constraints.
The facility failed to ensure that a resident participated in care conferences for care planning. The resident, with multiple diagnoses and intact cognition, reported not being invited to care conferences. Documentation was incomplete, missing critical information, and interviews revealed that the social worker did not fulfill their responsibilities in notifying the resident and completing the care conference summary.
The facility failed to ensure accurate MDS coding for two residents, leading to potential inaccuracies in care planning and federal reimbursement. One resident's wandering behaviors were not reflected in the MDS, and another resident's dental issues were not addressed, despite documentation and staff observations.
The facility failed to develop and maintain a comprehensive care plan for a resident with lymphedema, resulting in inconsistent application of compression wraps and lack of coordination between nursing and therapy staff. Observations and interviews revealed that the care plan, task list, and care guide lacked necessary information, leading to inadequate care for the resident.
The facility failed to reassess and develop interventions for a resident with a persistent skin condition and did not properly manage another resident's diabetes, leading to ongoing health issues. Nursing staff were unaware of the conditions, and no follow-up assessments were documented.
The facility failed to ensure a ROM restorative program for a resident with severe cognitive impairment and contractures, and did not complete or reassess recommended splint applications for two residents with hand contractures. Interviews and observations revealed lapses in communication and execution of care plans, leading to inadequate care.
The facility failed to maintain an appropriate communication system with an outside dialysis clinic for a resident requiring dialysis care. The resident's care plan lacked direction on coordinating with the clinic, and staff interviews revealed inconsistencies in the communication process. Dialysis Communication Records were often incomplete, and the dialysis clinic was not updated on the resident's medication holds or recent fall.
A facility failed to act on a consultant pharmacist's recommendation to update the diagnosis for a resident's antipsychotic medication. Despite the recommendation being signed by both the pharmacist and the physician, the diagnosis was not documented in the EMR, leading to staff confusion and resident frustration.
The facility failed to monitor orthostatic blood pressure for a resident on antipsychotic medication for three consecutive months. Despite orders for monthly checks, the required monitoring was not documented or completed, and the resident's care plan lacked an intervention for orthostatic hypotension. Interviews with staff confirmed the expectation for such monitoring, but the facility's records did not reflect this practice.
The facility failed to maintain a clean and sanitary environment in a resident's room and the main production kitchen. A resident's room had walls with dried human feces and other organic material, while a commercial oven in the kitchen was covered with dust, debris, and burnt food particles. Staff confirmed the issues and acknowledged lapses in cleaning schedules and reporting systems.
The facility failed to ensure call lights were accessible for three residents, compromising their ability to request assistance. Observations and interviews revealed that call lights were out of reach or unplugged, despite residents' ability to use them and staff acknowledging the importance of accessibility.
Failure to Individualize and Revise Behavioral Health Interventions for Alcohol-Related Behaviors
Penalty
Summary
The facility failed to develop, implement, monitor, and revise individualized behavioral health interventions for two residents with alcohol-related behaviors. One resident had diagnoses including non-Alzheimer's dementia, anxiety, and depression, was independent with his wheelchair and most ADLs, and had care plan focuses addressing substance abuse, antidepressant medication, and community life. His record showed a history of suicidal ideations, sadness, low self-esteem, withdrawal, ineffective coping, loneliness, alcohol use, and occasional cocaine use. Although multiple interventions were listed, including discussion of treatment options, observation for behavior patterns and triggers, room checks for smoking, encouragement of activities, and supervision of peer interactions, the record also showed ongoing alcohol use with repeated notes of slurred speech and strong odor of alcohol, including episodes where medications were held and fall precautions were used. The second resident had traumatic brain injury, malnutrition, depression, and psychotic disorder, and used antipsychotic and antidepressant medication. His care plan addressed substance use disorder, mood, and antipsychotic medication, and noted a history of alcohol dependence, stimulant dependence, and cocaine dependence. Interventions included coping skills education, non-pharmacological interventions, discussion of treatment options, and monitoring of mood and alcohol-related behavior. Despite this, the resident continued to have alcohol-related incidents, including intoxication, slurred speech, altercations, and repeated behavioral concerns. The record also showed that staff were not aware of resident-specific care plan interventions regarding intoxication management, and the facility representatives later stated there were no activity recommendations or care plan changes after the incident. On the smoking patio, the two residents were drinking together and became involved in an altercation that drew police involvement. Witnesses and staff described the first resident as intoxicated, loud, belligerent, and aggressive, with repeated requests for cigarettes, while the second resident was also drinking and was involved in the confrontation. Accounts differed on the exact sequence, but the incident involved yelling, physical contact, and a cane being used. Staff interviews showed that some staff did not intervene, some were unaware of the incident in real time, and the overnight nurse was helping elsewhere when the police arrived. The facility later reviewed the event and noted that the residents had been educated about respecting each other and not sharing cigarettes, but the records reviewed showed no individualized behavioral health plan revisions tied to the ongoing alcohol-related behaviors and the resident-to-resident altercation.
Food Storage and Refrigerator Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards when surveyors found multiple food safety issues in the main production kitchen and on a resident unit. In the walk-in refrigerator, a tray held 6 undated and unlabeled packages of meat that appeared to be in original packaging, alongside a package of raw meat dated 4/2/26 with a brown liquid substance leaking from the package and touching the undated packages. A chunk of turkey wrapped in clear plastic was also found on a shelf, dated 4/16 with a use-by date of 4/21, and the dietary manager stated the date must be wrong and planned to use it. The dietary manager stated weekly refrigerator checks were done on Monday mornings and that these items had been missed. In the walk-in freezer, surveyors found a prepackaged wild brown rice and chicken soup with visible ice on top, an opened cardboard box containing a plastic bag labeled personal belongings with a gray plastic tub holding 2 packages of brats that were not labeled with a name, and 4 bags of unopened egg noodles with ice buildup and frost inside the packaging. Food buildup was also observed under the freezer shelving, and the dietary manager stated the freezer should be cleaned daily. On a unit refrigerator, an open, labeled, and uncovered can of Monster energy drink was observed, along with two undated pitchers of juice on the bottom shelf and red-colored liquid substance in the drawers and at the bottom of the refrigerator. Nursing staff stated the can should be covered, and the dietary manager stated dietary staff were responsible for inspecting and cleaning the unit refrigerators daily.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when resident mail was not delivered to residents on Saturdays for 4 of 4 residents who raised the concern during Resident Council. During the meeting, residents stated that mail delivered by the post office on Saturdays was not given to residents until Monday. The DON stated mail was sorted when it came into the building and should be delivered the same day by facility staff, that it was the responsibility of all staff to ensure residents received their mail, and that timely mail delivery was a resident right; however, she could not identify a specific staff member responsible for overseeing mail delivery. The Administrator also stated that all staff were responsible for delivering mail to residents, including on weekends, and that mail should be delivered the same day it arrived at the facility. A policy was requested but not provided.
Failure to Document Non-Pharmacological Pain Interventions and Stop Unneeded Antifungal
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted and documented before PRN pain medications were administered for four residents reviewed for pain management. For residents with chronic or acute pain, the records showed scheduled and PRN analgesics were used, but the care plans and medication records did not identify resident-specific non-medication interventions that had been tried, what was effective, or what was ineffective. In interviews, residents stated they were not offered interventions such as ice, heat, massage, or other comfort measures before receiving pain medication, and staff confirmed that non-pharmacological interventions were not routinely offered unless a resident asked for them. For one resident with intact cognition and chronic left shoulder pain, the care plan addressed opioid side effects and pain observation, but it did not show resident-specific non-pharmacological interventions for pain. The resident stated staff did not offer ice, heat, or massage and said it would be helpful if they did. The MAR showed PRN acetaminophen was given twice, both times marked with unknown effectiveness, and there was no documentation that any non-pharmacological intervention had been offered or attempted before administration. Progress notes and the medical record also lacked evidence of non-medication interventions being offered before the PRN doses. For another resident with frequent pain and hospice involvement, the care plan included comfort measures such as music, aroma therapy, and soft lighting, but the record still lacked evidence that non-pharmacological interventions were offered or attempted before PRN oxycodone was administered 14 times. Several doses were marked ineffective or unknown, and the resident was observed in severe pain and moaning. A third resident with chronic lower extremity and wound-related pain had PRN acetaminophen and hydromorphone administered multiple times, again without documentation of non-pharmacological interventions before dosing. A fourth resident with chronic pain received PRN hydromorphone twice, and the record likewise lacked documentation of any non-pharmacological intervention being offered or attempted before administration. The facility also failed to ensure a scheduled antifungal medication was evaluated for continued need and stopped per the provider order for one resident. The resident had nystatin powder ordered for groin redness, but the medication continued to be administered daily even though progress notes documented no skin issues in the groin and the resident stated there was no current redness or open area. A pharmacist review noted antifungals should be discontinued when healing is complete and recommended stopping the nystatin powder, but the medication remained on the MAR without an end date and without evidence that it had been discontinued when the condition resolved.
Inaccurate Immunization Documentation in EMR
Penalty
Summary
The facility failed to ensure accurate and complete clinical records for 3 of 5 residents reviewed for immunizations, involving R7, R59, and R130. Each resident’s immunization record showed an influenza vaccination documented on 9/26/25 and a second influenza vaccination documented on 4/15/26, even though the April 2026 clinic was actually a COVID-19 vaccination clinic and not an influenza vaccination clinic. During interview, the DON, who also served as the facility’s IP, stated the influenza vaccinations documented in the EMR were entered incorrectly. The DON stated staff would use MIIC to verify which vaccine a resident actually received and acknowledged it was best practice for residents’ medical records to be accurate. A facility policy regarding accurate medical records was requested, but the facility was unable to provide a policy addressing the requirement for maintaining accurate and complete medical records.
Failure to Implement EBP and Safe Oxygen Equipment Practices
Penalty
Summary
The facility failed to identify and implement enhanced barrier precautions (EBP) for residents receiving dialysis through tunneled central venous catheters and for a resident with an open wound. R2, R10, and R135 each had MDS assessments showing dialysis during their stay, and treatment records identified tunneled CVCs on the chest that were used for dialysis access. Despite this, their care plans did not identify the need for EBP, and observations on multiple dates showed no EBP signage on their doors and no PPE bins or disposal bins outside their rooms. Interviews with nursing staff and the ADON confirmed that these residents were not on EBP precautions, even after their records were reviewed and the tunneled CVCs were verified. R60 had impaired cognition, dependence for personal hygiene, and documented open wounds on both gluteal folds, including a stage 2 pressure ulcer/injury on the left and a stage 3 pressure ulcer/injury on the right. Her care plan and provider orders addressed wound care, but neither identified EBP. During observation, R60’s room initially lacked EBP signage and an isolation cart. Nursing assistants provided toileting and peri-care while wearing gloves only, and later wound care was completed by an RN and NA with gloves only and no gowns. Staff stated they had not been using EBP for R60’s wound care, and one RN acknowledged that a gown probably should have been worn during the wound care encounter. The facility also failed to maintain infection prevention practices related to oxygen equipment for R51, who received oxygen therapy and used a noninvasive mechanical ventilator. During observation, R51’s oxygen tubing and nasal cannula were found lying on the floor while the oxygen tank remained on. An LPN picked up the tubing and cannula from the floor and immediately reapplied the nasal cannula to the resident without cleaning or replacing the equipment. The DON/IP was asked about the infection risk associated with this practice but refused to comment on the infection risk.
Resident dignity not maintained during personal care and delayed call light response
Penalty
Summary
Resident dignity was not maintained during personal care for a resident with severely impaired cognition, dependence on staff for personal hygiene, frequent bowel and bladder incontinence, and diagnoses including Alzheimer’s disease, dementia, bipolar disorder, and overactive bladder. During wound care and incontinent care, the resident’s door was left partially open, there was no privacy curtain, the resident’s pants were down to the ankles, the incontinent brief had been removed, and the resident’s exposed bottom was visible from the doorway. While the resident remained exposed, a housekeeper knocked, announced himself as laundry, and entered the room to place clean clothes in the closet without being stopped by the nurse or nursing assistant providing care. A second resident who was cognitively intact and required substantial to maximum assistance with most ADLs was also observed receiving incontinent care in bed while exposed. The nursing assistant removed the resident’s oxygen, turned off the oxygen concentrator, removed the blanket, and provided perineal and skin care while discussing the resident’s skin condition and treatments. During this care, multiple staff entered the room without waiting for permission, including the Administrator, who knocked and immediately entered while the resident remained uncovered from the waist up and wearing only a brief, as well as an LPN and an RN who also entered without waiting for a response. The facility also failed to maintain dignity for two residents who experienced prolonged waits for call light response and had bowel or bladder accidents while waiting for staff. One resident with intact cognition, mobility limitations, anxiety, COPD, respiratory failure, fibromyalgia, opioid abuse, pulmonary fibrosis, and oxygen dependence reported pressing the call light for help with toileting but not receiving assistance in time and having a bowel accident on the floor before reaching the bathroom. Another resident with intact cognition, frequent urinary and stool incontinence, an unhealed pressure ulcer, MS, heart failure, diabetes, obesity, and stroke-related lower-limb paralysis reported sitting in a soiled brief while waiting for staff after pressing the call light. Call light logs showed waits of 38 minutes and 53 minutes for one resident and 58 minutes and 15 seconds for the other.
Failure to Provide Ordered Larger Protein Portions
Penalty
Summary
The facility failed to honor a resident's request for larger protein portions and did not provide the larger servings that had been added to the resident's meal ticket and care plan. The resident had intact cognition and diagnoses of diabetes, depression, and malnutrition. The quarterly MDS indicated no significant recent weight gain or loss. The diet order called for a regular texture diet, and a dietary progress note documented that the resident had complained of increased hunger and that larger protein portions were to be provided at all meals. During observation, the resident was served a meal that included one piece of chicken that was noticeably smaller than the portions given to other residents whose tickets did not indicate larger portions. The resident stated he was supposed to receive larger portions because he gets hungry, but he was not getting them. An RN observed that the protein serving did not look like a large serving or larger than other residents' servings. The dietary manager stated that residents needing large portions should receive six ounces instead of three ounces of meat and that staff should find a larger piece of chicken for residents ordered larger protein portions, but also stated that the facility had been giving everyone the same standard chicken portions, including residents ordered larger protein portions. A dietary aide confirmed that tickets marked larger protein were supposed to receive two pieces of meat instead of one.
Failure to Provide SNFABN After Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to one resident whose Medicare Part A coverage ended and who remained in the facility. The resident’s quarterly MDS showed the most recent Medicare-covered stay was from 1/1/26 to 1/12/26. A Notice of Medicare Non-Coverage dated 1/12/26 indicated the last covered day of Medicare A would be 1/12/26 and that the resident representative was notified on 1/9/26. However, the SNF Beneficiary Protection Notification Review form dated 1/12/26 stated the resident had not been provided a SNFABN because the resident was dropped to a non-skilled level. A census list dated 4/19/26 showed the resident remained at the facility after the Medicare Part A discharge date. During interview, the assistant administrator confirmed reviewing the record and stated he would have expected a SNFABN to be completed, but it did not appear to have been done.
Inaccurate Care Plan and Missed Care Conferences
Penalty
Summary
The facility failed to ensure the comprehensive care plan for R128 was accurate and updated to reflect current transfer, mobility, ambulation, and toileting needs. R128’s quarterly MDS indicated independence with toileting and continence of bladder, while other documentation identified functional bladder incontinence, occasional bowel incontinence, and a check-and-change toileting schedule. The care plan also contained conflicting entries showing R128 as independent with toileting, needing toilet transfers marked not applicable because of pull-up briefs and barrier cream use, needing encouragement to toilet during rounds, having an independent toileting schedule, and requiring set-up/clean-up assistance for toilet hygiene. The care plan further included inconsistent transfer and mobility information. Entries identified supervision assist for transfers, chair-to-bed transfer as independent, use of a wheelchair with foot pedals for mobility, and use of a four-wheeled walker with supervision. Staff interviews showed R128 had returned from the hospital with a significant change in condition, was no longer ambulating on return, initially required a full body mechanical lift per therapy, then progressed to stand-pivot transfers with staff assistance, and was only to ambulate with therapy staff at that time. Staff also stated R128 knew when toileting was needed but could not independently get to the bathroom, and that the resident had fluctuating function after hospitalization. The facility also failed to ensure two care conferences were completed to correspond with R11’s MDS cycle. R11’s significant change MDS identified intact cognition, need for hygiene assistance, no rejection of care, and diagnoses including paralysis on the dominant side from a stroke, diabetes, and depression. R11 stated she did not recall having a care conference since admission and wanted to discuss discharge or transfer. The administrator stated there was no documentation supporting a care conference for R11’s quarterly and significant change MDS cycle, and staff interviews confirmed the expectation that care conferences occur with each MDS cycle. The record showed only one care conference at admission and no documentation for the quarterly or significant change MDS care conferences.
Failure to Provide Routine Nail Care
Penalty
Summary
The facility failed to ensure routine personal hygiene, specifically nail care, was completed for a resident who was dependent on staff for multiple activities of daily living. The resident had moderately impaired cognition, vascular dementia without behavioral disturbances, severe glaucoma, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, and received hospice services. The care plan identified the resident as dependent for personal hygiene and directed staff to check nail length and trim and clean nails on bath day and as necessary. The resident’s treatment record for May 2026 showed bath and shower documentation, but it did not show that fingernails or toenails had been trimmed or filed, and the record lacked evidence that nail care had been provided during that period. Progress notes from April 2026 through May 13, 2026 also lacked evidence that nail care had been offered or refused. During observations on May 11, May 12, and May 13, the resident’s fingernails were noted to be approximately 1/8 to 1/4 inch long, jagged, and with dark colored debris underneath. The resident did not respond when asked about the nails on one occasion, but nodded yes when asked if staff assisted with trimming and cleaning the fingernails. Staff interviews indicated the resident required extensive assistance and did not refuse ADL care, though staff said he needed enough time and routine. An RN observed the nails and stated they were long, had sharp edges, and had debris underneath, and that nail care should be a collaboration between hospice and the facility. The ADON and DON stated nail care was expected on shower days and as needed, and that the resident’s nail care may not have been getting done while hospice was providing bed baths. The facility policy stated care and services would be provided for ADLs including bathing, dressing, grooming, and oral care.
Failure to Follow Insulin and Wound Care Orders
Penalty
Summary
The facility failed to ensure insulin was administered as ordered for a resident with diabetes. The resident’s admission MDS identified intact cognition and no behaviors or rejection of care. The care plan included monitoring for signs and symptoms of hypoglycemia and hyperglycemia, and the May MAR/TAR showed an order for Aspart insulin 6 units subcutaneously with meals, with instructions to hold the dose if blood glucose was less than 130. Blood sugar readings documented on multiple mornings were below 130, yet the scheduled morning insulin dose was still recorded as given on several of those days. Progress notes did not show evidence that insulin was held when the blood glucose was below the ordered parameter. During interviews, nursing staff and administration acknowledged the order should have been followed. An LPN stated that if insulin was held due to low blood sugar, the provider should be notified. The ADON reviewed the record and verified the resident should not have received the scheduled morning Aspart doses on the dates when blood sugars were below 130, stating the orders were clearly not being followed. The NP stated staff should follow the orders because giving insulin to someone with a low blood sugar could result in hypoglycemia. The DON stated staff should follow provider orders, although also stated a resident could choose to receive insulin even if low. The facility also failed to provide wound care as ordered for a resident with severe cognitive impairment and pressure-related skin impairment. The resident’s care plan required treatment as ordered and daily wound monitoring. Provider orders directed daily cleansing and dressing changes to both gluteal wounds, with Medi honey ordered for the left gluteal wound and foam dressings for both wounds. The treatment record did not document wound care as completed on two consecutive days, and during observation an open wound was seen on the right gluteal fold with the left wound covered by an older dressing dated the prior day. When wound care was performed, the nurse used wound cleanser and foam dressings but did not use Medi honey on either wound, and stated he had not realized the order had changed to daily treatment and Medi honey use.
Missing CPAP/BiPAP Settings and Oxygen Orders
Penalty
Summary
The facility failed to ensure resident-specific settings were included in orders for non-invasive ventilation machines for two residents who used CPAP/BiPAP devices. R15’s record identified use of a non-invasive mechanical ventilator, and staff observed a CPAP/BiPAP machine at the bedside with the mask on the table. However, R15’s care plan did not identify the need for CPAP/BiPAP use, and the MAR/TAR orders only stated the machine was to be on at bedtime and off in the morning. The record lacked evidence of resident-specific pressure settings, and progress notes did not document settings that would distinguish whether the device was being used as CPAP or BiPAP. Staff interviews confirmed they assisted with turning the machine on and off and placing the mask, but the orders did not contain the settings. R23’s record also identified use of a non-invasive mechanical ventilator, and the resident stated she had been on the portable ventilator since admission and had recently returned from the hospital. R23’s care plan addressed altered respiratory status and inability to lie flat, but it did not include resident-specific settings for the CPAP machine. The MAR/TAR contained orders for CPAP/BIPAP use, filter maintenance, filling the reservoir with distilled water, and washing the mask and water chamber, but the record lacked evidence of any pressure settings. Progress notes likewise did not document specific settings. During interviews, staff stated nurses were responsible for the CPAP machine and confirmed the orders did not include settings. The ADON reviewed the record and verified the facility did not have orders for the settings for either resident. The facility also failed to ensure oxygen-related orders were reinstated after hospitalization and readmission for R51. R51’s record showed prior orders for continuous oxygen at 4 LPM, oxygen at 2 LPM while sleeping until CPAP supplies arrived, and CPAP/BIPAP settings of CPAP 16/EPAP 8 with 3 LPM oxygen, but those orders were discontinued after hospitalization and return to the facility. The May MAR/TAR had no active orders for oxygen therapy, CPAP/BIPAP use, oxygen saturation monitoring, or oxygen tubing changes. Despite this, R51’s care plan still identified altered respiratory status and oxygen use, and staff interviews indicated R51 should be on oxygen at 2 LPM to keep saturations above 90%. During observation, oxygen tubing and the nasal cannula were found on the floor while the oxygen tank remained on, and staff were unable to locate current orders for oxygen flow rate, tubing changes, or frequency of use.
Failure to Provide Behavioral Health Services and Trauma-Informed Support
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident with bipolar II disorder, PTSD, depression, and anxiety, and failed to implement trauma-informed care planning and coordinated mental health support. The resident’s trauma-informed screening documented that she had experienced something traumatic in the past, and the care plan identified PTSD, trauma, and triggers related to feeling that things were outside of her control. The care plan included general calming approaches, but it did not include specific trauma-informed interventions to guide staff in supporting the resident’s need for control while addressing ongoing sanitation, clutter, food tray, and environmental concerns in her room. The resident’s record also lacked evidence that the facility revised or implemented additional behavioral health interventions after 10/24/25 despite continued concerns. Notes referenced that the resident was not organizing her room and might benefit from staff support or a behavioral contract, but there was no evidence that a behavioral contract or other structured behavioral intervention was implemented. The record also lacked evidence of coordination with the resident’s outside mental health providers regarding her PTSD, trauma history, room conditions, behavioral concerns, or psychosocial needs. Staff interviews showed uncertainty about the resident’s trauma history, whether a behavioral contract existed, and whether any structured intervention or behavior monitoring had been used. Survey observations showed the resident’s room was extremely cluttered, had a strong urine odor, and contained old food trays, cups with liquid, milk cartons, and food debris. The floor was not visible due to the amount of belongings and clutter, and the facility had concerns about mice in the building. Additional observations showed lunch and dinner trays left in the room, and housekeeping later cleaned the room while the resident remained present and did not object. Interviews with nursing and social services staff confirmed that trays were often left in the room because the resident slept late, that staff were balancing resident rights with sanitation concerns, and that no trauma-informed guidance, behavioral monitoring, or structured plan had been put in place to address the ongoing room conditions.
Failure to Provide Medically-Related Social Services for Matching Shoes
Penalty
Summary
Medically-related social services were not provided to help a resident achieve the highest possible quality of life when staff failed to assist him with obtaining matching shoes after he returned with a prosthetic. The resident had intact cognition and diagnoses of diabetes, depression, and an amputation. His care plan identified a self-care performance deficit related to a right below-the-knee amputation, noted that he preferred to choose his own clothing, and indicated he required moderate assistance with tub/shower transfers, bathing, and lower body dressing. The resident was observed sitting in a wheelchair wearing a black shoe with a thick sole on his right prosthetic and a grey shoe with a noticeably shorter sole on his left foot. He stated he did not have money to buy matching shoes, wished he had matching shoes, and said the difference in shoe height caused hip pain. He reported that he had told staff and believed the social worker knew about the issue, but no one had helped. Staff interviews showed multiple employees had noticed the mismatched shoes, including the NA, RN, and social services designee, but none had offered assistance before the survey. The social services designee confirmed she had not helped him obtain new shoes, and the DON stated she was unsure whether anyone had contacted the prosthetic company about shoe wear recommendations.
Failure to Act on Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to ensure consultant pharmacist recommendations from monthly drug regimen reviews were acted upon in a timely manner for a resident with intact cognition who had diagnoses including panic disorder, generalized anxiety disorder, atrial fibrillation, and peptic ulcer. The resident’s orders included meloxicam, Eliquis, Jardiance, and buspirone. The pharmacist’s 3/31/26 review noted meloxicam should be given with food or milk, Jardiance was ordered for DM2 even though diabetes mellitus was not listed among the resident’s diagnoses, and buspirone and Eliquis were associated with diagnoses that were not appropriate for those medications; the pharmacist recommended clarifying the diagnoses and updating the MAR. A later 4/29/26 review repeated the same concerns about Jardiance and the need to verify and add the diagnosis to justify use. The MAR for April and May 2026 continued to list Eliquis for heart, Jardiance for dm2, and buspirone for psych, and the MAR lacked administration instructions for meloxicam. The facility also failed to develop and/or implement a procedure that outlined follow-up time frame expectations in the drug regimen review process for another resident with intact cognition and diagnoses of respiratory failure and debility. That resident had an order for nystatin powder applied to the groin in the morning without an end date. The pharmacist’s 3/30/26 review stated antifungals should be discontinued when healing was complete and recommended discontinuing the nystatin powder, but the review did not include a date by which a response was required. The review showed no response by 4/30/26. During interview, the CP stated the facility did not have a laid out time frame for nonurgent recommendations and typically expected a provider response within 60 days, while the DON stated recommendations affecting resident safety should be addressed as soon as possible but did not provide a timeframe for nonurgent recommendations.
Food Served at Improper Temperature
Penalty
Summary
The facility failed to ensure food was served at palatable temperatures for 1 of 1 residents observed receiving a meal in the transitional care unit. During the lunch dining service, a nursing assistant delivered a tray to R88 that had been temped by a dietary aide before delivery; the honey mustard chicken was 117 degrees Fahrenheit, the potato fingerlings were 118 degrees Fahrenheit, and the mixed vegetables were 100 degrees Fahrenheit. The dietary aide stated the chicken was supposed to be 145 degrees and above when served and said the food should be warmer than that when eaten. The dietary aide and cook stated the food sat on the trays too long before residents were served. R88 stated the chicken was cooked but definitely not warm or hot enough for their liking. The dietary manager stated the facility struggled with serving food at desirable temperatures because residents in the dining room were served first and then staff plated food for residents who ate in their rooms, leaving the plated food on the rolling cart for a lengthy time before delivery; the dietary manager also stated it was not desirable to serve food that was 117 degrees. The facility policy required foods and beverages to be distributed and served in a manner that prevented contamination and maintained proper temperature.
Failure to Document Indications and Non-Pharmacological Interventions Before PRN Opioid Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ drug regimens were free from unnecessary drugs by not identifying clear indications for opioid use and not documenting attempts or offers of non-pharmacological interventions prior to administering PRN pain medications. For Resident 1 (R1), the admission MDS showed intact cognition and diagnoses including end stage renal disease and a heel pressure ulcer, with a pain assessment indicating pain frequently interfered with therapy and daily activities. R1’s care plan for chronic neuropathic pain directed staff to offer non-pharmacological interventions such as rest and repositioning and to observe and document pain characteristics. Despite this, documentation showed that when R1 received PRN acetaminophen and hydromorphone, the associated progress notes consistently lacked details on pain location, associated symptoms, and whether any non-pharmacological interventions were attempted or offered before medication administration. R1 had PRN orders for both acetaminophen and hydromorphone. In January, R1 received PRN acetaminophen twice and PRN hydromorphone nine times. For the PRN acetaminophen doses, one note documented severe pain rated 8/10 and another documented moderate foot pain rated 5/10, but neither note included any record of non-pharmacological interventions being attempted or offered prior to giving the medication. For the PRN hydromorphone doses, pain ratings ranged from 0/10 to 9/10, yet the corresponding progress notes repeatedly only stated that the medication was administered and effective, without documenting pain location, symptoms, or any non-pharmacological measures tried beforehand. In one instance, hydromorphone was administered when the pain rating was documented as 0/10. During interview, R1 reported chronic pain in the knees and all over the body and stated that repositioning, ice packs, and rest helped relieve pain in addition to PRN medications, indicating that non-pharmacological measures were known to be helpful but were not reflected in the documentation. For Resident 2 (R2), the admission MDS indicated independent decision-making with diagnoses including amputation and end stage renal disease, and a pain assessment showing pain frequently interfered with day-to-day activities. R2’s care plan for pain management included an intervention to offer non-pharmacological measures and to notify the practitioner if these were unsuccessful or if the pain complaint represented a significant change. R2 had PRN orders for acetaminophen and oxycodone. In January, R2 received PRN acetaminophen twice for pain rated 10/10 and PRN oxycodone five times for pain rated between 5/10 and 7/10. The associated progress notes documented that medications were administered and, in some cases, that the resident felt better, but did not include pain location, associated symptoms, or any record of non-pharmacological interventions being attempted or offered prior to either non-opioid or opioid administration. During interview, R2 stated that pain sometimes occurred at the amputation site, in both arms, and all over the body when tired, and that repositioning, ice packs, and rest helped relieve pain along with PRN medications, again contrasting with the lack of documentation of such measures. Interviews with staff and facility leadership further highlighted the deficiency. An LPN stated that when a resident had pain, the nurse should ask about pain location and intensity, administer the requested PRN medication if multiple options were available, and document the time and pain level, with follow-up to reassess effectiveness. An RN stated that non-opioid medications should be offered first for pain less than 7/10 and opioids for pain rated 7–10/10, and that residents requesting opioids would be educated but ultimately given the requested medication, with documentation of administration and pain level and later follow-up. The DON stated that documentation for PRN pain medications should include pain location, pain scale rating, and any non-pharmacological interventions attempted prior to administration so that pain follow-up and trending could be done accurately. The nurse practitioner and pharmacist both indicated that non-opioid medications should be used first and that opioids are generally reserved for more severe pain, and the facility’s Pain Management Program policy required clear documentation of pain evaluation, interventions (including non-pharmacological measures), and post-administration pain relief. Despite these stated expectations and policies, the records for R1 and R2 showed repeated administration of PRN opioids and non-opioids without documented indication details or non-pharmacological interventions, constituting the cited deficiency.
Failure to Update Care Plan with Swallowing Safety Interventions
Penalty
Summary
The facility failed to update and implement a comprehensive care plan to address a resident's swallowing difficulties and risk of choking, despite multiple documented incidents and professional recommendations. The resident had a history of unspecified tremor, partial digestive tract removal, oropharyngeal dysphagia, and cognitive impairment, and required set-up assistance with meals. Although the resident was observed to have difficulty swallowing medications, resulting in coughing and choking episodes, the care plan only included a general intervention for eating set-up and did not reflect the specific risks or interventions needed for safe swallowing. Speech therapy evaluated the resident and provided detailed recommendations, including crushing medications, upright positioning during and after meals, slow eating, small bites and sips, thorough chewing, and specific swallowing techniques. These recommendations, as well as the physician's order to crush medications, were not incorporated into the resident's care plan or the nursing assistant care guide. Interviews with staff and family confirmed awareness of the resident's swallowing issues and the education provided, but the care plan remained incomplete, lacking the necessary interventions to address the identified risks.
Failure to Implement Individualized Behavioral Health Care Plans and Professional Recommendations
Penalty
Summary
The facility failed to develop and implement individualized behavioral health care plans for two residents with behavioral health needs, specifically neglecting to utilize recommendations from professional psychological services to support sobriety efforts. For one resident with moderate cognitive impairment, depression, and a history of substance use, the care plan acknowledged his desire for sobriety and alternative living arrangements, as well as recommendations from a psychological provider to monitor mood, encourage engagement in meaningful activities, and reinforce strengths. However, facility staff, including the community life coordinator and director of social services, were unaware of or did not implement these recommendations. The resident continued to leave the facility unsupervised, sometimes resulting in hospitalizations, and staff did not actively support his sobriety or address his psychological needs as outlined by the consulting psychologist. Another resident, who was cognitively intact but had a history of substance use disorder, depression, and loneliness, also did not receive an individualized behavioral health care plan that incorporated professional recommendations. Despite documentation from a psychologist recommending harm reduction strategies, increased engagement, and consideration of a private room to support sobriety and mental health, the facility did not implement these interventions. The resident continued to consume alcohol in her room, left the facility unsupervised, and was hospitalized for alcohol intoxication. Staff were aware of her drinking but did not establish a behavioral contract or safety plan, and were not fully informed of the psychologist's willingness to assist with harm reduction or safety planning. Facility policy required care planning interventions to address risks for residents with substance use disorders, including providing diversions, substance use treatment services, and increased monitoring. Despite this, the facility did not follow through with the necessary individualized interventions or incorporate the recommendations from psychological services into the residents' care plans. This lack of action resulted in ongoing substance use, unaddressed behavioral health needs, and repeated incidents of residents leaving the facility unsupervised and requiring hospital care.
Failure to Assess and Supervise Residents' Community Safety Needs
Penalty
Summary
The facility failed to comprehensively assess the supervision needs of residents and develop individualized, person-centered interventions to identify and mitigate risks and hazards for residents when they were out in the community and upon their return. This deficiency was evident in the cases of three residents with significant cognitive and behavioral health issues, including moderate vascular dementia, substance use disorder, and alcoholism with impaired insight and judgment. The facility did not conduct or document comprehensive community safety assessments for these residents, nor did it establish clear prevention strategies or interventions to ensure their safety while outside the facility. One resident with moderate vascular dementia and a history of substance use, psychiatric hospitalizations, and cognitive impairment repeatedly left the facility unsupervised, often without signing out or notifying staff. On multiple occasions, this resident was missing for extended periods, sometimes over 17 hours, and was found by police or returned via ambulance after hospitalizations for medical issues such as COPD exacerbation. The resident's care plan lacked interventions related to community safety, and staff interviews revealed there was no systematic process to assess or address the resident's ability to be independent in the community. Another resident with a history of alcohol and opioid abuse, psychiatric diagnoses, and repeated falls was frequently found intoxicated both inside and outside the facility. This resident left the facility independently, often without using an assistive device, and was hospitalized multiple times for alcohol-related medical issues. The care plan did not address supervision needs or interventions for community safety, and there was no evidence of comprehensive assessment or monitoring for withdrawal symptoms, nor strategies to prevent or mitigate risks associated with the resident's behavior in the community or upon return. Staff interviews confirmed the absence of a clear process for assessing community safety or implementing individualized interventions for residents at risk.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's advance directives were accurately and consistently documented in the electronic health record (EHR), Provider Order for Life-Sustaining Treatment (POLST), and physician orders. This discrepancy involved a resident, identified as R84, whose code status was not accurately documented, leading to immediate jeopardy. The POLST signed by the resident and a nurse practitioner indicated a do not resuscitate (DNR) status, while the physician's order incorrectly documented a full code status. The inconsistency in documentation was discovered during a review of R84's records, which showed conflicting information regarding the resident's code status. The admission orders and EHR banner indicated a full code status, while the POLST and progress notes confirmed a DNR status. Interviews with staff revealed that the health unit coordinator (HUC) was responsible for updating the EHR to match the POLST, but audits to ensure accuracy had not been completed due to staffing issues. Interviews with various staff members, including licensed practical nurses (LPNs) and the director of nursing (DON), highlighted the reliance on the EHR banner to determine code status in emergencies. This reliance posed a risk of performing CPR against the resident's wishes due to the mismatch in documentation. The facility's policies required that the POLST and EHR be reviewed and updated to reflect the resident's wishes, but this process was not followed, leading to the deficiency.
Removal Plan
- Corrected R84's code status on the EHR banner/provider order to DNR
- Completed a facility-wide audit to ensure there were no other code status discrepancies
- Reviewed related policies and procedures
- Provided education for all staff involved in ensuring advance directives were honored on the CPR and POLST policies/procedures and their respective roles in the process
Failure to Provide Routine Personal Hygiene Care
Penalty
Summary
The facility failed to ensure routine personal hygiene care for several residents who were dependent on staff for assistance with activities of daily living (ADLs). One resident, who had intact cognition and multiple medical conditions including multiple sclerosis and malnutrition, was observed with long, soiled fingernails despite expressing a desire for them to be cleaned. The resident's care plan required substantial assistance with personal hygiene but lacked specific instructions regarding nail care. Staff interviews revealed uncertainty about documentation and responsibility for nail care, and the resident's medical record lacked evidence of recent nail care. Another resident with moderately impaired cognition and various mental health diagnoses was observed with unwanted chin hair over several days. The resident's care plan required assistance with personal hygiene but did not address preferences for facial hair. Staff interviews indicated that chin hair should be addressed during personal care, but there was no documentation of refusals or attempts to address the issue. Similarly, a resident with severe cognitive impairment and behavioral symptoms was observed with thick chin hair, and staff interviews revealed inconsistencies in addressing and documenting personal hygiene care. A fourth resident with moderate cognitive impairment and a history of mental health issues was observed in soiled clothing with long, ungroomed nails. The resident's care plan required assistance with dressing and personal hygiene, but staff interviews indicated that personal care was not consistently offered or documented. The resident was observed in the same clothing over multiple days, and staff failed to address the resident's hygiene needs despite the presence of urine odor and visibly soiled clothing. The facility's policies required regular bathing and nail care, but these were not consistently followed or documented for the residents involved.
Failure to Address Skin Conditions in Residents
Penalty
Summary
The facility failed to ensure timely identification, assessment, and intervention for skin conditions in two residents, R103 and R158, leading to deficiencies in care. R103, who had intact cognition and was dependent on staff for mobility and dressing, expressed concerns about dry and cracked skin on her feet, which had not been addressed despite her requests. Observations revealed that staff had not been checking her feet during routine care, and there were no treatment orders or monitoring documented for her skin condition. The nursing assistant and LPN involved were unaware of the issue, and the care plan's directive to observe skin during care was not followed. R158, who was cognitively intact and at risk for pressure ulcers, had a deep tissue injury and was supposed to have regular skin assessments. However, documentation was inconsistent, and staff failed to identify and report a painful area on the bottom of her right foot and an open area on her right thigh. The resident self-administered a cream without proper hygiene, and staff were unaware of the skin concerns until prompted by the resident. The RN and nursing assistants involved did not perform thorough skin checks, and there was a lack of communication and documentation regarding the resident's skin condition and necessary interventions. The facility's Skin Management Program Policy required regular body audits and skin observations, but these were not consistently performed or documented for both residents. The lack of timely assessment and intervention for skin conditions in R103 and R158 highlights a failure in the facility's processes to monitor and address residents' skin integrity, potentially leading to complications such as infection or worsening of the conditions.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement planned fall interventions for a resident identified as R125, who was at risk for falls due to moderately impaired cognition and a history of falls. R125's care plan included interventions such as auto-locking brakes on the wheelchair, gripper socks or shoes at all times, and keeping the wheelchair at the bedside when in bed. Despite these interventions, R125 experienced multiple falls between December 2024 and February 2025, often attempting to self-transfer without assistance and not using the call light. Observations revealed that R125's wheelchair was frequently not positioned next to the bed as required by the care plan, and the wheelchair did not have the specified auto-lock brakes. Staff interviews indicated a lack of consistent adherence to the care plan, with some staff unaware of the specific interventions or failing to implement them. For instance, a trained medication assistant and a nursing assistant both confirmed the absence of auto-lock brakes and the improper placement of the wheelchair, which was kept away from the bed to prevent self-transfer attempts. The director of nursing confirmed that staff were expected to follow the care plan interventions, which included keeping the wheelchair at the bedside and ensuring it had auto-lock brakes. However, the observations and interviews indicated that these interventions were not consistently implemented, contributing to the resident's repeated falls. The facility's Adverse Event policy required falls to be reviewed to ensure correct interventions, but the repeated incidents suggest a failure in this process.
Failure to Administer Nutritional Supplements as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as R18, received the necessary nutritional supplements as ordered, which was crucial for maintaining their health. R18 had severe cognitive impairment and required assistance with eating. The resident had multiple diagnoses, including dementia, peripheral vascular disease, and chronic obstructive pulmonary disease, among others. Despite being on a fortified diet and having a significant weight loss noted over 30 and 180 days, the facility did not consistently provide the prescribed nutritional supplement, a magic cup, twice daily as recommended by the registered dietician. During observations, it was noted that R18 did not receive the magic cup supplement during breakfast, and there was confusion among staff regarding the administration of supplements. Interviews with various staff members, including a registered nurse, dietary aide, and nursing assistants, revealed inconsistencies in the delivery of the supplements. The registered nurse was unsure if R18 received the supplement, and the dietary aide confirmed that the supplements were still in the refrigerator, indicating they had not been distributed as required. The director of nursing stated that staff were expected to administer supplements as ordered or document if a resident refused them. However, the failure to provide R18 with the necessary supplements as ordered was evident, as the supplements were not given during the observed shifts. This deficiency in care was contrary to the facility's policy, which required immediate interventions for residents with undesired weight loss trends to prevent further decline.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene
Penalty
Summary
The facility failed to consistently implement enhanced barrier precautions (EBP) as recommended by the CDC to prevent the spread of multidrug-resistant organisms (MDROs) for two residents. One resident, identified as R38, had a care plan indicating the need for EBP due to an indwelling medical device, specifically a feeding tube. Despite signage indicating the requirement for gowns and gloves during high-contact care activities, nursing assistants were observed providing care without the necessary protective equipment. The nursing assistants were unaware of the EBP requirements until questioned by the surveyor, after which they sought clarification and donned the appropriate PPE. Another resident, R25, also required EBP due to a wound. During an observation, a nursing assistant was seen performing peri-care without changing gloves or performing hand hygiene between tasks, despite the presence of signage indicating the need for EBP. The nursing assistant admitted to not performing hand hygiene between glove changes due to a reaction to hand sanitizer and instead washed their hands in a different room. The registered nurse confirmed that R25 was on EBP and expected staff to adhere to the guidelines for glove and gown use during direct care. The facility's policies on hand hygiene and PPE use were not followed, contributing to the deficiencies observed. The infection preventionist confirmed the ongoing education efforts for EBP but acknowledged the lapses in adherence to the protocols. The failure to implement EBP and proper hand hygiene practices as outlined in the facility's guidelines and CDC recommendations resulted in the identified deficiencies.
Inaccessible Survey Results and Missing Complaint Investigations
Penalty
Summary
The facility failed to ensure that complaint investigations for 2024 and 2025, along with any plans of correction, were posted in prominent and accessible areas for public review. This deficiency was identified during observations and interviews conducted on February 25, 2025. The survey results binder was placed in a wire basket 60 inches off the ground, making it inaccessible to individuals in wheelchairs. Multiple residents, including those using wheelchairs, confirmed that they could not reach the binder without assistance. The facility's social services director and administrator acknowledged that the binder was not within reach for wheelchair users. Additionally, the facility administrator admitted that the survey results binder did not contain the results of any complaint surveys for 2024 and January 2025, which should have been included. The facility's policy on posting survey results was requested but not provided. The administrator was responsible for delegating the task of posting the survey results and acknowledged the oversight in the placement and content of the binder.
Failure to Protect Resident Privacy
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of residents' personal and medical records, as observed during a survey. On two separate occasions, care sheets containing sensitive information such as residents' names, room numbers, and personal care details were left unattended and face up on medication carts. This information was accessible to unauthorized personnel, including staff members and residents, who walked past the exposed documents. The care sheets included detailed personal information such as sleep/wake preferences, assistance needed with daily activities, and personal interests. During interviews, both an LPN and an RN acknowledged that the care sheets should not have been left exposed, citing concerns about privacy and HIPAA compliance. The Director of Nursing also confirmed that care sheets should be flipped over to prevent unauthorized access, noting that maintaining privacy is an ongoing challenge for the facility. Despite requests, the facility's policy on privacy practices was not provided to the surveyors.
Undignified Dining Experience for Residents Needing Assistance
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents requiring assistance during mealtime on a locked dementia unit. During an observation, a nursing assistant (NA-A) was seen preparing the dining area and distributing desserts and drinks to residents. NA-A communicated with another nursing assistant (NA-N) across the room, instructing them to set up all the 'feeders' first. This term was used in the presence of residents, which was acknowledged by NA-N as inappropriate and undignified. NA-N explained that typically, residents needing assistance were served last to provide immediate help, but on this occasion, they had extra help to assist those residents first. Interviews with staff, including another nursing assistant (NA-I) and a licensed practical nurse (LPN-E), confirmed that the term 'feeders' was inappropriate and could make residents feel infantilized. The director of nursing (DON) also agreed that the term was not dignified. A care sheet indicated that six residents required assistance with eating, and the facility's Standards of Care Guidelines emphasized promoting dignity and quality of life for residents. The use of the term 'feeders' and the manner of communication during mealtime did not align with these guidelines, leading to the deficiency.
Unauthorized Photos Taken of Resident Without Consent
Penalty
Summary
The facility failed to protect a resident from potential mental abuse by allowing a contracted therapy staff member to take unauthorized pictures without consent. The resident, who had diagnoses of paranoid schizophrenia and schizoaffective disorder bipolar type, was identified as having moderately impaired cognition and physical limitations, making him susceptible to abuse. The resident's care plan noted a history of refusing care and exhibiting behaviors such as refusing to change clothes and becoming verbally and physically abusive when assisted. Despite these vulnerabilities, a contracted therapy staff member took unauthorized pictures of the resident while he was sleeping in his wheelchair, which were later shared via text message. The facility's executive director and assistant executive director acknowledged the inappropriateness of the action, as it violated the facility's policy on personal phones and communication devices. The policy explicitly prohibits taking pictures without prior approval and defines mental abuse to include unauthorized photographs. The guardian of the resident was not informed of the incident and expressed concern that the resident would become upset if he knew about the unauthorized pictures. The facility's policy also emphasizes the protection of vulnerable adults from abuse, neglect, and mistreatment, highlighting the failure to adhere to these guidelines in this incident.
Failure to Investigate Allegations of Staff-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of staff-to-resident abuse involving a certified occupational therapy assistant (COTA) and two residents. One resident, who was no longer at the facility, reported having consensual sexual relations and a relationship with the COTA. The facility's executive director (ED) admitted that during the investigation, only two therapy staff were interviewed, and no facility floor staff were questioned regarding the interactions between the resident and the COTA. Additionally, the assistant executive director (AED) confirmed that the investigation did not include interviews with facility staff, as it was deemed unnecessary due to the location of the alleged incident. Furthermore, the investigation uncovered text messages from the COTA to the resident, which included pictures of another resident. However, these pictures were not addressed or investigated further. The facility's policy on Vulnerable Adult/Maltreatment-Communication, Prevention, and Reporting required immediate reporting and investigation of such findings, but it lacked specific guidance on what should be included in the investigation. This oversight contributed to the deficiency in addressing the allegations and ensuring a comprehensive investigation.
Failure to Provide Routine Bathing, Nail Care, and Shaving Assistance
Penalty
Summary
The facility failed to ensure routine bathing, nail care, and shaving assistance for four residents who were dependent on staff for these activities of daily living. Resident R35, who had moderate cognitive impairment and required assistance with bathing, received only four showers in two months despite being care planned for two showers a week. R35 expressed frustration about not receiving regular baths and was observed with greasy, matted hair and unshaved chin hairs. Staff interviews revealed inconsistencies in following the bathing schedule and documenting refusals of care. Resident R20, who had moderately impaired vision and required maximal assistance with bathing and nail care, was found with long, dirty fingernails despite progress notes indicating regular showers and nail trims. R20 expressed dissatisfaction with the infrequent nail care, and staff confirmed that nail care was not being consistently provided or documented. Observations and interviews highlighted a lack of adherence to the care plan and the importance of nail care for infection control and resident dignity. Resident R52, who had moderately impaired cognition and required maximal assistance for personal hygiene, was also found with long, dirty fingernails despite documentation of regular bed baths and nail trims. R52 indicated a desire for nail care, and staff confirmed the nails had not been trimmed recently. Similarly, Resident R102, who required assistance with grooming, was observed with overgrown facial hair and expressed dissatisfaction with the lack of shaving assistance. Staff interviews confirmed that grooming needs were not being consistently met, and the DON emphasized the importance of honoring residents' grooming needs for their overall well-being.
Failure to Address Routine Dental Needs
Penalty
Summary
The facility failed to ensure routine dental needs were evaluated and addressed timely for four residents. Resident R92 had a broken upper partial denture that was identified during an annual evaluation by Apple Tree Dental, but no follow-up action was taken to repair the denture despite the recommendation. The resident and their family member confirmed that no discussion about fixing the denture had occurred, and the medical record lacked evidence of any subsequent dental appointments since the issue was identified over three months prior. Resident R26 had severe cognitive impairment and was missing dentures that were lost before admission to the facility. The resident's family member stated that no one at the facility had offered to help set up a dental appointment to get new dentures, despite the resident's poor dentition and the importance of wearing dentures to the resident. The medical record did not indicate that the resident had been offered, refused, or received dental services. Resident R68 had broken natural teeth and loose-fitting dentures but had not been seen by a dentist for a comprehensive assessment since 2022. The resident expressed a desire for help in setting up a dental appointment to fix the dentures, but no follow-up action was taken by the facility. The medical record lacked evidence of any dental appointments or offers for dental services since the last visit in 2022. Additionally, Resident R102, who had multiple missing teeth and difficulty chewing, had not been assisted in setting up a dental appointment for dentures, and the medical record did not contain a completed dental consent form for the resident.
Failure to Administer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer or provide the pneumococcal vaccine to two residents and did not engage in shared clinical decision-making for the pneumococcal vaccine for two additional residents. Specifically, one resident who was cognitively intact and admitted to the facility had received previous doses of the pneumococcal vaccine but was not administered the recommended PCV20 or PPSV23 dose as per CDC guidelines. Another resident with severe cognitive impairment had no record of receiving the pneumococcal vaccine and was not offered the vaccine or educated on its risks and benefits upon admission. Additionally, two other residents with varying degrees of cognitive impairment had received previous doses of the pneumococcal vaccine but lacked documentation of shared clinical decision-making regarding the administration of the PCV20 vaccine. During an interview, the infection preventionist (IP) acknowledged the expectation that residents should be offered vaccines upon admission and that consent should be obtained. The IP admitted to being aware of the new CDC guidance on shared clinical decision-making for pneumococcal vaccines but had not yet implemented it due to time constraints. The IP also conducted an audit to identify residents needing the pneumococcal vaccine but had not completed the necessary vaccinations for the identified residents. The facility's policy indicated that the pneumococcal vaccine should be offered to all residents aged 65 or older, but this was not consistently followed.
Failure to Ensure Resident Participation in Care Planning
Penalty
Summary
The facility failed to ensure that a resident and/or their representative participated in care conferences for the care planning process. The resident, who had intact cognition and multiple diagnoses including anxiety, depression, COPD, amputation of the left leg above the knee, and a right hip replacement, reported not being invited or made aware of care conferences. The facility's documentation did not indicate whether the resident was invited or included in any care conferences, and the care conference summary documents were incomplete, missing critical information such as hospital stays and medication reconciliation. Interviews with the director of social services and the social worker revealed that it was the social worker's responsibility to notify residents and their families about care conferences and to ensure that all relevant sections of the care conference summary were filled out. However, the social worker admitted that the documents were incomplete and that the required sections were not filled out. The facility's policy required documentation of attendee names, areas discussed, concerns presented, and action items for follow-up, but this was not adhered to in the case of the resident in question.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded, leading to potential inaccuracies in federal reimbursement and resident care planning for two residents. One resident, diagnosed with severe cognitive impairment and Alzheimer's disease, exhibited wandering behaviors that were documented multiple times during the MDS reference period. However, these behaviors were not accurately reflected in the MDS, which indicated no wandering behaviors. Interviews with staff confirmed the resident's wandering behavior and the need for secure unit placement, which was not properly coded in the MDS. Another resident, diagnosed with multiple sclerosis, malnutrition, and depression, had issues with broken or loosely fitting dentures that were documented during the MDS reference period. Despite this, the MDS did not reflect these dental issues, and the care plan did not address the resident's dental needs. Interviews with the resident and staff revealed that the resident had not received assistance in addressing his dental issues, which had persisted for a significant period. The MDS coordinator acknowledged the discrepancies in the MDS coding for both residents after reviewing their medical records. The director of nursing emphasized the importance of accurate MDS coding for creating effective care plans. The facility's policy/procedure regarding MDS completion was requested but not provided, indicating a potential gap in procedural adherence or documentation.
Failure to Develop and Maintain Comprehensive Care Plan for Resident with Lymphedema
Penalty
Summary
The facility failed to ensure a comprehensive care plan was developed and maintained for a resident with lymphedema. The resident's care plan lacked evidence of occupational therapy (OT) for lymphedema treatment, the need for compression socks or wraps, and coordination between providers. The resident's task list and care guide also lacked information about leg compression stockings or wraps, which would have been triggered from the care plan. Observations revealed the resident's legs were swollen and dry, and compression wraps were inconsistently applied, indicating a lack of proper care and coordination among staff members. Interviews with nursing assistants, licensed practical nurses, and occupational therapists confirmed the lack of communication and coordination in the resident's care. Nursing assistants were unsure if the resident received compression socks or wraps, as it was not mentioned in their task list or care sheets. The licensed practical nurse and registered nurse verified that the care plan and electronic medical record (EMR) lacked orders for lower extremity wraps or compression socks. The occupational therapist stated that treating the resident's lymphedema was a collaborative effort, but the most recent recommendation sheet was outdated and not up to date with the current recommendations. The director of nursing (DON) and director of rehab (DOR) acknowledged the importance of collaboration between therapy and nursing for the success of treatment. However, the DON was unaware of the concern with the resident's care plan and the missing information. The facility's policy on person-centered care plans indicated that the care plan should be clear, concise, and consistent with the nursing assistant care plan, which was not the case for this resident.
Failure to Reassess Skin Condition and Manage Diabetes
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions for a resident (R71) with a non-pressure skin impairment on their feet. Despite initial treatment with Ketoconazole cream, the condition persisted, and no follow-up assessment was conducted after the treatment ended. The resident reported ongoing issues with dry, flaking skin and itching, which were not adequately addressed by the nursing staff. Observations and interviews revealed that the nursing assistants and licensed practical nurses were unaware of the resident's skin condition, and no post-treatment evaluation was documented in the medical record. Additionally, the facility failed to properly manage the diabetes of another resident (R26), who had consistently elevated blood glucose levels. The resident's blood sugar levels were frequently above the acceptable range, with some readings exceeding 400 mg/dL. Despite these elevated levels, there was no evidence that the provider was consistently notified, and no adjustments were made to the resident's diabetic management plan. Interviews with nursing staff and the nurse practitioner indicated a lack of communication and follow-up regarding the resident's blood glucose trends. The facility's policies and procedures for non-pressure skin management and diabetic management were either not provided or insufficiently detailed. The lack of comprehensive reassessment and follow-up for both the skin condition and diabetes management led to ongoing health issues for the residents, highlighting significant gaps in the facility's care processes and communication protocols.
Failure to Implement ROM and Splint Programs
Penalty
Summary
The facility failed to ensure a range of motion (ROM) restorative program was completed for a resident (R46) who was on a ROM program to prevent contractures. Despite having severe cognitive impairment and being dependent on staff for all activities of daily living (ADLs), R46's care plan lacked an intervention to provide ROM to her arms. Interviews with nursing staff and the director of rehabilitation (DOR) revealed confusion about who was responsible for R46's ROM exercises, resulting in the exercises not being performed as required. The director of nursing (DON) confirmed that R46 should be on a restorative program and that the therapy team should be completing the ROM exercises, but R46 was not on the list for therapy programs, indicating a lapse in communication and execution of care plans. The facility also failed to ensure a recommended splint application was completed and reassessed as needed for two residents (R19 and R68) with contractures of the hands. R19, who had severe cognitive impairment and multiple medical conditions, was supposed to have a palm protector applied to her left hand and receive ROM exercises. However, documentation showed inconsistent application of the splint and ROM exercises, with several instances of refusal or missed therapy sessions. Interviews with staff revealed a lack of awareness and communication regarding R19's need for the splint and ROM exercises, leading to inadequate care. Similarly, R68, who had multiple sclerosis and other medical conditions, was supposed to have a left-hand splint applied every evening and removed every morning. Despite this, observations and interviews indicated that the splint was not being applied consistently, and staff were unaware of the requirement. The DOR confirmed that R68 was not on a restorative program and that there had been poor staff follow-through with the wear schedule. The DON stated that she expected staff to notify the provider, therapy, and/or the resident representative if a resident was refusing to wear a needed orthotic device, but this had not occurred in R68's case.
Failure to Maintain Communication with Dialysis Clinic
Penalty
Summary
The facility failed to implement or maintain an appropriate communication and collaboration system with an outside dialysis clinic for a resident requiring dialysis care. The resident, who had moderate cognitive impairment and several medical conditions including anemia, high blood pressure, and renal failure, was unsure of the processes used by the facility to communicate with the dialysis clinic. The resident's care plan lacked evidence or direction on how the facility would coordinate or collaborate with the offsite dialysis clinic for the resident's care. The facility's staff, including nursing assistants and registered nurses, were interviewed and revealed inconsistencies in the communication process with the dialysis clinic. The Dialysis Communication Records were often left blank and not completed, and there was no evidence that the dialysis clinic was updated on the resident's repeated medication holds for low blood pressure or a recent fall. The health unit coordinator and health information system manager also confirmed that the communication records were not consistently sent or returned completed, and there was no scanning backlog to account for the missing records. The facility's policy on dialysis care plans and treatment sheets lacked information on how or how often the care center would collaborate or coordinate care with the offsite clinic. The registered nurse clinical director acknowledged the issue and mentioned that the offsite dialysis clinic was notorious for not completing or returning the communication records. However, no prior efforts had been made to address this issue with the clinic before the survey. The deficiency highlights a significant gap in the continuity of care for the resident receiving dialysis treatment.
Failure to Update Medication Diagnosis
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendation for a resident (R73) who was prescribed Prochlorperazine Maleate without a documented diagnosis. The resident's physician orders did not include a diagnosis for the antipsychotic medication, and the consultant pharmacist had recommended updating the diagnosis in February 2024. Despite this recommendation being signed by both the consultant pharmacist and the physician, the diagnosis was not updated in the electronic medical record (EMR). Interviews with the resident, a trained medication aide, a licensed practical nurse, and the director of nursing revealed that the staff were unaware of the reason for the medication and acknowledged the importance of having the diagnosis documented in the EMR. The director of nursing confirmed that the monthly medication regimen reviews are collected and reviewed, and any recommendations are supposed to be addressed by the facility. However, in this case, the diagnosis for Prochlorperazine was not updated in the EMR, despite the consultant pharmacist's recommendation. The resident expressed frustration and confusion about the medication, stating that the facility did not communicate with them about their medications. The facility's policy on medication regimen review was requested but not provided, indicating a potential gap in the facility's adherence to its own policies and procedures.
Failure to Monitor Orthostatic Blood Pressure for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to ensure appropriate side effect monitoring, specifically orthostatic blood pressure monitoring, for a resident on antipsychotic medication. The resident, who had severe cognitive impairment, legal blindness, and vascular dementia with psychotic disturbance, was prescribed quetiapine furmate. Despite orders for monthly orthostatic blood pressure and pulse monitoring, the facility did not complete these checks for three consecutive months. The treatment administration records for January, February, and March 2024 showed that the required monitoring was either not documented or marked as incomplete without proper follow-up or explanation in the electronic medical record. Interviews with facility staff, including a registered nurse, pharmacist, and the director of nursing, confirmed the expectation for monthly orthostatic blood pressure monitoring for residents on antipsychotic medications. However, the facility's records lacked evidence of this monitoring for the resident in question. Additionally, the resident's care plan did not include an intervention to monitor for orthostatic hypotension, despite the known risks associated with antipsychotic medications. A facility policy on antipsychotic medication use and side effect monitoring was requested but not provided.
Facility Fails to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in a resident's room and the main production kitchen. In the case of the resident's room, the walls were observed to have bubbling paint, torn areas, and multiple dark-brown colored smears, which were identified as dried human feces and other organic material. The issue was confirmed by a registered nurse and the maintenance and housekeeping staff, who acknowledged that the room had not been properly cleaned or repaired. The last deep cleaning of the room was recorded over a month prior, and the Tels system used for reporting maintenance and housekeeping issues had not been utilized effectively by the staff to address the problem in a timely manner. In the main production kitchen, one of the two commercial ovens was found to be in an unsanitary condition. The top of the Vulcan double-stack convection oven was covered with a thick layer of black and gray-colored dust, debris, and burnt food particles, with metallic oven racks stored directly on this soiled surface. The kitchen staff, including a cook and the nutrition service director, confirmed that the oven had not been cleaned as per the facility's cleaning schedule. The cleaning log provided lacked specific instructions for cleaning the oven, and the last recorded cleaning was nearly three weeks prior. The nutrition service director acknowledged the oversight and the potential risk of cross-contamination due to the unclean oven. The facility's policies on reporting maintenance and housekeeping issues and kitchen equipment cleanliness were not effectively followed. The Tels system, intended to alert maintenance and housekeeping of environmental concerns, was not properly utilized by the staff. Additionally, the cleaning schedule for the kitchen equipment was not adhered to, leading to the unsanitary condition of the oven. These deficiencies highlight a lack of adherence to established protocols and inadequate communication among the staff, resulting in an unsafe and unsanitary environment for residents, visitors, and staff.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to accommodate the needs of three residents by ensuring their call lights were accessible. Resident R96, who had intact cognition and multiple diagnoses including schizophrenia and morbid obesity, was observed twice with the call light out of reach. R96 expressed frustration about the call light's inaccessibility, and staff interviews confirmed that the call light should have been within reach. Similarly, Resident R114, who had severe cognitive impairment and was receiving hospice services, was observed twice with the call light out of reach while seated in a wheelchair. Both the resident and a family member indicated that the call light should be accessible, and staff interviews corroborated this requirement. The Director of Nursing acknowledged the importance of accessible call lights but noted the facility lacked a written policy on this standard of care. Resident R10, who had moderately impaired cognition and dementia, was observed twice with the call light unplugged from the wall while seated in a wheelchair. Despite being able to use the call light in the past, R10 was found repeatedly yelling for help. A nursing assistant confirmed that R10 could use the call light but was unsure why it was not used on this occasion. These observations and interviews highlight the facility's failure to ensure call lights were accessible to residents, compromising their ability to request assistance when needed.
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 1,043 citations issued within 25 miles in the last 12 months — including the 27 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Minneapolis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Fairview University Trans Serv | 2.2 mi | ★★★★★ | 0 | 0 |
| Mn Veterans Home-mpls | 2.2 mi | ★★★★★ | 17 | 0 |
| Andrew Residence | 2.4 mi | ★★★★★ | 3 | 1 |
| Grand Avenue Rest Home | 2.5 mi | ★★★★★ | 1 | 0 |
| Redeemer Health Care Center | 2.5 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.