Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Southside Care Center during CMS and state inspections, most recent first.
Incomplete investigation of alleged sexual abuse: The facility failed to thoroughly investigate an allegation that a cook had a sexual relationship with a resident who had multiple psychiatric diagnoses and was cognitively intact. The DON and administrator were notified by two residents, but the resident witnesses were not interviewed, the resident’s chart lacked documentation of the allegation and related communication attempts, and the cook denied the allegation. The DON did not file a police report, and the allegation was concluded to be unsubstantiated without a thorough investigation.
Rodent feces were found throughout the facility, including resident rooms, the dining room, kitchen, food storage, medical supply storage, and linen areas, along with cracks in the foundation and gaps around window A/C units. Residents reported mice in their rooms, damaged belongings, food contamination concerns, and seeing rodents at night, while staff and leadership acknowledged an ongoing infestation, incomplete structural repairs, and limited oversight of pest control efforts.
Medical record security and confidentiality were not maintained when four discharged residents' records were found in an unlocked furnace room and an open box of health record information was found on the floor in a shared resident room near the door. The administrator said the box held records for referred but never admitted residents and that the facility lacked a shredder or proper disposal method. The DON said she had already alerted the administrator and owners weeks earlier, and the facility had no shredding service or secure storage method.
Unsafe and Poorly Maintained Environment: The facility failed to maintain a safe, clean, comfortable, and homelike environment when multiple A/C units were installed with large gaps, the dining room unit was hanging with a blanket around it, cracks were seen in the foundation, and broken window treatments, a hole in a shared resident room, and dark gray buildup on walls and doors were observed. A resident reported repeated requests to have an A/C unit fitted, and another resident said a wall hole and an open hall A/C issue had been present for weeks without repair; the admin stated there was no designated maintenance staff and the units had been in that condition for over a year.
A facility failed to keep a furnace room free of fire hazards when a hospital bed mattress and board were found leaning against the gas furnace and gas water heater, and leadership was unaware of the unsafe storage. The facility also failed to complete required follow-up after a cognitively intact resident with schizoaffective disorder and psychotic disturbances left the building, became lost, and fell while getting into a car service, with no incident report, post-fall observations, care plan, or new interventions documented.
Unsafe Food Storage and Unsanitary Kitchen Conditions: Staff failed to follow safe food handling practices in the kitchen. A cook was observed without a beard net, another cook was observed preparing food without a hairnet, and multiple opened food items were left unlabeled and unsecured. The kitchen refrigerator was not working correctly and was observed at 42 degrees F, while rodent feces, dirty surfaces, loose floor tiles, and other unsanitary conditions were found throughout the kitchen area.
The facility failed to oversee operations when a severe rodent infestation, poor food service, and building disrepair were present. Surveyors found rodent feces in resident rooms, the dining room, food storage and prep areas, and near clean dishes, while residents and staff reported mice and other rodents throughout the building. Residents also reported limited menu compliance and poor food options, and the cook stated the facility often had expired food and a broken kitchen refrigerator. Surveyors additionally found resident records unsecured in an unlocked furnace room and in a shared resident room, and the administrator stated he had not reviewed pest control reports and the facility lacked a shredder or maintenance staff.
Failure to Address Ongoing Rodent Infestation in QAPI: The facility did not use its QAPI process to address a known rodent problem. Rodent feces and traps were observed in resident rooms, dining and food areas, clean dish and linen areas, and other parts of the building. Interviews confirmed the infestation was ongoing, recommended structural repairs had not been made, the issue was not discussed in the QAPI meeting, and no education had been provided to residents or staff.
Failure to maintain a sanitary environment amid an ongoing rodent infestation. Rodent feces were observed in resident rooms, the dining room, food storage, food prep areas, clean dish areas, medical supply storage, and sanitary linen areas, and traps were found in resident rooms, on a resident dresser and bed, in closets, hallways, and the basement. The administrator had not reviewed pest control reports, the DON had raised concerns about the unsanitary conditions, the IP did not audit the environment for rodent activity, and the exterminator reported the infestation was longstanding and structural repairs had not been made.
Failure to involve a resident in person-centered care planning. A cognitively intact resident with schizoaffective disorder, psychotic disturbances, and multiple care needs was not offered a care conference or asked about personal, cultural, or religious preferences, other providers, medical needs, or concerns. The care plan lacked resident preferences and only addressed nutrition, while the charted care conference focused on goals, medical history, and orders without the resident’s preferences or goals.
A resident was not given the Resident Bill of Rights orally or in writing upon admission, and the chart lacked documentation that it was provided. The DON and administrator gave differing accounts of who was responsible for reviewing the rights and grievance process, and the resident stated staff did not verbally educate her or provide a written copy. Facility policy referenced resident rights and grievance information, but one policy did not direct staff to provide the Bill of Rights upon admission.
Failure to notify the resident's representative after an incident involving a resident who became lost and fell while entering a car service. The resident, who was cognitively intact and had schizoaffective disorder and psychotic disturbances, was able to call the facility with help from a security guard after being unable to find her way back. The DON said the provider was notified, but the emergency contact was not, and the resident stated her daughter should have been informed.
Failure to document and follow up on resident grievances. A resident with depression, anxiety, PTSD, and chronic cough complained about rodents chewing on her quilt, while two other residents with PTSD, anxiety, panic disorder, TBI, depression, and cognitive impairment reported concerns about food portions and fearful kitchen staff behavior. The DON also raised concerns about unsanitary conditions, mice, loud and disruptive kitchen behavior, expired food, and menu issues, but the administrator and owners did not follow up. The facility lacked a formal grievance process, grievance forms were not available where designated, and residents were not informed of the complaint procedure.
A cook verbally threatened two residents, telling them they would need to find a new place to live if they spoke with the surveyor about what occurs at the facility. One resident with PTSD, anxiety, borderline personality disorder, depression, and diabetes, and another resident with panic disorder, TBI, anxiety, depression, PTSD, and moderate cognitive impairment reported feeling uncomfortable and unsafe due to the cook and another cook slamming items in the kitchen and playing explicit music loudly. The administrator was unaware of the residents' concerns, and the DON stated the facility did not initiate abuse education after the alleged sexual abuse and the witnessed verbal threat.
Failure to Immediately Report Abuse Allegations: The facility did not immediately report an alleged sexual relationship between a cook and a resident to the SA within the required timeframe. Two residents reported the allegation to the DON, but the report was not made until days later, the administrator did not interview the resident witnesses, and the resident’s chart lacked documentation of the allegation and related investigation. A later observation also found the cook telling residents not to say anything or they would have to move out.
The facility failed to document a resident’s discharge and coordinate care with the receiving provider. The resident had diagnoses including endocarditis, anxiety, depression, bipolar disorder, and adjustment disorder, and was cognitively intact. The care plan lacked discharge planning, the chart lacked a discharge record and communication with the primary provider or receiving facility, and the DON stated she did not complete a discharge summary because she did not know where the resident went.
Failure to establish a baseline care plan within 48 hours of admission. A resident with schizoaffective disorder, psychotic disturbances, behavioral symptoms, and ADL assistance needs was admitted and later had only a partial care plan that addressed nutrition but lacked other care areas and interventions. The DON said she was not trained to enter care plans, the administrator said the admitting nurse developed the baseline care plan, and an RN said the DON was responsible. The resident stated the facility did not ask about personal, cultural, or religious preferences, did not offer a care conference, and did not address other providers, medical needs, or transportation for appointments.
Failure to Develop and Implement a Comprehensive Care Plan: A resident admitted with schizoaffective disorder, psychotic disturbances, and multiple care needs had only a nutrition care plan, with no evidence of a comprehensive, interdisciplinary care plan covering other triggered areas such as ADLs, mood, falls, psychotropic use, or return-to-community needs. The DON said the resident was not care planned because she was not trained to enter care plans, the dietician did not collaborate with the IDT, and the resident reported the facility did not ask about her preferences, offer a care conference, or address her other medical and transportation needs.
Incomplete and inaccessible medical records were found for two residents. One resident’s chart lacked key care plan elements, progress note documentation, emergency contact information, provider notes/orders, post-fall assessments, and lab results, while another resident’s EHR did not include physician visit notes or orders even though the DON said the physician had been notified about medication refusal and had issued an order. The DON and administrator stated some records were kept in an outside clinic/hospital EHR and were not downloaded into the facility chart.
Failure to Follow Established Menus: The DON, administrator, and dietician described repeated meal service that did not match the posted menus, including cold cereal with water instead of the planned breakfast, turkey sandwiches instead of the listed lunch, and other substitute meals when the facility lacked ingredients or had broken refrigerators. Residents with PTSD, diabetes, anxiety, depression, TBI, schizoaffective disorder, and other diagnoses reported that the menu was frequently not followed and that pork and other items were served without regard to the posted menu or resident preferences.
Failure to honor and communicate resident food preferences: residents reported receiving meals that did not match the menu, including sugary cereal for a diabetic resident and pork served to residents who did not eat it for personal or religious reasons. The DON said the menu was rarely followed and pork was served twice in one day without an alternative, while the dietician kept notes on likes and dislikes but did not share them with the IDT or collaborate with nursing, leaving cooks unaware of resident preferences.
The facility lacked a policy for personal food storage while rodent feces was observed in resident rooms and throughout the facility. Food items were stored in residents’ rooms, the owner reported an ongoing rodent infestation, and the DON and an LPN stated no education had been provided to residents or staff about reducing or controlling the infestation or food storage in rooms. The administrator stated there was no policy on personal food storage.
A facility failed to keep advance directive and code status information consistent between the EHR and hard chart. Two residents had conflicting POLST and physician order information, and staff interviews showed one LPN would not start CPR for one resident based on an incorrect DNR order while another resident would have been given CPR despite a DNR/DNI POLST. A third resident was later found during audit to have a similar mismatch between the POLST and EHR orders, and the DON acknowledged there was no process to ensure the records matched.
Activities were not comprehensively assessed, planned, or provided to meet resident needs. Several residents with intact cognition and documented interests reported boredom and said group activities were not being offered, while records showed incomplete activity assessments, missing activity preference documentation, and care plans that were not individualized. The activities director stated he was the only activities staff member, did not document attendance or progress notes, and did not schedule activities with times or locations; staff also confirmed there were no weekend activities and no organized activities had been observed for weeks.
Unqualified Activities Director and Incomplete Activity Program Documentation: The facility did not have a qualified activities professional directing the activity program. The activities director said he was the only activities staff, created the monthly calendar, was also expected to transport residents to appointments, and did not complete progress notes, attendance records, care plan updates, or QAPI participation; he also had no prior training, licensure, or full-time therapeutic activities experience. The DON and administrator confirmed there were no weekend activities, no attendance or progress note documentation, and that the director was not licensed or registered.
RN staffing was not maintained for the required 8 consecutive hours each day. PBJ staffing data and timecards showed multiple shifts with no RN hours, and the building owner stated that on several occasions an RN was scheduled but an LPN covered the shift or an RN called in. The administrator acknowledged the facility had previously struggled to consistently fill RN hours, especially on weekends, despite a policy requiring RN coverage 7 days a week.
Improper Food Storage, Labeling, Cleaning, and Hair Restraint Use: Surveyors observed multiple opened food items in the kitchen refrigerator, freezer, and dry storage areas that were not dated or labeled, along with an unclean freezer containing frozen residue and black matter on the door seal. A cook was also observed preparing food without a hair net, despite posted expectations and staff statements that food items must be dated and labeled and cooks must wear hair restraints.
QAPI Program Lacked a Formal Plan and Failed to Address Repeated Quality Deficiencies: The facility did not have a formal QAPI plan or process for collecting data, tracking performance, setting goals, or identifying and analyzing quality deficiencies. QAPI meeting notes did not address concerns in activities or dietary/kitchen practices, even though the CASPER report showed repeated citations for activities, food sanitation, the QAPI program/plan, QAPI improvement activities, and the QAA committee. The administrator stated the QAPI committee was new and no formal process was in place.
Failure to maintain an effective QAPI program: The facility held monthly QAPI meetings, but the meeting notes did not show data-driven quality metrics over time or any PIPs. The DON/administrator stated there was no formal process for collecting data, no formal QAPI plan, no established goals, and no process for identifying high-risk or problem-prone areas or gathering input from residents or staff.
QA committee meetings did not include the required members. Review of QAPI notes showed only the administrator, DON, medical director, and consultant pharmacist regularly attended, while the infection preventionist did not regularly participate. The administrator stated he knew additional staff were needed, but scheduling conflicts prevented full attendance. The facility policy required the QAA committee to meet at least quarterly and include the administrator, medical director, DON, infection preventionist, and other departments as requested.
Improper Laundry Infection Control Practices: The housekeeper was observed transporting soiled resident laundry in an uncovered basket, carrying clean linen uncovered, and handling soiled and clean linen without a PPE gown. A resident also placed personal laundry on the utility sink near the running washer while clean linen sat uncovered on the dryer. The housekeeper stated laundry baskets were not washed or sanitized between uses unless visibly dirty, and the facility policy required linen to be covered during transport and soiled linen to be bagged or contained.
Failure to Implement Active Antibiotic Stewardship Program: The facility did not have an active antibiotic stewardship program with protocols and a system to monitor appropriate antibiotic use, including prophylactic use. The IC-MDS worked part time and reviewed MARs weekly, but she was not notified when residents started antibiotics before her visits, had no written guide for antibiotic timeouts or reviews, and was not involved in periodic review of prescribing practices or QAPI discussions. Monthly tracking forms were incomplete and lacked required details such as resident name, diagnostic testing, symptoms, standardized criteria, timeouts, and response to antibiotics.
Failure to maintain building and grounds in good repair: A resident’s room had a damaged closet door jamb, gaps around a window AC unit, and a dirty fan, while other areas of the facility showed rotted and peeling window casings, a hanging piece of exterior trim above the smoking patio, and a hole in the patio sidewalk. The DON described the hanging wood as dangerous and the administrator stated there was no system to track or follow up on environmental concerns and no maintenance staff to monitor or audit these issues.
Failure to Complete Required Resident Rights Training: The facility failed to ensure an RN completed mandatory resident rights training. Review of records showed the RN had not completed education including resident rights within the past year, and the HRA confirmed the training had last been completed in 2024. The DON stated staff would be expected to complete training twice a year when asked about resident rights, abuse, QAPI, and infection control training.
The facility failed to ensure an RN completed required abuse/vulnerable adult training. The facility assessment and Abuse Prevention Policy called for annual training, but personnel records showed the RN had not completed abuse/vulnerable adult education in the last year. The DON expected staff to complete training twice a year, and the HRA confirmed the RN’s resident rights, abuse, and infection control training had last been completed in 2024.
Failure to complete required QAPI training was identified for the DON, two RNs, and two LPNs. The facility assessment required annual QAPI training for clinical staff, but personnel records showed these staff had not completed QAPI education in the prior year. The DON stated she expected staff to complete training twice a year, and the HRA said QAPI training had not been automatically added after training requirements changed. The facility policy did not specify that QAPI training would be completed.
Missed Infection Control Training for RN. The facility failed to ensure an RN completed mandatory infection control training. Records showed the RN had not completed education including infection control within the last year, and the HRA confirmed the last completion was in 2024. The DON stated staff were expected to complete infection control training twice a year, and the facility assessment called for annual training for clinical staff.
Unsecured resident records were left in a basement room used by staff for laundry and food storage and in a public dining area where residents were eating. The papers and binders contained PHI such as resident names, addresses, DOBs, med lists, orders, MARs, glucose readings, vital signs, and weight information. The DON and administrator acknowledged the information was private and should not have been left out in the open.
Unsecured Medication Refrigerator: The facility failed to store refrigerated medications in a locked compartment for 5 residents whose meds were kept in a mini fridge that did not have a lock. RN-A showed a small lock box inside the fridge but said it was not being used, and multiple medication boxes, including Copaxone, Ozempic, and Trulicity, were observed inside the refrigerator. The DON stated the meds had been moved from a locked box in the main refrigerator to the mini fridge and had not considered that the medication refrigerator needed a lock.
Failure to document and offer flu and pneumococcal vaccinations: The facility did not ensure recommended influenza and pneumococcal immunizations were offered or provided in a timely manner for 13 reviewed residents. The DON stated there was no process to document vaccination status, residents were sent to Walgreens for vaccines, and the paper charts and EMRs lacked immunization records. The facility also lacked documentation or provider messaging to determine immunization status, despite policies requiring assessment, offering, and documentation of vaccination status, refusals, contraindications, education, and dates.
The facility failed to maintain documentation of COVID-19 vaccination status for all 13 residents and failed to document COVID-19 education and vaccination status for a cook. The DON stated there was no process in place to track resident immunization records, and chart review showed no immunization documentation for any resident. The cook stated he was never asked about his COVID-19 status or given education on the vaccine’s benefits, risks, or side effects, and the DON confirmed there was no documentation that education was offered or declined.
Failure to reasonably accommodate a resident's preference for private, usable space in a shared room. A resident with intact cognition and diagnoses including depression, diabetes, anxiety, and PTSD was observed in a twin bed enclosed by a privacy curtain that wrapped around the bed and a dresser, leaving no floor space inside the curtained area to stand or get dressed. The resident said the space was the smallest in the facility and wanted a bigger area; the administrator, DON, and co-owner all acknowledged the room was too tight and lacked usable square footage.
The facility failed to report suspected resident-to-resident abuse to the SA within the required timeframe for two residents. One resident with intact cognition and a hx of anxiety, depression, and PTSD reported that her roommate called her names, threatened her, and stole her phone, while the roommate’s notes documented verbal aggression, threats, and other disturbing behaviors. The DON stated the incidents were not reported because she believed reporting was only required for physical or sexual abuse, despite the facility abuse policy requiring allegations of abuse to be reported within two hours.
A resident’s annual MDS was incomplete, with Section C for cognition, Section D for mood, Section F for preferences, and most of Section GG for functional abilities left unassessed or dashed. The IC-MDS stated the facility’s transition from paper charts to an EHR was poorly implemented, staff training was poor, and the facility did not have a good process to ensure MDS assessments were completed and documented.
Incomplete Quarterly MDS Assessments: The facility failed to complete quarterly MDS assessments thoroughly for two residents. One resident’s MDS had Section C, Section D, and Section GG items not assessed or dashed, and another resident’s MDS had Section C items not assessed. The MDS coordinator stated the facility’s transition from paper charts to EHR had poor implementation and staff training, and the facility lacked a good process to ensure MDS completion and documentation.
MDS coding was inaccurate for two residents. One resident’s MDS omitted an active dementia diagnosis despite provider documentation of vascular dementia, and another resident’s MDS incorrectly coded Trulicity as insulin even though the MAR showed no insulin use. The DON confirmed the dementia diagnosis and cognitive decline, and the IC-MDS stated she misunderstood Trulicity and did not realize the dementia diagnosis should have been included.
The facility failed to complete quarterly care conferences for 3 residents and did not document interdisciplinary review with resident participation in care planning. One resident had intact cognition and a BIMS of 15/15, but the last care conference note in the chart was months old; two other residents with intact cognition and multiple diagnoses also had no care conference documentation matching their MDS cycles. The DON and MDS coordinator confirmed the missing conferences, and residents stated they had not been invited or involved in care meetings.
Failure to Provide Routine Dental Services: The facility failed to document or provide routine dental appointments for two residents. One resident had cognitive intactness, diabetes, and poor oral status with cavities and missing teeth, while the other resident had intact cognition and reported never being offered a routine dental visit despite being in the facility for nearly two years. The DON verified the missing documentation and stated there was no system to monitor dental appointments or refusals.
Incomplete Daily Nurse Staffing Posting: The facility failed to post required nurse staffing information daily and the posting did not include the daily census or the total number of licensed nursing staff working each shift. The DON stated she usually completed the posting at the end of the week because of call-ins and was not aware census and total licensed staff had to be included. The facility policy required the information to be posted at the beginning of each shift.
The facility failed to employ a registered dietician, affecting all 11 residents receiving food. Interviews revealed inconsistencies in menu adherence and a lack of dietician involvement. The facility was between dieticians, with nursing staff completing nutritional assessments in the absence of a registered dietician. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed.
Incomplete Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of abuse involving a resident who had diagnoses of endocarditis, anxiety, depression, bipolar disorder, adjustment disorder, and was cognitively intact. The resident’s chart lacked a vulnerability care plan, lacked documentation of the alleged sexual abuse, and lacked documentation of attempts to communicate with the resident to investigate the allegation. The report stated that two residents told the DON that a cook had a sexual relationship with the resident, and the resident later left the facility after becoming upset. The administrator stated he attempted to contact the resident on multiple days but the resident did not return his calls, and he interviewed the cook, who denied the allegation. He also interviewed two other residents who were severely cognitively impaired, but he did not interview the two roommates who reported overhearing the resident on the phone discussing breaking up with her boyfriend because of a sexual relationship with the cook. The administrator concluded the allegation was unsubstantiated. The DON stated she informed the administrator and owner by text message, did not file a police report, and said the administrator did not interview the resident witnesses who reported the allegation. The facility’s internal investigation report stated the resident could not be interviewed because she had been discharged, the cook denied the allegation, and the findings were unsubstantiated due to insufficient evidence. During survey observation, the cook was seen telling residents not to say anything or they would have to move out. The facility policy required prompt reporting of abuse, interviewing staff and residents, notifying police for sexual abuse, and documenting all actions taken, but the investigation described in the report did not include those steps before the cook returned to work.
Rodent infestation and unsanitary conditions
Penalty
Summary
The facility failed to maintain a clean and sanitary environment free of pests, with rodent feces observed in resident rooms, common areas, the kitchen, food storage areas, medical supply storage, and sanitary linen areas. Surveyors also observed large cracks in the concrete foundation of the front porch/patio and window air conditioning units propped in windows with large gaps on either side throughout the facility, including hallways and resident rooms. Bait stations, glue traps, and snap traps were seen in resident rooms, on a resident’s dresser and bed, in closets, hallways, the dining room, food storage areas, and the basement. Several residents described direct impact from the rodent infestation. One resident with anxiety disorder and schizoaffective disorder reported rodents had gotten into a bag of belongings and urinated on important papers, and stated mice were seen running in groups at night. Another resident with depressive disorder, anxiety disorder, PTSD, and chronic cough reported a quilt had been chewed up, rodent feces were on the bed, and the resident had to store snacks in a plastic tub and buy personal traps. A resident with diabetes, borderline personality disorder, and PTSD reported needing to keep food up because mice got into garbage cans and food, and said mice were seen running around the room at night. Other residents stated mice had run over them while sleeping or that they sometimes saw mice and a squirrel in the house. Facility staff and leadership acknowledged the ongoing infestation and related concerns. The administrator stated the DON found a lot of rodent feces, that the facility had a monthly contract with an exterminator, and that he did not review pest control reports. The owner stated there was an ongoing rodent problem and that a deceased rodent had been found. The exterminator reported recommended structural repairs had not been made and that residents were keeping food caches in their rooms; he also noted the severity of the infestation was not new and the owners were aware. The DON stated she had reported unsanitary conditions and rodent problems to the administrator and owners, but no education had been provided to residents or staff to reduce or control the infestation. Staff members, including an LPN, RNs, and housekeeping staff, described seeing rodents or rodent feces throughout the facility, including during meals and while cleaning.
Medical Records Left in Accessible Common Areas
Penalty
Summary
The facility failed to maintain medical record security and confidentiality when residents' medical records were stored in areas accessible to residents. During observation, four discharged residents' records were found in the corner of an unlocked furnace room, and an open top box containing residents' health record information was observed on the floor in a shared resident room about 6 inches from the door. The administrator stated the box contained medical records and personal information for residents who had been referred to the facility but were never admitted, and he was unaware it was in the shared resident room. He also stated the records were there because the facility did not have a shredder or method of proper disposal. The DON stated she had already made the administrator and facility owners aware of the box of health information in the shared resident room weeks earlier and said the facility did not have a shredding service or method to store the records securely. A policy regarding the security and confidentiality of medical records was requested but not received.
Unsafe and Poorly Maintained Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment when housekeeping and maintenance services were not implemented to address multiple environmental issues throughout the building. During observation, large cracks were seen in the concrete foundation of the front porch/patio, and window A/C units were propped in windows with large gaps on either side in hallways and shared resident rooms, including Rooms 101, 203, and 205, as well as the second floor hallway. The dining room A/C unit had a blanket wrapped around three sides and was hanging down to the dining room floor. Resident rooms were observed to be cluttered with minimal space for clothing and personal items, window treatments appeared broken, and a shared resident room occupied by R2 and R3 had broken sheetrock with a hole measuring approximately four inches by four inches. Dark gray matter was built up on the base of the walls and bottoms of doors in the kitchen, hallway, front foyer, and back foyer. R4 stated she had made several requests to the administrator and other staff to have the window A/C unit fitted to her window, and R2 stated the hole in the wall had been present for over two weeks and that complaints about the hall A/C unit being open to the outside had not been fixed. The administrator stated the facility did not have designated maintenance staff and that the A/C units had been in their current status for over a year, and the owner stated the facility relied on contractors for projects as needed.
Fire Hazard in Furnace Room and Inadequate Follow-Up After Resident Elopement and Fall
Penalty
Summary
The facility failed to maintain an environment free from fire hazards when a hospital bed mattress was found leaning against the gas furnace and gas water heater in the basement furnace room, with a large board also leaning against the mattress. The owner stated she did not know who placed the mattress there, and the administrator stated he was not aware the mattress was stored in that manner. The administrator also stated his work schedule was 9:00 a.m. to 1:00 p.m. and 16 hours per week, which he said did not allow the opportunity to provide the supervision he needed to provide. The facility also failed to identify resident risks and implement interventions after a resident with schizoaffective disorder and psychotic disturbances, who was cognitively intact and used tobacco, became lost after leaving the facility independently. The resident returned after calling the facility from a bus stop with help from a security guard, and then fell while getting into the car service arranged to pick her up, sustaining a superficial scrape to the bottom of her foot. The chart lacked an incident report and post-fall observations for the event, and the DON stated the fall protocol was not followed because the fall occurred off the facility premises. The DON also stated the provider was notified but not the resident's emergency contact, and that the resident did not have a care plan and no new interventions were implemented following the incident.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Food was not properly prepared and stored in accordance with safe food handling practices in the kitchen. During interview, the cook stated he knew he was supposed to wear a beard net to keep hair out of food, but said the facility refused to purchase them. During observation, the cook was in the kitchen with a beard approximately one and one-half to two inches long and was not wearing a beard net. The administrator stated the cook’s beard length required a beard net while in the kitchen and acknowledged he had previously directed the cook to order beard nets. The kitchen refrigerator was observed at 42 degrees F, and the administrator stated it was not working correctly and was not being used. Items stored in that refrigerator included a gallon of milk, ketchup, mustard, barbeque sauce, and mayonnaise that had been previously opened but were not labeled with the date. In the freezer, a pink-tinged frozen liquid was observed under frozen chicken. On the counter were opened jars of grape jelly and strawberry jelly with no date-opened labels, and in the cabinets opened paper sacks of flour and sugar were folded over and unsecured without dates. Two opened bags of chips were also folded over, unsecured, and not labeled with the date opened. The kitchen was observed to be unsanitary, with rodent feces behind seasonings in an upper cabinet, under counters, sink, dishwasher, oven, and refrigerator/freezer, and in cabinets next to clean pots and pans and on the shelf where clean plates and bowls were stored. There was also rodent feces on the food prep counter and piles of feces behind both kitchen doors. Additional concerns included loose floor tiles with dark brown matter underneath, a brown residue on the toaster, a hairbrush with hair stored in a drawer with clean utensils and unused supplies, and staff observed preparing food without hairnets. The DON stated she had reported concerns about the food storage and unsanitary kitchen two weeks earlier, and the owner stated she was unsure of the proper refrigerator temperature for safe food storage.
Failure to Manage Rodent Infestation, Food Service, and Record Security
Penalty
Summary
The facility failed to provide oversight and management when there was a severe rodent infestation, food service problems, and disrepair throughout the building. Pest control invoices documented heavy rodent activity in the basement, mice seen during service, and repeated recommendations for structural repairs to holes in the siding or foundation, the front patio, the door threshold, and window frames. The invoices also noted that the facility should move to monthly pest control and inspect residents’ rooms for food storage and nesting sites, but the recommended repairs had not been made. The administrator stated he did not review the pest control reports and that the facility did not have a designated maintenance person. During observations, surveyors found rodent feces in residents’ rooms, the dining room, food storage areas, food preparation areas, near clean dishes, on the kitchen floor, in medical supply storage areas, and in sanitary linen areas. Large cracks were observed in the concrete foundation of the front porch/patio, and window A/C units were propped in windows with large gaps open to the outdoors throughout the facility. Fruit, bakery items, leftover meals, crackers, and granola bars were stored in residents’ rooms. Residents reported trapping mice in their rooms, seeing rodents in the facility, and one resident stated rodents had run over her while she was sleeping. Staff also reported that rodents had been a problem for years and that residents complained about them frequently. The facility also had problems with food availability and record security. Residents stated the facility lacked healthy food options and did not follow the menu; one resident described being served cold cereal with water for breakfast, and another reported receiving unpalatable food when asking for an alternative. The cook stated the facility often had expired food and lacked ingredients for the menu, and the kitchen refrigerator had not been functioning since 7/10/26. Surveyors also found discharged residents’ records in an unlocked furnace room and an open box of health information on the floor in a shared resident room. The administrator stated the records were stored there because the facility did not have a shredder or proper disposal method, and the DON stated she had raised concerns about the unsanitary conditions, rodent problem, and unsecured records to the administrator and owners.
Failure to Address Ongoing Rodent Infestation in QAPI
Penalty
Summary
The facility failed to establish a system to address, monitor, and take action on a known rodent problem through its QAPI process. The QAPI committee notes from 7/14/26 did not document any plan for the rodent infestation, monitoring of the identified issue, infection concerns related to the infestation, or the structural repairs recommended by the pest control service. The meeting was documented as attended by the owner, administrator, DON, and IP, but the rodent problem was not addressed in the notes. During observation on 7/15/26, rodent feces were seen in resident rooms, the dining room, food storage, food preparation areas, clean dishes, the kitchen floor, medical supply storage areas, and sanitary linen areas. Bait boxes, glue traps, and snap traps were also observed in resident rooms, on a resident's dresser and bed, in closets, hallways, the dining room, food storage areas, and the basement. R4 stated she had recently trapped three rodents in her room and had purchased her own traps. Interviews with the administrator, owner, exterminator, DON, and IP confirmed the facility had an ongoing rodent problem, that recommended structural repairs had not been made, that the issue was not addressed at the QAPI meeting, and that no education had been provided to residents or staff to reduce or control the infestation.
Failure to Maintain Sanitary Environment Amid Rodent Infestation
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when it did not maintain a sanitary environment in the presence of an ongoing rodent infestation. A pest control invoice dated 7/15/26 noted that recommended structural repairs had not been made, including repairs to the door threshold and window frame, and stated that mice were seen during service, with foundation deterioration and poor window and door framing. During observations on 7/15/26, rodent feces were found in resident rooms, the dining room, food storage, food preparation areas, clean dish areas, the kitchen floor, medical supply storage, and sanitary linen areas. Bait boxes, glue traps, and snap traps were also observed in resident rooms, on a resident dresser, on a resident bed, in closets, hallways, the dining room, food storage areas, and the basement. Facility staff and leadership were aware of the infestation but had not effectively monitored or addressed it. The administrator stated he was unaware of a trap on a resident bed, had not reviewed pest control reports, and the facility did not have a designated maintenance person. The owner stated there was an ongoing rodent problem, and the exterminator reported that the severity of the infestation was not new and that the facility had declined a recommendation to increase service from quarterly to monthly. The DON reported she had raised concerns about unsanitary conditions and the rodent problem the week of 6/22/26, and that no education had been provided to residents or staff to reduce or control the infestation. The infection preventionist stated she knew about the rodent infestation but did not audit the environment for rodent locations or presence in care or food areas.
Failure to Involve Resident in Person-Centered Care Planning
Penalty
Summary
The facility failed to allow a resident to participate in the development and implementation of the resident’s person-centered plan of care. R5’s admission MDS indicated diagnoses of schizoaffective disorder and psychotic disturbances, that R5 was cognitively intact, had behavioral symptoms, used tobacco, ambulated 10 feet independently, and needed staff assistance with showering, putting on footwear, walking distances over 10 feet, and supervision with stairs. The MDS also showed R5 received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic medications, and care area assessments were triggered for multiple areas including cognitive loss/dementia, ADLs, mood state, falls, nutritional status, psychotic drug use, and return to community referral. R5’s care plan lacked resident preferences and only included nutrition. The chart contained a care conference note with the DON and R5 present, but it addressed goals, medical history, and orders without R5’s preferences, R5’s goals for herself, or any concerns. The DON stated R5 had been admitted over one month earlier but had never had a care conference and did not have a care plan, and that care was directed by physician orders. The administrator stated care plans were established by the admitting nurse talking with the resident and that care conferences were to be held within the first 14 days and then quarterly or as needed. RN-B stated care was directed by physician orders and the DON was responsible for setting up care conferences. R5 stated the facility had not asked about personal, cultural, or religious preferences, had not offered a care conference, had not asked about other providers or medical needs, had not offered a meeting to discuss concerns or needs, and had not provided a copy of a care plan.
Failure to Provide Resident Bill of Rights on Admission
Penalty
Summary
The facility failed to provide 1 of 3 residents, R5, with the Resident Bill of Rights orally or in writing upon admission. R5's chart did not contain documentation that she received a copy of the Resident Bill of Rights. During interviews, the DON stated the administrator was responsible for reviewing the Bill of Rights and explaining the grievance process to new residents upon admission, while the administrator stated the admitting nurse was responsible for informing new residents of the rights and the DON was responsible for verifying the admission process was complete. The administrator also stated the admission process was not in written form, acknowledged R5's chart lacked evidence that she was provided the Resident Bill of Rights, and noted that a full listing of the rights was posted on a facility wall. R5 stated she was not given a written copy when admitted and was not verbally educated or reviewed on the rights. The facility's Resident Rights and Responsibilities policy listed resident rights and grievance information but did not direct staff to provide the Resident Bill of Rights prior to or upon admission, while the Abuse Prevention policy stated residents and families are informed on admission how to report concerns, incidents, and grievances and that a copy of the Resident Bill of Rights is provided and covered upon every admission.
Failure to Notify Resident Representative After Incident
Penalty
Summary
The facility failed to notify the resident's representative after an incident involving a resident who was cognitively intact and had diagnoses of schizoaffective disorder and psychotic disturbances. The resident's chart identified her friend as her emergency contact. On 7/2/26, the resident returned to the facility after becoming lost, and around midnight she called the facility with help from a security guard because she was disoriented and unable to find her way back. A car service was arranged to pick her up, and she fell while getting into the car, sustaining a superficial scrape to the bottom of her foot. The DON stated the resident had left the facility independently, became unable to find her way back, and fell while entering the car service. The DON also stated the provider was notified, but the resident's emergency contact was not. The administrator stated he was not notified of the incident and said all falls require nursing to follow the fall protocol, which included notifying the emergency contact. The resident stated her daughter should have been notified, and her friend stated she was not informed of any incidents and wished she had been notified. The facility's Fall Prevention and Fall Management Program directed staff to notify the RN and physician when falls occur, but it did not include direction to notify the resident's representative when accidents occur.
Failure to document and follow up on resident grievances
Penalty
Summary
The facility failed to document, track, and follow up on grievances filed by residents for 3 of 3 residents reviewed for complaints. R4, whose diagnoses included depressive disorder, anxiety disorder, post-traumatic stress disorder, and chronic cough, stated she had complained to the DON over the past couple of weeks about rodents chewing on her quilt, but no action had been taken to resolve her concern. R2, whose quarterly MDS indicated diagnoses of PTSD and anxiety with intact cognition, stated she had made complaints directly to the administrator over the past few months about food portion sizes and being fearful of kitchen staff because of their behavior, and stated nothing gets done. R3, whose quarterly MDS indicated diagnoses of panic disorder, traumatic brain injury, anxiety, depression, and PTSD with moderate cognitive impairment, stated she told the administrator and DON that she was scared of two kitchen staff because they slammed things around and made her feel uncomfortable. She also complained about the food served and the amount of food provided. R3 stated the administrator did not make any changes or follow up with her regarding her complaints. During interviews, the DON stated she had raised concerns to the administrator and owners about unsanitary conditions, a mouse problem, loud music with explicit language, staff slamming things around in the kitchen, loud noises, the amount of food served, not following the menu, expired food being served, and lack of activities, but the administrator and owners failed to follow up with her concerns. The administrator stated the facility only had one complaint in the last year and identified himself as the grievance officer, with grievance forms kept in a wall pocket near the front door. However, observations on multiple dates found no grievance forms in the designated location. Staff also stated the facility did not have a formal process to handle complaints, and complaints were simply reported to the administrator and DON. R5 stated she was not informed of the grievance and complaint procedure or that complaint forms were available. The facility policy lacked several elements related to grievance notification, anonymous complaints, time frames, grievance official identification, BFCC-QIO and SA contact information, immediate action during investigations, reporting abuse, follow-up, and record retention.
Verbal Threats to Residents and Lack of Administrative Oversight
Penalty
Summary
The facility failed to protect residents from verbal abuse, mental abuse, and neglect when cook-A verbally threatened two residents during an observation on 7/15/26 at 10:45 a.m. Cook-A told R2 and R3 that they would be looking for a new place to live if they told the surveyor what occurs at the facility. R2 had diagnoses including PTSD, anxiety, borderline personality disorder, depression, and diabetes, and her care plan directed staff to encourage her to express feelings and discuss concerns. R3 had diagnoses including panic disorder, traumatic brain injury, anxiety, depression, PTSD, and moderate cognitive impairment, and her care plan directed staff to discuss concerns, fears, or issues with her. During interview, R3 stated cook-A's threat would make her want to stay in her room to avoid him, and she reported that cook-A and cook-B slamming things around in the kitchen made her feel uncomfortable and unsafe. She said she had reported these concerns to the administrator and DON, but nothing was done. The administrator stated he was unaware residents felt uneasy with cook-A and cook-B and did not witness the behavior because he left the facility by 1:00 p.m. each day. The DON stated she also heard cook-A threaten the residents and had been told about complaints regarding slamming things around and playing explicit music loudly in the kitchen, but the facility did not initiate abuse education for staff after an alleged employee-to-resident sexual abuse on 7/10/26 or after the witnessed verbal threat. The facility abuse prevention policy directed that systems be in place to prevent abuse and that incidents be reviewed by the program director or administrator.
Failure to Immediately Report Abuse Allegations
Penalty
Summary
The facility failed to immediately report abuse allegations to the State Agency within 2 hours for 3 of 3 residents reviewed for abuse. On 7/10/26, two residents reported to the DON that cook-A had a sexual relationship with a resident, and the resident became upset and left the facility. The resident involved had diagnoses including endocarditis, anxiety, depression, bipolar disorder, and adjustment disorder, and was cognitively intact. Her chart lacked a vulnerability care plan, lacked documentation of the alleged sexual abuse, and lacked documentation of attempts to communicate and investigate the allegation. Another resident involved had PTSD and anxiety with intact cognition, and a third resident had panic disorder, TBI, anxiety, depression, PTSD, and moderate cognitive impairment. The administrator stated he was aware abuse must be reported immediately but thought the DON reported the alleged abuse. The DON stated she informed the administrator and owner by text message on 7/10/26, did not file a police report, and did not report to the SA until 7/13/26. The administrator did not interview the two resident witnesses who reported the allegation, and he concluded the allegation was unsubstantiated after interviewing cook-A, who denied the relationship. The facility’s QAPI committee meeting notes dated 7/14/26 lacked review of the allegation of a sexual relationship between cook-A and the resident. A later report to the SA also documented that cook-A was observed telling residents not to say anything or they would have to move out.
Failure to Document Resident Discharge and Coordinate Care
Penalty
Summary
The facility failed to document the discharge for 1 of 3 residents reviewed for the discharge process. The resident’s quarterly MDS indicated diagnoses of endocarditis, anxiety, depression, bipolar disorder, and adjustment disorder, and the resident was cognitively intact. The care plan lacked discharge planning, the progress notes lacked documentation of coordination and communication of the discharge with the primary physician or receiving provider, and the chart lacked documentation of the resident’s discharge or coordination of care with the primary physician or receiving provider. The administrator stated the resident left the facility with a case worker to move to another facility without advance notice, and the DON stated she did not complete a discharge summary or coordinate care with the receiving facility because she was unaware of where the resident went. The DON stated the resident was provided with most of her medications upon discharge and that the physician and NP were notified of the discharge.
Failure to Establish Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to establish a baseline care plan within 48 hours of admission for one resident. The resident’s face sheet showed admission to the facility, and the admission MDS identified diagnoses of schizoaffective disorder and psychotic disturbances. The resident was cognitively intact, had behavioral symptoms, used tobacco, ambulated 10 feet independently, and needed staff assistance with showering, putting on footwear, and walking distances over 10 feet, with supervision needed for stairs. The MDS also showed the resident received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic medications. Care area assessments were triggered for cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral. The resident’s progress note indicated she was admitted and was alert and oriented to self, time, place, and situation. A care plan dated several days after admission included nutrition but lacked other areas of care and interventions. During interviews, the DON stated the resident had been admitted over one month earlier but did not have a care plan because she was not trained to enter care plans into the resident’s chart, and she stated care was directed by physician orders. The administrator stated baseline care plans were established by the admitting nurse through a conversation with the resident. An RN stated care was directed by ordered treatments and that the DON was responsible for establishing the resident’s care plan. The resident stated the facility had not asked about personal, cultural, or religious preferences, had not offered a care conference, had not asked about other providers or medical needs, and had not helped arrange transportation for needed appointments.
Failure to Develop and Implement a Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for one resident who was admitted with schizoaffective disorder and psychotic disturbances. The resident's admission MDS indicated she was cognitively intact, had behavioral symptoms, used tobacco, ambulated 10 feet independently, required staff assistance with showering, putting on footwear, and walking distances over 10 feet, and needed supervision with stairs. She also received antipsychotic, antidepressant, antibiotic, diuretic, and hypoglycemic medications. Care area assessments were triggered for cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence/catheter, mood state, falls, nutritional status, psychotic drug use, and return to community referral. The resident's care plan included nutrition but lacked other areas of care and interventions, and progress notes did not show evidence of care planning. The DON stated the resident had not been care planned because she was not trained to enter care plans into the chart, although she knew all residents should have a care plan and that care was directed by physician orders. The dietician stated she gathered resident preferences and reviewed medical history for care plans but did not collaborate with nursing or other disciplines and did not share her notes with the IDT. The administrator stated care plans were established by the admitting nurse through conversation with the resident, while an RN stated care was directed by ordered treatments and the DON was responsible for setting up care conferences and establishing the care plan. The resident stated the facility had not asked about her personal, cultural, or religious preferences, had not offered a care conference, and had not discussed other providers or medical needs, including scheduling procedures and transportation.
Incomplete and Inaccessible Medical Records
Penalty
Summary
The facility failed to maintain complete, accurate, and readily accessible medical records for 2 of 3 residents reviewed. For one resident, the record showed an admission MDS with diagnoses including schizoaffective disorder and psychotic disturbances, cognitive intactness, behavioral symptoms, tobacco use, and assistance needs for some ADLs. Although the care area assessments were triggered for multiple areas, the care plan dated 6/19/26 included nutrition but lacked other care areas and interventions. The resident’s progress notes also lacked evidence of care planning, care coordination with providers, the 7/2/26 fall away from the facility, and response to interventions. The chart was missing the resident’s preferred emergency contact information, provider visit notes, physician/NP orders, assessments after the fall, and lab results. The resident stated her daughter should have been notified after the incident. For the second resident, the face sheet identified diagnoses of schizophrenia, bipolar disorder, and diabetes, and the quarterly MDS indicated the resident was cognitively intact and independent for all transfers. Review of the EHR from 6/16/26 through 7/16/26 did not include physician visit notes or orders. The DON stated the resident had been refusing medication at times and that the physician had been notified and gave an order on 7/10/26 to discontinue some medications, but those notes were not in the facility chart. The DON and administrator stated the physician notes and orders were kept in an outside clinic/hospital EHR, that the facility did not own those records, and that not every nurse had access to them. The administrator also stated the facility did not have a policy on maintaining a complete and accurate medical record.
Failure to Follow Established Menus
Penalty
Summary
The facility failed to follow established menus and served meals that did not match the posted menu items. The breakfast menu for 7/15/26 called for turkey sausages, a fruit muffin, and a banana, but the DON stated the facility served cold cereal with water because the kitchen refrigerator was broken and milk and other breakfast items were not available. The administrator later stated the kitchen refrigerator broke on 7/10/26, the milk left in the kitchen refrigerator was discarded because it was not cold enough, and he did not expect staff to serve cold cereal with water. He also stated the cooks were responsible for ordering food and that the noon meal was changed to turkey sandwiches because the facility did not have the ingredients for the menu meal. Residents interviewed described repeated failures to serve the menu as written. One resident with depression, anxiety, PTSD, and diabetes stated cereal with water was served for breakfast and that the facility frequently ran out of food on the menu. Another resident with PTSD, diabetes, and anxiety stated the facility served cold cereal with water and no fruit, and that the menu was frequently not followed. A resident with panic disorder, TBI, anxiety, depression, and PTSD stated pork was frequently served even when it was not on the menu, and another resident with schizoaffective disorder and psychotic disorder stated he was served cold cereal with water because it was the only option and the food on the menu had been tossed out. Additional observations showed the facility continued to serve meals that did not match the menu on multiple days. On 7/15/26, residents were observed receiving a turkey and cheese sandwich and chips for lunch instead of the listed Italian sub meal, and on 7/16/26 the menu listed turkey muffins, tabouleh salad, roasted zucchini, and brownie, but the administrator stated he planned to cook meatloaf because the facility did not have the ingredients and did not know what turkey muffins were; residents were then observed being served meatloaf and mashed potatoes. On 7/21/26, the lunch menu listed a ham and Swiss sandwich, side salad, and oranges, but residents were served barbeque chicken, boiled potatoes, and mixed vegetables. The dietician stated she created the menus, met with residents about preferences, did not share those preferences with facility staff, did not review the menus with the cooks, and was not informed when the facility did not follow the menus. A policy regarding establishing and following menus was requested but not provided.
Failure to Honor and Communicate Resident Food Preferences
Penalty
Summary
The facility failed to communicate residents’ food preferences to the interdisciplinary team and failed to honor those preferences once they were known. During interviews, residents reported that the facility frequently served food that did not match the menu, including cold cereal with water for breakfast and pork being served often, even though some residents did not eat pork. One resident stated she was diabetic and did not want sugary cereal, while two residents stated they did not eat pork, including one who identified religious reasons as Buddhist and said she had told the DON, administrator, and cooks about her preference. Staff interviews showed there was no system to communicate resident likes and dislikes. The DON stated the cooks rarely followed the menu and that pork was served twice on one day without an alternative for residents who did not eat pork. The dietician stated she created the menus and interviewed residents about likes and dislikes, but did not share those notes with the IDT, did not attend care conferences, and did not collaborate with nursing or other disciplines. The administrator stated resident food preferences should be documented in each resident’s electronic health record and expected food dislikes to be listed under allergies, while cooks stated they were unaware of residents’ preferences and simply made what they were told.
Lack of Policy for Personal Food Storage Amid Rodent Infestation
Penalty
Summary
The facility lacked a policy regarding the use and storage of foods brought to residents by family and other visitors, and the deficiency affected all 13 residents living in the facility. During an observation on 7/15/26 at 10:45 a.m., rodent feces was seen in resident rooms and throughout the facility, and fruit, bakery items, leftover meals, crackers, and granola bars were stored in residents’ rooms. The facility owner stated on 7/15/26 at 1:00 p.m. that there was an ongoing rodent infestation. The contracted exterminator stated on 7/15/26 at 1:30 p.m. that he was concerned about residents maintaining food caches in their rooms because of the rodent infestation. The DON stated on 7/15/26 at 2:40 p.m. that she had complained the week of 6/22/26 about unsanitary conditions and the rodent problem to the administrator and owners, and that no education had been provided to residents or staff to reduce or control the infestation, including food storage in residents’ rooms. An LPN stated on 7/15/26 at 3:25 p.m. that the facility had not provided education regarding reducing or controlling the rodent infestation. On 7/16/26 at 2:17 p.m., the administrator stated the facility did not have a policy on personal food storage, and a requested policy was not provided.
Inconsistent Advance Directive Documentation and Code Status Mismatches
Penalty
Summary
The facility failed to ensure resident advance directives were accurately and consistently documented between the physician orders in the electronic health record (EHR) and the POLST in the hard chart. Surveyors found that code status information for multiple residents did not match across records, including two residents whose wishes were not documented consistently enough for staff to rely on in the event of a cardiac arrest. The deficiency was identified through observation, interview, and document review and was cited as immediate jeopardy for two residents, with an additional discrepancy found during a facility-wide audit. For one resident, records were inconsistent across the chart and EHR. The resident had intact cognition on a quarterly MDS and stated that full resuscitation was desired if the heart stopped and breathing ceased. The POLST in the hard chart indicated attempt resuscitation/full treatment and was signed by the resident and provider, but the EHR order summary contained a DNR order. Provider notes repeatedly listed the resident as full code, while the care plan, progress notes, and care conference documentation did not clearly and consistently reflect the code status. During interview, an LPN stated he would check the EHR profile and orders and would not start CPR because the order summary showed DNR/DNI. The DON confirmed the mismatch and stated the POLST was correct, but also acknowledged there was no process in place to ensure the POLST code status matched the EHR orders/documentation. For another resident, provider notes identified the resident as DNR and stated a POLST was on file and uploaded, but the EHR profile, face sheet, care plan, and physician orders did not identify code status. The resident stated that DNR/DNI wishes had been communicated to the facility and that he did not want CPR. During interview, the LPN reviewed the EHR and face sheet and stated he would perform CPR because the resident was not identified as DNR/DNI in those locations. The DON later reviewed the paper chart and confirmed the signed POLST identified the resident as DNR/DNI, while the EHR indicated full code. A third resident was later found during audit to have a POLST indicating DNR/allow natural death with selective treatment, while the EHR order summary still showed full code orders and did not include the DNR order. The resident stated a desire to let nature take its course and not have chest compressions performed.
Activities Not Assessed or Provided to Meet Resident Needs
Penalty
Summary
The facility failed to comprehensively assess, develop, and implement meaningful and engaging activities for 4 of 4 residents reviewed who expressed concerns about a lack of activities. Residents with intact cognition and documented activity preferences, including interests in bingo, Pokeno, crafts, television, outings, news, fresh air, and group activities, reported boredom and stated that organized activities were not being offered. One resident stated the facility had not really had activities for months, and another stated she wished the residents could do things as a group but had to find things to do on her own. The records showed that activity assessments and care planning were incomplete or not individualized for several residents. One resident’s care plan identified enjoyment of small group activities such as pizza and ice cream socials, bingo, and Pokeno, but the resident reported no group activities were occurring. Another resident’s therapeutic recreation assessment identified interests in crafts, television, conversing, and outings, yet the resident stated she got bored and could not remember anything being set up other than going downstairs to get a puzzle or cards. For another resident, the CAA identified a problem with adjustment to a new living environment and prior preference for group activities, but the medical record did not show further assessment of activity preferences and needs, and the DON stated the activity assessment had not been completed. A fourth resident’s MDS did not complete the activity preferences section, and the resident stated she had agoraphobia, had never been asked about activity preferences, and was bored. The activities director stated he was the only activities staff member, created the monthly calendar, did not schedule activities with times or locations, did not write progress notes, update care plans with preferences and choices, or keep attendance documentation, and did not attend QAPI meetings. The DON and administrator stated there were no weekend activities, and multiple staff members confirmed there had been no group activities for several weeks. Facility calendars from October 2025 through April 2026 listed weekday activities only, without times or locations, and observations from late March through early April showed no activities performed or offered.
Unqualified Activities Director and Incomplete Activity Program Documentation
Penalty
Summary
The facility failed to have a qualified therapeutic recreation specialist or other qualified activities professional directing the activities program, as required. During interview, the activities director stated he was hired in September 2025, was the only activities staff member, created the monthly activities calendar, and was also supposed to drive residents to appointments. He stated that nothing was scheduled for time or place of activities, he did not write progress notes, update resident care plans with preferences and choices, keep documentation of activity attendance, or attend QAPI meetings, and that he had no previous training, licensure, or full-time experience to be a qualified activities director. The DON stated the facility did not have weekend activities and that activities were mostly cards or puzzles, and verified there were no attendance records or progress notes regarding activity participation. The administrator stated the facility did not have a full-time activities employee and there were no activities scheduled or planned on weekends, and also verified the activities director was not licensed or registered and had no prior full-time therapeutic activities experience. A former activities director stated he had worked in the role since 2012, resigned in October 2025, and had previously documented the MDS assessment portion for resident preferences when assigned by the MDS coordinator, but the current activities director did not complete progress notes, attendance records, or care plans. The facility assessment identified services to include learning residents' preferences and routines and providing opportunities for social activities and life enrichment, and the staffing plan listed Social Services/Activities Director and Health Unit Coordinator for Medical Appointments at approximately 60 hours per pay period.
RN Staffing Gaps
Penalty
Summary
The facility failed to ensure a registered nurse (RN) was scheduled for a minimum of eight consecutive hours each day. Review of the Payroll Based Journal staffing data for the first quarter of 2026 identified no RN hours on 11/5/25, 11/8/25, 11/16/25, 11/20/25, and 12/21/25. Facility timecards from 10/1/25 through 12/31/25 also showed no RN hours on 11/5/25, 11/16/25, 11/20/25, and 12/21/25. In an email, the building owner stated that on several of those dates an RN had been scheduled but an LPN covered the shift, and on one date an RN called in and an LPN covered. During interview, the administrator acknowledged the facility had previously had difficulty consistently filling RN hours, especially on weekends, and had used agency staff, though March 2026 timecard data showed no gaps in RN hours. The facility policy stated an RN would be staffed a minimum of eight consecutive hours a day, seven days a week.
Improper Food Storage, Labeling, Cleaning, and Hair Restraint Use
Penalty
Summary
Food items in the main production kitchen were found improperly stored, dated, and maintained during surveyor observation and interview. In the main refrigerator, an opened 3-pound container of sour cream, orange juice, apple juice, strawberry jam, a gallon of milk, and seven unpasteurized eggs were present, and CK-A verified that the items were not dated or labeled except for their product expiration/use-by dates. CK-A stated he did not know when the items were first opened. In the attached freezer, surveyors observed an undated package of breakfast muffin, an open pitcher of clear fluid, and a half-inch of frozen yellow-tan material covering the bottom of the unit with the pitcher frozen to it. The freezer door seal had dark black matter on the entire seal, and CK-A stated he had never cleaned the freezer unit before, although he had occasionally wiped down the refrigerator. Surveyors also observed multiple dry food items stored above the countertop in the main kitchen that were opened and undated, including large containers of spices, creamy peanut butter spread, breadcrumbs, and fried onions. A bottle of chili garlic sauce had an expiration date of 12/23/25, and a large plastic container with a worn-off product name had an expiration date of 4/22/22. CK-A stated the breadcrumbs and fried onions looked and smelled stale and that he went by the product expiration date. CK-A also stated he did not know what the unidentified container was or how long it had been in the spice cabinet. A kitchen checklist posted near the refrigerator stated that food service employees wear hair restraints and clean clothing, and another form stated that all dry foods must be stored in a container with a tight-fitting lid, labeled and dated. During additional observation, CK-B was seen cooking hamburger in a saucepan on the stovetop without wearing a hair net and stated he should always wear one when cooking. The infection control preventionist stated cooks are supposed to wear hair nets at all times to prevent bacterial contamination. The administrator stated it was the expectation that all food products be dated and labeled with the date opened and that all logs, including cleaning logs, be completed and documented every day by the cooks. The facility Food Storage and Procurement Policy and Procedure required opened bags of food to be labeled with the date opened and directed staff to discard spoiled or contaminated food, and to label food prepared at the facility with the name of the food, date made, and use-by date.
QAPI Program Lacked a Formal Plan and Failed to Address Repeated Quality Deficiencies
Penalty
Summary
The facility failed to ensure a comprehensive QAPI plan was identified, implemented, and maintained to support acceptable levels of performance and continual improvement. Based on interview and document review, the facility had a QAPI Program policy dated 2/2020 that described an ongoing, facility-wide, data-driven QAPI program with processes for tracking and measuring performance, setting goals and thresholds, identifying and prioritizing quality deficiencies, analyzing underlying causes, developing corrective actions, and monitoring effectiveness. However, when surveyors requested documentation of a QAPI plan showing how the facility carried out these requirements, none was provided. The facility also failed to identify and prioritize quality deficiencies that it was or should have been aware of, including concerns related to activities and dietary/kitchen practices. QAPI meeting notes from 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26 did not reference activities or dietary department/kitchen practices. The CASPER report showed repeated deficiencies for activities, food storage and sanitation, QAPI program/plan, QAPI improvement activities, and the QAA committee. During interview, the administrator stated the QAPI committee was fairly new, the facility did not currently have a formal process for collecting data to track and measure performance, and there were no established goals or identified quality deficiencies being analyzed for corrective action.
Failure to Maintain an Effective QAPI Program
Penalty
Summary
The facility failed to maintain a QAPI committee that effectively identified and responded to quality deficiencies and failed to develop procedures for feedback, data collection, and monitoring systems. Document review showed QAPI meeting notes dated 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26, but the notes lacked tracking of data-driven quality metrics over time and did not show any PIPs. The deficiency was identified through document review and interview, and it was stated that the facility held monthly QAPI meetings, but the committee was fairly new. During an interview on 4/6/26 at 1:28 p.m., the administrator stated the facility did not currently have a formal process for collecting data to track and measure performance or a formal QAPI plan at the moment. The administrator also confirmed the facility had no established goals, no identified quality deficiencies being analyzed, and no PIP in place. The administrator stated there was no process to collect data for identifying high-risk, high-volume, or problem-prone areas or to collect information from residents or staff. The facility's QAPI Program policy dated 2/2020 stated the facility should develop and maintain an ongoing, facility-wide, data-driven QAPI program, but further documentation such as a QAPI plan was requested and not received.
QA Committee Did Not Include Required Members
Penalty
Summary
The Quality Assurance (QA) committee failed to ensure that the required members attended its meetings. Review of QAPI meeting notes dated 10/14/25, 11/11/25, 12/9/25, 1/13/26, 2/10/26, and 3/10/26 showed that only four members regularly attended: the administrator, the DON, the medical director, and the consultant pharmacist. The notes did not show attendance by the infection preventionist. During interview, the infection preventionist stated she did not regularly attend QAPI meetings. The administrator stated the facility had four staff members who regularly attended QAPI and acknowledged he had tried to include the infection preventionist in the past, but her schedule did not work. He also stated he knew additional staff members were needed at QAPI meetings, but there were scheduling conflicts. The facility policy stated the QAA committee would meet at least quarterly and include the administrator, medical director, DON, infection preventionist, and other departments as requested by the administrator.
Improper Laundry Infection Control Practices
Penalty
Summary
The facility failed to maintain proper infection control practices during laundry services. During observation and interview, the housekeeper stated the facility had one washing machine and one clothes dryer in the basement and that she was responsible for all personal and facility laundry, as well as sweeping, dusting, vacuuming, and washing hard surfaces. She was observed transporting soiled resident laundry in an uncovered plastic laundry basket with holes/openings, and she stated she did not cover laundry when moving it from resident rooms to the basement or when transporting clean linen to resident rooms and facility closets. She also verified that she did not wear a PPE gown when sorting and handling soiled and clean linen. During later observation, the housekeeper was again seen carrying resident personal laundry uncovered to the basement. A resident also walked downstairs with personal laundry and placed it on the utility sink next to the washing machine while the machine was running. Clean linen was observed folded on top of the dryer, uncovered, and the housekeeper moved the clean linen into an uncovered plastic laundry basket while soiled personal laundry remained on the utility sink. The housekeeper then carried the uncovered basket back downstairs, transferred items from the washing machine to the dryer, and placed the soiled linen from the basket into the washing machine. The housekeeper stated she had never washed or sanitized laundry baskets between handling soiled linen and bringing clean linen back to residents and the facility unless the baskets were visibly dirty. The infection control preventionist stated the expectation was to cover linen during transport and clean laundry baskets after each use to prevent contamination. The facility policy stated that gown and gloves are available for workers sorting linens, linen is covered during transport, soiled linen should be bagged or contained, and soiled linen should not be placed on furniture, floor, or other surfaces.
Failure to Implement Active Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement an active antibiotic stewardship program that included development of protocols and a system to monitor the appropriateness of antibiotic use, including prophylactic antibiotic use. During the entrance conference, the administrator stated the infection control preventionist (IC)-MDS was responsible for infection control, surveillance, and the antibiotic stewardship program. The IC-MDS stated she worked part time at the facility, visited once per week, and usually reviewed the MARs for antibiotics and related information. She also stated she was notified by email or when she arrived weekly of signs and symptoms of potential illness, but there was no communication to her regarding residents being started on antibiotics before her weekly visits. The IC-MDS stated she used Monthly Tracking Sheets to monitor resident infections or antibiotic use, but the Infection and Antibiotic use Monthly Tracking forms reviewed for the previous 12 months lacked multiple required elements, including resident name, diagnostic testing and results, whether standardized criteria were used, resident symptoms, timeouts, and response to antibiotics. She also stated there was nothing written down for her to use as a guide for her role in the antibiotic stewardship program, including antibiotic timeouts or reviews, and that she was not involved in periodic review of prescribing practices because the physician and pharmacist could look at that. The facility policy required collection of specific antibiotic use information and stated the Infection Preventionist and Pharmacy Consultant would provide regular feedback on antibiotic use and outcomes to staff, the QAPI committee, and providers, but the IC-MDS stated she did not attend monthly QAPI meetings and could not speak to the facility's reports on antibiotic use, resistance patterns, practices, or facility assessment involvement.
Failure to Maintain Building and Grounds in Good Repair
Penalty
Summary
The facility failed to maintain the building and grounds in good repair. The Facility Assessment dated 7/21/2025 identified that the resident population must be ambulatory and not require a wheelchair, and also noted that outside grounds and the building are maintained and repaired using an online maintenance work-order system. During the survey, the State Agency requested a list of residents who smoked, and the administrator identified 6 of the 13 residents as smokers. Observation of a resident in a shared room found a closet door jamb with about 3 inches of missing wood where the strike plate and latch met, a window air conditioner unit with gaps around it where the outdoors was visible, and a small fan with visibly soiled fins that the resident said had not been wiped down or cleaned despite weekly use. Additional observations showed a large piece of window casing trim hanging from the front of the building above the smoking patio, with two residents sitting below it. In another shared bedroom above the patio, three street-facing windows had cracked, peeling, and missing paint along the inside casing, and one resident stated a window was so rotted it would not stay open. The DON later observed the hanging wood and described it as dangerous, and also observed a 12-inch by 5-inch hole in the concrete patio sidewalk connecting the smoking patio to the side of the facility for wheelchair accessibility. The administrator stated the facility did not have a system to document and follow up on environmental concerns such as water leaks, pest control, electrical issues, room temperature problems, torn carpet, or wall and window issues, and said there was no maintenance staff to monitor and audit environmental issues. Facility policy stated that areas around the buildings, including sidewalks and patios, shall be maintained in a safe and orderly manner at all times.
Failure to Complete Required Resident Rights Training
Penalty
Summary
Staff members were not educated on resident rights and facility responsibilities as required. Based on interview and document review, the facility failed to ensure mandatory resident rights training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive annual training on resident rights, but review of personnel records showed RN-B had not completed education that included resident rights in the last year. During an interview on 4/6/26 at 11:40 a.m., the DON stated she would expect staff to complete training twice a year when asked about abuse training, resident rights training, QAPI training, and infection control training. During an interview on 4/6/26 at 12:35 p.m., the HRA stated the facility did not usually have staff who continued employment past a year as RN-B had, so she had missed re-assigning RN-B's training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024. The facility's Sufficient and Competent Nursing Staff policy dated 4/2025 indicated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including resident rights.
Missing Mandatory Abuse Training for RN
Penalty
Summary
The facility failed to ensure that mandatory abuse/vulnerable adult training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] stated that clinical staff were to receive annual training on vulnerable adults/abuse, and the facility's Abuse Prevention Policy dated 5/30/25 stated that staff would complete abuse training annually and upon hire. Review of personnel records showed that RN-B had not completed education that included abuse/vulnerable adult training in the last year. During interviews, the DON stated she would expect staff to complete training twice a year, and the HRA stated the facility did not usually have staff who remained employed past a year as RN-B had, so RN-B had missed re-assigning training for resident rights, abuse, and infection control; the HRA confirmed the last time these were completed for RN-B was in 2024.
Failure to Complete Required QAPI Training
Penalty
Summary
Mandatory training on the facility’s Quality Assurance and Performance Improvement (QAPI) Program was not completed for 5 of 5 staff members reviewed, including the DON, RN-A, RN-B, LPN-A, and LPN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive QAPI training annually, but personnel records showed that these staff members had not completed education including QAPI in the year before survey entrance. During interview, the DON stated she would expect staff to complete training twice a year when asked about abuse, resident rights, QAPI, and infection control training. The HRA stated that training requirements had changed at some point and QAPI training had not automatically been added, and that she added QAPI training during the survey after realizing the requirement was not being met. The facility’s Sufficient and Competent Nursing Staff policy dated 4/2025 did not specify that QAPI training would be completed.
Missed Infection Control Training for RN
Penalty
Summary
The facility failed to ensure that mandatory infection control training was completed for 1 of 5 staff members reviewed, RN-B. The facility assessment dated [DATE] indicated that clinical staff were to receive infection control training annually, but review of personnel records showed that RN-B had not completed education including infection control in the last year. During an interview on 4/6/26 at 11:40 a.m., the DON stated she would expect staff to complete abuse training, resident rights training, QAPI training, and infection control training twice a year. During an interview on 4/6/26 at 12:35 p.m., the HRA stated the facility did not usually have staff who remained employed past a year as RN-B had, so RN-B had missed being re-assigned training for resident rights, abuse, and infection control, and confirmed the last time these were completed for RN-B was in 2024. The facility's Sufficient and Competent Nursing Staff policy dated 4/2025 stated that licensed staff would demonstrate the skills and techniques necessary to care for resident needs, including infection control.
Unsecured resident records left in basement and dining room
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when multiple documents containing resident information were left unsecured in common areas. In a basement room accessed by staff for laundry and food storage, surveyors observed a small cabinet with an approximately two-foot-high pile of papers that included resident order summary sheets and medication administration records for multiple current residents and discharged residents. The documents were dated from 6/2025 to 1/2026 and were stored in an unprotected manner in a room where staff routinely passed through to reach the washer, dryer, cleaning supplies, and food storage areas. Surveyors observed the basement area being used by the cook and housekeeper, who stated they regularly went downstairs for food, deliveries, laundry, and cleaning tasks. Residents also reported using the basement for their own laundry. The administrator later acknowledged that the stack of papers had been there since he started the prior year and stated the documents should not have been stacked unprotected there. He also stated some of the papers should be uploaded to PCC and that he would speak with the DON about them. In the dining room, surveyors observed unsecured three-ring binders on a portable shelving unit in front of windows while residents were eating. The binders contained medication error reports, pharmacy paperwork, resident names, addresses, dates of birth, medication lists, orders, glucose readings, vital signs, and weight information. The RN, DON, and administrator all identified the dining room as a public area and acknowledged that the binders contained private personal and medical information that should not have been left out in the open. Facility policy required resident information to be protected from unauthorized release or disclosure and limited access to authorized personnel.
Unsecured Medication Refrigerator
Penalty
Summary
The facility failed to ensure medications were stored in a manner to reduce the risk of unauthorized access for 5 of 5 residents whose medications were kept in an unsecured facility refrigerator. During an observation and interview on 4/1/26 at 9:21 a.m. in the dining room, a medication cart with a small mini refrigerator beside it was observed, and the mini fridge did not have a lock. RN-A stated that refrigerated medications were stored in the small mini refrigerator and showed a small lock box inside the refrigerator, but said it was not being used. No medications were observed inside the lock box. Inside the medication refrigerator, multiple boxes of medication were observed, including Copaxone, Ozempic, and Trulicity. During an interview on 4/1/26 at 12:46 p.m., the DON stated that about two to three months earlier, medications had been moved from a locked box in the main refrigerator where food was stored to the new mini refrigerator, and she had not thought about the medication refrigerator needing a lock. In email correspondence on 4/6/26 at 2:12 p.m., the administrator identified the residents whose medications were stored in the small medication fridge as R1, R2, R3, R4, and R5. The facility's Medication, Labeling, and Storage policy dated 2/2023 stated that all medications would be stored in a locked compartment and only authorized personnel would have access to the keys.
Failure to Document and Offer Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure recommended influenza and pneumococcal vaccinations were offered and/or provided in a timely manner for all 13 residents reviewed for immunizations. During interview, the DON stated the facility did not have a process in place to document vaccination status for all residents and that residents were being sent to Walgreens to obtain vaccinations and copies of their immunization information. The DON reviewed the paper charts and EMRs for all 13 residents and stated they lacked immunization records, adding that it was hard to tell who needed a vaccine at that time. The DON also stated the facility lacked documentation or messaging to providers to determine or ask about immunization status. Facility policy required residents to be assessed for current immunization status within 5 days of admission, offered pneumococcal vaccine within 30 days when indicated, and have immunization status, contraindications, refusals, education, and vaccination dates documented in the medical record. The influenza policy similarly required residents to be interviewed upon admission and annually to determine influenza season status and to document contraindications, refusals, and vaccination dates.
Failure to Document COVID-19 Vaccination Status and Education
Penalty
Summary
The facility failed to establish and maintain documentation of COVID-19 vaccination status for all 13 residents. During interview, the DON stated the facility did not have a process in place to document vaccination status for all residents and that the residents were mobile and were sent to a pharmacy, with staff asking for a copy of vaccination information. Review of the residents’ paper charts and EMRs for all 13 residents showed no immunization records, and the DON stated it was hard to tell who needed a vaccine at that time. The DON also stated the facility lacked documentation or messaging to providers to determine or ask about immunization status. The facility also failed to document COVID-19 vaccination education and status for staff, including cook (CK)-B. CK-B stated he had worked at the facility for almost one year and had never been asked about his COVID-19 immunization status upon hire, and he stated the facility never provided education on the benefits, risks, or side effects of the vaccine. The DON stated the facility did not have documentation showing that CK-B was offered education on the benefits, risks, or side effects of the COVID-19 vaccine or whether he declined. Facility policy stated all residents and staff members would be provided SARS-CoV-2 education and offered an opportunity to be immunized unless contraindicated or declined, with documentation completed.
Failure to Provide Usable Private Space in Shared Room
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not met for a resident with intact cognition who was independent with most personal cares and had diagnoses of depression, diabetes, anxiety, and post-traumatic stress disorder. During observation, the resident was lying in a twin bed in a two-person room, with the bed positioned inside the doorway, parallel to the north wall, and with the footboard against a closet that extended 20 inches from the wall. A privacy curtain started above the foot of the bed and wrapped around a dresser that measured 18 inches deep by 30 inches long, then continued parallel to and against the bed to the head of the bed and wall. There was no carpet or floor area inside the curtained space for the resident to stand, making it impossible to obtain clothes and get dressed without standing outside the privacy curtain. The resident stated the area was the smallest in the facility and that the curtain went around the bed and that was all, adding that he would like the space to be much bigger but there was not a bigger space. The administrator verified the measurements and agreed the curtain wrapped around the bed with no floor space to stand or move unless the resident was outside the curtained area. The DON also stated there was not enough room to move around privately and there was barely any floor to walk on inside the privacy curtain. The co-owner stated the facility was licensed for 17 beds, the rooms were tight, and the resident's personal space was much tighter than desired, and that usable square footage had not been taken into account.
Failure to Report Suspected Resident-to-Resident Abuse
Penalty
Summary
The facility failed to immediately report suspected resident-to-resident abuse to the state agency within two hours for two residents. One resident had intact cognition on a quarterly MDS and was diagnosed with anxiety and depression. Her progress notes did not show that her allegations of abuse by her roommate were reported to the state agency. She told staff that her roommate had been calling her names, threatening her, asking to fight her, and had taken her phone and thrown it into a neighbor’s yard. She also stated that the roommate’s yelling was triggering because of her PTSD from an abusive ex-partner. The other resident had intact cognition on admission MDS and was diagnosed with schizophrenia, with verbal behavioral symptoms directed toward others. She and the first resident shared a room. Progress notes documented that she took cigarettes from her roommate without permission, became verbally aggressive, used name-calling, and threatened to physically fight her. Additional notes described ongoing paranoid delusions, verbal aggression, death threats, profanity toward staff, and disparaging remarks toward her roommate about her critically ill mother, causing significant emotional distress. The DON stated the verbal altercations were not reported because she believed reporting was only required for physical or sexual abuse, and the facility’s abuse policy required allegations of abuse, serious bodily injury, or suspicion of a crime to be reported to the state agency within two hours.
Incomplete MDS Assessment for a Resident
Penalty
Summary
The facility failed to ensure a complete and comprehensive annual MDS was completed for one resident, R7. R7’s annual MDS showed that Section C for cognitive patterns was not assessed, including the Brief Interview for Mental Status and related items on mental status, memory, cognitive skills, and signs of delirium. Section D for mood was also not assessed, including the resident mood interview and staff assessment of mood, and Section F for preferences for customary routine and activities was not assessed, including the interview for daily and activity preferences and staff assessment of preferences. In addition, Section GG for functional abilities was largely not assessed, with the entire section dashed except for one item indicating the resident did not use a wheelchair and/or scooter. During interview, the IC-MDS stated the facility had transitioned from paper charts to an EHR at the beginning of the year and did not have a good process in place to ensure MDS assessments were completed and documented during that time. The IC-MDS stated there was poor implementation and poor staff training during the transition, and that many MDS assessment areas had been missed, including R7’s. The facility’s MDS Completion and Submission Timeframe policy identified the assessment coordinator or designee as responsible for submitting the MDS according to the RAI manual, but did not further describe the process for completing the MDS before submission.
Incomplete Quarterly MDS Assessments
Penalty
Summary
The facility failed to ensure that quarterly MDS assessments were completed in a thorough manner for 2 of 5 residents reviewed for assessment accuracy. The CMS RAI 3.0 User’s Manual was cited as requiring the full RAI process, including the MDS, CAA, and utilization guidelines, and describing quarterly assessments as non-comprehensive assessments completed every 92 days to monitor changes in resident status. The report also noted that Section C is used to assess cognitive patterns and Section D is used to address mood distress and social isolation, with specific methods and instructions provided for accurate coding. For one resident, the quarterly MDS indicated that the Brief Interview for Mental Status or Staff Assessment for Mental Status in Section C was not assessed, Section D was not assessed in its entirety, and Section GG functional ability items such as self-care and mobility were not assessed or were dashed. For the second resident, the quarterly MDS indicated that Section C cognitive pattern items were not assessed. During interview, the infection control preventionist/MDS coordinator stated the facility had recently transitioned from paper charts to an EHR, did not have a good process in place to ensure MDS assessments were completed and documented during the transition, and had poor implementation and poor staff training, resulting in many MDS assessment areas being missed. The facility’s MDS Completion and Submission Timeframe policy identified the assessment coordinator or designee as responsible for submitting the MDS according to the RAI manual, but did not further describe the process for completing the MDS before submission.
MDS Coding Errors for Diagnoses and Medications
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) was accurately coded for 2 of 5 residents reviewed. For one resident, the quarterly MDS did not indicate a diagnosis of non-Alzheimer's dementia in Section I: Active Diagnoses, even though the diagnosis report showed vascular dementia had been added and a provider note documented vascular dementia with some progression. For the other resident, the quarterly MDS incorrectly coded Section N - Medications as having 1 day of insulin injections during the review period, while the MAR showed the resident received a single dose of Trulicity and no insulin during the lookback period. During interview, the DON stated the resident did have dementia and related cognitive decline, but remained alert and oriented for some decisions. The IC-MDS stated she did not have a good understanding of Trulicity and mistakenly coded it as insulin, and she had not realized the other resident had a recent, active diagnosis of dementia that probably should have been added. The facility policy stated the assessment coordinator or designee was responsible for submitting the MDS according to the RAI manual.
Missed Quarterly Care Conferences and Lack of Interdisciplinary Review
Penalty
Summary
The facility failed to ensure timely person-centered care conferences for 3 of 3 residents reviewed, and failed to include periodic review and revision by an interdisciplinary team with the residents in decisions about their care. R2’s quarterly MDS showed intact cognition with a BIMS score of 15/15, and a later quarterly MDS indicated she was admitted to the facility, but the BIMS and staff assessment for mental status were not assessed. Her medical record showed the last care conference note was dated 8/21/25, and the administrator confirmed that was the most recent note available. R2 stated she did not recall being offered or attending a care conference in the last few months, and the DON stated she could not find documentation showing a care conference had been completed since last August. R4’s quarterly MDS identified intact cognition and independence with hygiene and dressing, with diagnoses including PTSD, borderline personality disorder, diabetes, and depression. Her EMR and paper chart contained no care conference notes matching her MDS cycles for 10/31/25, 12/10/25, and 2/2/26 since admission. R4 stated she had not been invited or involved in any care conference since admission. R6’s quarterly MDS identified intact cognition and diagnoses of depression with recurrent psychotic symptoms, diabetes, anxiety, and PTSD, but his EMR and paper chart contained no care conference note since admission. R6 stated he did not recall having an in-person care meeting or care conference to discuss his plan of care and discharge goals, and both the DON and MDS coordinator verified that R6’s quarterly care conference had not been done and that R4’s EMR lacked evidence of a care conference corresponding to the last MDS assessment. Facility policy stated all residents were to have a care conference hosted at minimum quarterly.
Failure to Provide Routine Dental Services
Penalty
Summary
The facility failed to provide routine dental services for 2 of 2 residents reviewed for dental care. One resident had a face sheet showing admission in 2020, an MDS identifying intact cognition, independence with personal and oral hygiene, and diagnoses including schizoaffective disorder, bipolar disorder, diabetes, anxiety, and epilepsy. The resident’s CAA noted obvious cavities, missing most of the upper teeth, and a dental care plan triggered by medications and unstable diabetes. The care plan identified a need for supervision to assistance with hygiene and included an intervention to coordinate dental care and transportation as needed, but the EMR and paper chart did not show when the resident was offered or provided a routine dental appointment. The second resident’s quarterly MDS identified intact cognition, independence with all hygiene, and diagnoses including diabetes, PTSD, depression, and borderline personality disorder. The resident’s CAA did not assess dental care planning, and the care plan only included general encouragement for good hygiene and oral care. During interview, the resident stated she had been at the facility for nearly two years and had never been offered or provided a routine dental appointment. Review of the EMR and paper chart also failed to show documentation of a routine dental appointment being offered or completed for this resident. The administrator and DON both verified the lack of documentation, and the DON stated there was no system to monitor or follow up on dental appointments and no documentation of refusals or where residents went for appointments.
Incomplete Daily Nurse Staffing Posting
Penalty
Summary
The facility failed to ensure the required nurse staffing information was posted daily and that it included required details such as the daily census and the total number of licensed nursing staff working. During observation and record review, the nurse staff posting was found in a hallway between the dining room and the kitchen on a bulletin board and contained columns for days of the week, shift, RN hours, LPN hours, and date, but it did not include the daily census or the total number of licensed staff working every shift. The posting showed incomplete information for Monday and Tuesday, and no hours were recorded for Wednesday or Thursday. The DON stated she oversaw the posting and usually waited until the end of the week, on Saturday, to complete it because staff call-ins could make it inaccurate, and she was not aware that census or the number of staff members had to be included. The facility policy dated 8/2022 stated the nurse staffing information would be posted daily at the beginning of each shift and would include resident census and the total number of licensed nurses.
Facility Lacks Registered Dietician, Affecting Nutritional Services
Penalty
Summary
The facility failed to employ a registered dietician or other qualified clinical nutrition professional to carry out the functions of a facility registered dietician, potentially affecting all 11 residents receiving food from the kitchen. Interviews revealed that the head cook, C-B, noted inconsistencies in menu adherence, with eggs not being served daily as planned, and other cooks not following the menu, complicating food ordering and usage. C-B also mentioned a lack of involvement from the registered dietician, who they believed had quit. The facility administrator and director of nursing, RN-A, acknowledged the absence of a dietician, stating that the newly hired dietician was not as involved as the previous one and that they were in the process of contracting a new dietician. Further interviews indicated that the facility was between dieticians, as the previous dietician had retired or resigned, with the last day being 5/31/24. RN-A confirmed that nursing staff completed nutritional assessments in the absence of a registered dietician, and C-B made menu changes as needed. The facility policy allowed for dietary orders to be delegated to a qualified dietitian under physician supervision, but this was not being followed due to the lack of a dietician. The certified physician assistant, CPA-B, stated they were not involved in nutritional assessments or diet orders, highlighting the gap in professional oversight in the facility's food and nutrition services.
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 1,153 citations issued within 25 miles in the last 12 months — including the 28 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) |
|---|---|---|---|---|
| Birchwood Care Home | 0.6 mi | ★★★★★ | 3 | 0 |
| Redeemer Health Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| The Estates At Chateau Llc | 0.9 mi | ★★★★★ | 2 | 1 |
| Benedictine Health Center Of Minneapolis | 1.3 mi | ★★★★★ | 11 | 0 |
| Lakehouse Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.