Below average — CMS composite of the measures below.
The next survey window likely opens around June 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 The Gardens At Winsted Llc during CMS and state inspections, most recent first.
A facility failed to answer resident call lights in a timely manner for multiple residents with significant care needs, including incontinence, toileting assistance, and transfer support. Logs showed repeated delays well beyond 30 minutes, with some responses lasting over an hour. Residents reported waiting for help with incontinent care and other needs, and staff stated call lights were expected to be answered within 8-10 minutes, while the DON acknowledged staff relied on hallway boards or the nurses’ station screen and that some call light boards were broken or not working properly.
Food storage and kitchen hygiene were not maintained. A walk-in freezer had a large ice buildup on the floor and on stored food boxes, and the dining room resident fridge/freezer contained ice, opened and undated food items, and food particles in the seals, shelves, and bottom. In the kitchen, a dietary aide had no beard cover or hair cover, and an NA entered without a hair net or hand hygiene before going into the cooler to get milk.
The DON/IP did not maintain oversight of the IC program for employee illness surveillance. Resident illness was tracked, but employee surveillance was not included in the IC documentation, and call-in records showed multiple employees with GI symptoms returning to work without documentation of symptom resolution or confirmation that return-to-work criteria were followed. The staffing coordinator and department managers handled call-ins, while the DON/IP stated she did not track employee illness and did not keep documentation of morning meetings.
Failure to complete and follow self-administration assessments for bedside meds. A resident with asthma had an inhaler kept at bedside even though the SAM eval said she no longer self-administered meds, and staff gave conflicting accounts about the assessment. Another resident with TBI, DM, and asthma had tablets/capsules repeatedly left at bedside despite updated SAM findings that only certain meds could remain there and other meds were to be administered by nursing, with no matching provider communication or care plan update. A third resident with hepatic encephalopathy, HF, and DM had nasal spray at bedside even though the SAM eval said she was not reliably safe to self-administer and no bedside-med order was shown.
Failure to Accommodate Resident Sensitivity to Scents: A cognitively intact resident with diabetes, HF, asthma, allergies, and multiple scent intolerances reported that fragrances and chemicals in the shower room kept her from getting scheduled showers, and she said she had gone up to 3 weeks at times without bathing. Staff acknowledged she was very sensitive to odors, wore an N-95 mask often, and had a scent-free room sign posted, while the RN mgr said the facility had only once arranged for her to have the first shower of the day.
Use of Handcuffs as a Physical Restraint Without a Medical Symptom: A resident with diagnoses including AAA without rupture and DM was placed on a care plan that incorporated law enforcement handcuffs because of criminal history and jail-related supervision needs. The order allowed handcuffs as needed for safety, but it did not identify a medical symptom for restraint use. Staff interviews showed conflicting directions about when handcuffs were required, who could apply or remove them, and whether the resident was to be handcuffed when the guard briefly left the room.
PRN psychotropic medication orders for a resident with emphysema, depression, panic disorder, PTSD, and anxiety lacked stop dates, specific durations, and documented prescriber rationale for use beyond 14 days. The resident had orders for olanzapine, trazodone, and hydroxyzine PRN, and RN and DON interviews confirmed the orders did not include required end dates per facility policy.
A facility failed to keep discontinued controlled meds separate from in-use meds when a deceased resident’s lorazepam tablets, lorazepam liquid, and hydromorphone liquid were found in the South Hall medication cart narcotic cabinet. The RN said the meds stayed in the locked narcotic drawer until two licensed nurses had time to destroy and log them, and the DON confirmed they should have been counted, documented in the narcotic log, removed from the cart, and stored in a secure double-locked area.
A facility failed to provide enough nursing staff to meet residents’ needs, resulting in repeated delayed call light responses for multiple residents with needs including toileting, transfers, CHF, diabetes, renal failure, and cognitive impairment. Residents reported waiting 30 minutes to more than an hour for help, including one resident who waited about an hour while short of breath, and another who said she sometimes had to sit in her own waste. Call light logs confirmed prolonged response times on day, evening, and night shifts, while staff reported short staffing, rushed care, and only a few NAs covering the building at times.
A resident with respiratory failure with hypoxia, a stage 3 pressure ulcer to the spine, and a colostomy/ileostomy had weekly skin check tasks marked complete in the TAR, but the record lacked corresponding skin assessment documentation. An RN said she checked off the task without completing the assessment and passed it to the next shift, an LPN did not recall completing the assessment, and the DON confirmed supporting documentation was missing.
The facility failed to complete a facility-wide assessment with active input from direct care staff and did not include unit-by-unit or shift-by-shift staffing needs, a plan to recruit and retain direct care staff, or contingency planning for staffing/resource shortages. Interviews and records showed repeated long call light waits, staffing cuts tied to census, and residents, family members, NAs, and an RN reporting delays, incontinence while waiting, and concerns that staffing was not enough to meet resident needs.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A deficiency was cited when a resident's care plan did not address all identified needs and lacked measurable timetables and specific actions, resulting in incomplete planning and documentation.
Surveyors found that a resident did not receive appropriate care for bowel/bladder continence or incontinence, catheter management, and UTI prevention. The care provided did not meet required standards, resulting in a deficiency.
A resident with paraplegia and no cognitive impairment reported that a nursing assistant inserted a finger into her anus during care, which she found painful and distressing. The allegation was not reported to the charge nurse or State Agency within the required two-hour window, despite staff being aware of the reporting policy.
A resident reported a painful and upsetting incident involving a contracted NA during care, where the NA inserted a finger into the resident's anus. Investigation revealed that the contracted NA had not received the facility's required abuse training, including education on sexual abuse and reporting requirements. The facility's policy did not address how contracted staff would be included in abuse prevention training, and documentation from the agency lacked evidence of sexual abuse education.
A resident with severe cognitive impairment and an indwelling catheter received personal care from a CNA who failed to change gloves or perform hand hygiene between multiple care tasks, despite facility policy and enhanced barrier precautions. The CNA also handled personal items and equipment with contaminated gloves. Additionally, the facility did not track or trend symptoms of illness for residents not on antibiotics, as infection logs only included cases treated with antibiotics and did not document other types of illnesses.
Two residents' rooms had persistent, strong odors due to limited staff access for personal care and cleaning, as both individuals often refused assistance and housekeeping. Despite care plans indicating the need for staff support, the odors continued to permeate surrounding areas. Additionally, a resident's missing clothing item was not thoroughly investigated or tracked, as facility staff were unaware of the established policy and did not consistently follow the grievance process.
Two residents reported during Resident Council that mail was not delivered to them on Saturdays, and staff confirmed that mail was only collected and distributed on Mondays due to the absence of a receptionist and lack of a policy. The post office verified that mail was delivered to the facility on Saturdays, but the facility failed to ensure timely distribution, affecting all residents.
Surveyors found that the facility did not consistently identify or address residents' individual activity preferences, failed to develop or update resident-specific activity care plans, and did not coordinate or document activities of interest. Several residents reported boredom and a lack of meaningful activities, with activity calendars lacking variety and scheduled weekend or evening options. Staff confirmed that activity records were incomplete and that some activities listed were not actually provided.
A resident with chronic pain and multiple diagnoses was found with several OTC medications at bedside without a complete self-administration of medications (SAM) assessment or provider orders for each medication. While the care plan and assessment addressed only one of the bedside medications, the facility failed to follow its policy requiring individual SAM evaluations and orders for all medications kept at bedside.
Residents repeatedly voiced concerns about limited activities and lack of follow-up on their requests during council meetings. Despite ongoing grievances related to Therapeutic Recreation, such as requests for more crafts, games, and the return of popular programs, the facility did not provide feedback or resolutions. Activity calendars showed minimal offerings, and no policies for program development or council grievance follow-up were available.
A resident filed multiple grievances over several months, but the facility failed to consistently follow up, document, and resolve these complaints as required by policy. Some grievances lacked any documented resolution or follow-up, and the process for timely investigation and communication of outcomes was not adhered to, as confirmed by staff interviews.
A resident with severe cognitive impairment and multiple medical conditions was enrolled in hospice, but the facility failed to integrate the hospice plan of care with its own care plan. The facility's documentation did not specify the hospice services provided or include the hospice plan of care, leaving staff without necessary reference information, despite requirements outlined in the hospice agreement.
A resident with end stage renal disease and other comorbidities did not consistently receive Midodrine at the correct time before dialysis due to unclear medication orders and inconsistent communication between facility staff and the dialysis center. Required documentation was missing for some dialysis sessions, and staff were unclear about the timing of medication administration, leading to deviations from the dialysis center's instructions.
A resident who had previously received PPSV23 and PCV13 vaccines had a physician order for PCV20, but the vaccine was not administered despite being available and consented. Review of the MAR showed no documentation of administration, and staff confirmed the immunization was not given as required by facility policy.
A resident with cognitive impairment and elopement risk did not have consistent or clearly documented monitoring of their Wanderguard device, with staff unclear on procedures and missing manufacturer guidance. Another resident was observed using e-cigarettes in their room despite policy requiring use only in designated areas, and staff did not effectively enforce this rule. Additionally, a resident with dysphagia and a modified diet was left unsupervised in the dining room while eating, including being served food not prepared according to dietary orders, contrary to facility policy requiring supervision during meals.
Two residents with significant medical and behavioral health needs experienced persistent room odors that permeated surrounding areas, with no documented social services interventions or evidence that social workers addressed or were aware of the issue. Both residents were cognitively intact and had care plans noting behavioral and psychosocial risks, but progress notes and care conferences failed to address the odor concerns.
The facility did not ensure that required survey results and complaint investigation documentation, including CMS 2567 forms for complaint investigations and revisits, were available for review. Interviews confirmed staff were aware of the posting requirements, but the necessary documents were missing from the survey binder, and no policy for posting survey results was in place.
A resident with multiple chronic conditions and a wound requiring daily care did not receive proper Enhanced Barrier Precautions (EBP) during a wound care procedure, as the DON failed to wear a gown as required by physician orders and the care plan. The DON acknowledged the omission, and the facility could not provide an EBP policy when requested.
The facility failed to maintain cleanliness in a resident's room and the dining room, affecting the living environment. Brownish stains, soiled tissues, and uncleaned plates were found in the dining room, and a housekeeper cleaned without gloves and did not wash hands. A white powder-like substance was also found in a resident's room, which was not cleaned promptly. The DON expected these areas to be cleaned before and after meals, as per facility policy.
The facility failed to ensure proper use of PPE and EBP for residents with Foley catheters, leading to infection control deficiencies. A resident with a urinary tract infection lacked EBP signage, and staff did not wear gowns and gloves during high-contact care. Another resident with a bladder disorder had EBP signage, but staff were observed not using PPE. A third resident with acute kidney failure also lacked EBP signage, and staff failed to use PPE during care activities.
A facility failed to communicate a resident's medication orders to the pharmacy, resulting in delayed delivery. The resident, with multiple health conditions, missed doses of critical medications, including insulin, due to ineffective use of the E-Kit by pool staff. The pharmacy received incomplete orders, and the facility's policy for handling missing medications was not adequately communicated to temporary staff.
A resident with severe cognitive impairment and multiple medical conditions was hospitalized due to an infected ulcer. The facility failed to notify the resident's representative of changes in the resident's condition and treatment, including new orders for antibiotics and pain medications. Interviews revealed that staff did not consistently communicate these changes, despite facility policy requiring notification of the resident's representative.
A resident with severe cognitive impairment and multiple medical conditions developed worsening pressure ulcers due to inadequate monitoring and documentation by the facility. Despite having a care plan, staff failed to consistently document wound conditions, leading to a lack of communication and the resident's hospitalization for sepsis from an infected wound.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure residents’ call lights were answered in a timely manner for 5 of 6 residents reviewed for call light response times. The deficiency involved prolonged waits for assistance, with multiple documented response times exceeding 30 minutes and several lasting well over an hour. The facility’s call light policy stated that call lights must relay the call to staff at a centralized location such as the nurses’ station, but it did not address how quickly calls had to be answered. R4 was cognitively intact, had chronic respiratory failure, heart failure, and anxiety disorder, and was dependent on staff for dressing, transfers, and toileting. R4 used a wheelchair, had lower extremity impairment on both sides, and was frequently incontinent. R4 stated concern about long call light times, and the call light logs showed repeated delays, including response times of 44, 68, 61, 70, 77, 92, and other minutes over the review period. Nursing assistant C stated R4 used the call light frequently and required 2 staff with a mechanical lift for transfers. R6 was cognitively intact, required staff assistance with toileting, had an indwelling catheter, and was incontinent of bowel. Diagnoses included Crohn’s disease, urinary tract infection, muscle weakness, chronic pain, neuromuscular dysfunction of the bladder, and neurogenic bowel. R6 stated the call light had been on for up to an hour while waiting for incontinent care and said she ended up sitting in bowel movement for extended periods, resulting in bladder infections. R13 was cognitively intact, had hip fracture, traumatic brain injury, and depression, used a wheelchair, required transfer assistance, and was frequently incontinent; she stated she was concerned about long call light times and did not want to be incontinent. R20 was cognitively intact and needed assistance with ADLs; an odor of urine was noted in the room and a bedpan was on the floor under the bed, and R20 stated there were several times the call light was on for over half an hour. R38 had bladder and bowel elimination issues, including urge incontinence, and stated he had waited half an hour or more and had been left sitting in urine-soaked sheets while waiting for staff to answer the call light.
Food Storage and Kitchen Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain the walk-in freezer in a clean and safe condition. During observation, a large accumulation of ice was seen on the freezer floor at the end of the shelving on the right side, measuring about 18 inches high with a base of about 3 feet by 2 feet. A separate chunk of ice was resting on top of a box, and another box in the corner had a coating of ice on the top and side. The head cook stated the ice accumulation was not present the last time he had worked, and the regional culinary director stated the ice mound should have been taken care of long before because someone could slip and the food could be affected. He also stated it likely took about three to four months for the ice to reach that size. The facility also failed to maintain the dining room resident refrigerator/freezer and to ensure kitchen staff followed hand hygiene and hair covering requirements. The resident freezer compartment had about a 1/2-inch layer of ice, opened and undated food items, and food particles on the shelves, bottom, door seal, and hinge area. The refrigerator section contained opened and undated items, including sour cream dip, pickles, and a paper bag with a sandwich and fries, along with spilled food particles and a black granular substance in the seal and hinge area. In the kitchen, a dietary aide with a full beard had no facial hair cover and no hair cover, and a nursing assistant entered the kitchen with a long ponytail, no hair net, and did not perform hand hygiene before entering or retrieving milk from the walk-in cooler. The dietary manager stated unauthorized staff walking into the kitchen had been an ongoing issue.
Infection Preventionist Lacked Oversight of Employee Illness Surveillance
Penalty
Summary
The facility failed to ensure the infection preventionist, who was also the director of nursing, had appropriate oversight of the infection control program, including employee surveillance for all employees. Review of the infection control surveillance documents showed resident illness surveillance was being tracked, but employee surveillance was not included in the documentation. During interview, the DON/infection preventionist stated she had nothing to do with tracking or managing employee illness and that employee illness was tracked by the human resources/scheduling coordinator. She also stated employee call-ins were discussed in morning meetings, but she did not maintain documentation of those meetings. Review of staff call-in forms showed multiple employees reported gastrointestinal symptoms and returned to work without documentation showing symptom resolution or that infection control return-to-work criteria had been followed. A nursing assistant reported diarrhea, another nursing assistant reported nausea, a cook reported vomiting and returned to dietary work the next day, and a dietary aide reported nausea and returned the next day. The staffing coordinator stated call-in forms were kept in her scheduling binder and that she primarily handled nursing staff, while department managers handled their own staff call-ins for other departments. The dietary manager stated he had followed the posted policy requiring employees to wait 24 hours after their last symptom before returning to work, and he identified that one cook returned before that time frame. The Infection Preventionist job description and the facility's infection prevention and control policy identified the IP as responsible for oversight of infection surveillance, including monitoring employee infections and coordinating the program.
Failure to complete and follow self-administration assessments for bedside medications
Penalty
Summary
The facility failed to ensure a self-administration of medications assessment was completed for all medications kept at bedside for 3 residents who were observed with medications within reach or at the bedside. One resident with respiratory failure, chronic pain, anxiety, and asthma had an order allowing inhaler self-administration at bedside after nursing assessment, but the self-administration evaluation stated she no longer self-administered medications or creams. Despite that, her Ventolin inhaler was observed on the overbed table next to her bed on two separate observations, and staff gave conflicting statements about whether the inhaler was still kept at bedside and who completed the assessment. A second resident with TBI, diabetes, and asthma had medications repeatedly observed on the bedside table, including a cup with tablets/capsules while she was in and out of the room, and she stated medications had been left at bedside for at least 6 months. Her records showed orders allowing some medications to be left at bedside after nursing setup, but the updated self-administration evaluation indicating only certain medications could remain at bedside and that other medications were to be administered by nursing had not been communicated to the provider, and the orders and care plan were not updated to match the evaluation. A third resident with hepatic encephalopathy, heart failure, and diabetes had fluticasone nasal spray observed at bedside even though the self-administration evaluation stated she was not reliably safe to self-administer medications and did not indicate any medications could be kept at bedside; the MAR also did not show any order for self-administration or bedside medications.
Failure to Accommodate Resident Sensitivity to Scents
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of a resident with multiple allergies and sensitivities to environmental scents. The resident’s quarterly MDS indicated she was cognitively intact and had diagnoses including diabetes, heart failure, asthma, and allergies. Her care plan noted multiple allergies and intolerances, including allergies to different scents, and that she required assistance of one with bathing. The resident stated she used an N-95 mask for scent blockage, did not participate in activities because of allergies, and did not receive her scheduled shower because of chemicals and fragrances used in the shower room. She reported that she had gone up to three weeks a couple of times without showers. During interviews, staff acknowledged the resident was very sensitive to smells and wore a mask often. One NA stated the resident required supervision with showers and was very sensitive to scents or odors. Environmental services stated the facility took residents’ sensitivity to chemical smells seriously, that the resident had a scent-free sign on her door, and that staff followed posted restrictions. The RN manager stated the facility had made arrangements one time for the resident to be offered the first shower of the day, but the resident had not requested that again. The facility’s Employee Handbook stated scents must be limited and barely perceptible in recognition of resident sensitivities and allergies.
Use of Handcuffs as a Physical Restraint Without a Medical Symptom
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraints that were not required to treat a medical symptom when it incorporated the use of law enforcement handcuffs into the resident’s care plan. The resident was admitted with diagnoses including abdominal aortic aneurysm without rupture and diabetes. The care plan, initiated after admission, stated that a physical restraint was deemed necessary by county policy because of the resident’s criminal history, that corrections staff would remain in the room or observe the resident at all times, and that the resident would be handcuffed if security left the room. The care plan also stated staff would place and remove handcuffs as needed. The informed consent identified handcuffs as the restraint when the resident was not in view of the security guard due to the need for 24-hour supervision related to admission to the hospital and SNF from jail. The order summary report included an order allowing handcuffs to be applied as needed for safety every shift, but it did not identify a medical symptom that warranted restraint use. During interviews, staff described that the resident was to be handcuffed to a shower chair or bed when the guard left the room, while the correctional officer stated he had been told handcuffing was not necessary if he briefly stepped away. The DON stated the resident was to be handcuffed to the bed whenever the guard left the room, that skin assessments related to the handcuffs were to be completed, and that only guards were to apply or remove the handcuffs. The administrator stated the resident was handcuffed whenever the guard stepped away and that facility staff could remove the handcuffs in an emergency. Facility policy regarding physical restraints was requested but not provided.
PRN psychotropic orders lacked required stop dates
Penalty
Summary
The facility failed to ensure a resident was free from unnecessary psychotropic medications by allowing PRN psychotropic orders to remain active without required stop dates, specific durations, or documented prescriber rationale for extending use beyond 14 days. The resident reviewed, R20, was cognitively intact and needed staff assistance with ADLs. R20’s diagnoses included emphysema, major depression, panic disorder, PTSD, and anxiety. R20’s physician orders included olanzapine 5 mg by mouth every 12 hours PRN for anxiety, trazodone 25 mg every 24 hours PRN for insomnia, and hydroxyzine 50 mg every 6 hours PRN for anxiety, all initiated on 7/2/26. The orders dated 7/8/26 did not include stop dates, specific durations, or documented rationale for continuing the PRN psychotropic medications beyond 14 days. RN-C confirmed the orders lacked end dates, and the DON stated nurses were expected to contact the provider to obtain an end date when PRN psychotropic medication orders were received. The facility’s Psychotropic Medication Use policy stated PRN psychotropic medications were limited to 14 days unless the physician identified the rationale to extend them beyond 14 days.
Discontinued Controlled Medications Left in Narcotic Cabinet With Active Medications
Penalty
Summary
The facility failed to ensure discontinued controlled narcotic medications for a resident who had died remained separated from in-use medications. During an observation of the South Hall medication cart narcotic cabinet, three medications identified for the deceased resident were found stored in the cabinet with current medications. The medications included lorazepam tablets, lorazepam liquid, and hydromorphone liquid, with remaining quantities still present in each container. During interview, the RN stated the controlled medications were kept in the locked narcotic drawer on medication carts until two licensed nurses had time to destroy and log them, and said she was unaware discontinued controlled medications were not to be stored with in-use medications. The DON confirmed the resident had died in the facility and stated the medications should have been counted, documented in the narcotic log, removed from the narcotic cabinet on the medication cart, and stored in a secure, double-locked area until two licensed nurses could destroy them. A policy on management of controlled discontinued medications was requested but not provided.
Delayed Call Light Responses Due to Insufficient Nursing Staffing
Penalty
Summary
The facility failed to ensure there were a sufficient number of nursing personnel to provide care and respond to residents’ basic needs, resulting in delayed call light responses for multiple residents. Residents reported waiting 30 minutes to more than an hour for assistance after activating call lights, and several stated they avoided using the call light unless absolutely necessary because of the delays. The report identified affected residents as having diagnoses and care needs including CHF, hypertension, diabetes mellitus, renal failure, hip fracture, traumatic brain injury, diuretic use, and assistance needs for toileting and transfers. Resident interviews described repeated delays and unmet needs. One resident reported waiting about an hour for staff when experiencing SOB and said a nurse brought an inhaler rather than oxygen. Another resident stated call lights were often unanswered for 45 minutes or more and that staff were short-staffed and unfamiliar with resident needs. Other residents reported call light waits ranging from 30 minutes to 1 hour 42 minutes, including times when they had to sit in their own waste while waiting for help. Facility call light logs confirmed multiple delayed responses across day, evening, and night shifts. Staff interviews supported the staffing concerns. An NA stated there were times when only two NAs were covering the whole facility and that call lights had to wait when staff were assisting another resident. Another NA said a reasonable response time should be 5 to 10 minutes but that multiple simultaneous needs caused extended waits. An RN stated she never got time to complete nursing tasks because of workload and staffing levels, and the DON stated staff were expected to answer call lights immediately or within a reasonable timeframe. The facility did not provide a requested call light audit or policy, and its ad hoc QAPI document identified issues related to reducing call lights and wait times.
Incomplete documentation of weekly skin assessments
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with respiratory failure with hypoxia, a stage 3 pressure ulcer to the spine, and a colostomy/ileostomy. The resident’s order summary included a weekly skin inspection order by a licensed nurse every Monday on day shift. Review of the March and April 2026 TAR showed weekly skin check tasks were marked completed on 3/16/26, 3/23/26, and 4/13/26, but there was no corresponding skin assessment documentation in the record to show the assessments were actually completed. During interview, an RN stated she cared for the resident on the evening shift of 3/23/26, checked off the skin assessment task in the TAR, but did not complete the skin assessment and verbally passed the task to the night shift because she was behind on medication administration. An LPN stated he cared for the resident on 3/16/26 but did not recall completing a skin assessment, and said a completed TAR task should have matching skin assessment documentation. The DON stated that when a licensed nurse checked off a weekly skin check, supporting documentation identifying the presence or absence of impaired skin integrity was also required, but documentation could not be located for the resident’s skin assessments on 3/23/26 and 4/13/26.
Facility Assessment Lacked Required Staffing Input and Planning
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that included the required components for competent resident care during day-to-day operations and emergencies. The assessment dated 7/22/24 did not show active involvement from direct care staff, including RNs, LPNs, and NAs. Instead, the document listed involvement from the administrator, DON, Governing Body representative, medical director, pharmacist, and residents or resident representatives/family members through letters, family council, and resident council. The assessment also failed to consider staffing needs for each unit and each shift in the facility. Although the document stated acuity needs were reviewed through resident assessments, care plans, and census, and that staffing needs were determined by resident population, CMI, census, admissions, and discharges, it did not include a unit-by-unit or shift-by-shift staffing analysis. The assessment also lacked a plan to recruit and retain direct care staff and did not include contingency planning for events that did not require activation of the emergency plan but could affect resident care, such as availability of direct care nurse staffing or other resources. Facility records and interviews showed ongoing staffing concerns and delayed call light response times. Daily schedules from 7/15/25 through 8/14/25 showed nurses and TMAs on the north and south units and NAs assigned to specific room groups with a float aide, while call light records for four residents showed 115 waits over 20 minutes, 28 over 30 minutes, 50 over 40 minutes, 3 over 50 minutes, 4 over 60 minutes, 2 over 70 minutes, 2 over 80 minutes, 1 over 90 minutes, and 1 over 120 minutes. Residents, family members, NAs, and an RN reported long waits, incontinence while waiting for assistance, and staffing being cut due to empty beds, including one NA leaving early at 9:00 p.m. The SC stated staffing was being cut to meet labor and census, and the DON and administrator stated call lights should be answered within 15 minutes, while the administrator also stated the facility assessment was to be completed annually and the facility lacked a policy for the assessment.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the facility's failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care requirements. This deficiency was based on observations and review of the care planning process, which did not meet regulatory standards for comprehensive and measurable care planning.
Deficient Bowel/Bladder and Catheter Care Leading to UTI Risk
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder, as well as the management of catheter care and the prevention of urinary tract infections (UTIs). Surveyors found that appropriate care was not consistently provided to residents in these areas. Specific failures included inadequate attention to the needs of residents with continence or incontinence issues, improper catheter care, and insufficient measures to prevent UTIs. These deficiencies were observed through direct surveyor findings, indicating lapses in the standard of care required for residents' bowel and bladder management, catheter maintenance, and infection prevention.
Failure to Timely Report Alleged Sexual Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the State Agency (SA) within the required two-hour timeframe. A cognitively intact resident with paraplegia, neurogenic bowel, and major depressive disorder reported that, during assistance with a brief change, a nursing assistant inserted a finger into her anus in a manner the resident described as painful and upsetting. The resident reported the incident to a nursing assistant, who delayed reporting the allegation to the charge nurse, citing that no other nurse was available at the time. The nursing assistant eventually reported the allegation to the registered nurse at approximately 8:30 a.m., who then spoke with the resident and subsequently reported the incident to the administrator and the SA. Interviews and document review revealed that staff were aware of the expectation to report abuse allegations immediately to the charge nurse and to the SA within two hours, as outlined in the facility's policy. Despite this, there was a delay in reporting the incident, as the allegation was not communicated to the appropriate personnel and the SA within the required timeframe. The deficiency was identified for one of three residents reviewed for abuse reporting.
Failure to Train Contracted Staff on Facility Abuse Policy and Sexual Abuse Reporting
Penalty
Summary
The facility failed to ensure that contracted agency staff received training on the facility's abuse policy and annual abuse training, which had the potential to affect all 37 residents. A resident reported an incident involving a contracted nursing assistant (NA) who, during care, inserted a finger into the resident's anus, which the resident described as painful and upsetting. The incident was reported to a registered nurse, and subsequent review of the contracted NA's training records revealed that while the agency provided some abuse training, it did not include education on sexual abuse or the facility's specific reporting requirements. The NA confirmed that he had not received any abuse training from the facility itself, only from his agency, and that his last agency training was several months prior. Further review of the facility's policies indicated that orientation and annual in-service training on abuse and reporting were required for all new employees, but there was no evidence or process to ensure that contracted staff were included in this training. The facility's policy did not specify how contracted staff would be trained or who was responsible for ensuring their compliance with abuse prevention and reporting education. Documentation from the contracted agency also lacked evidence of sexual abuse training and did not meet the facility's requirements.
Failure to Perform Hand Hygiene and Track Non-Antibiotic Illnesses
Penalty
Summary
The facility failed to ensure proper hand hygiene and glove changes during personal care for a resident with enhanced barrier precautions due to an indwelling catheter. During an observed care episode, a certified nursing assistant (CNA) donned gloves and a gown before entering the resident's room and proceeded to provide a range of personal care activities, including washing, dressing, pericare, and catheter care, without changing gloves or performing hand hygiene between tasks. The CNA also touched personal items, used a walkie talkie, and handled objects in the room while wearing the same gloves, only removing them at the end of the care episode. Interviews with the CNA and supervisory staff confirmed that gloves were not changed unless visibly soiled, and hand hygiene was not performed as required by facility policy and standard infection control practices. The resident involved had significant cognitive impairment and was dependent on staff for activities of daily living. The care plan specified the use of enhanced barrier precautions and outlined the need for staff to don and doff personal protective equipment appropriately and to perform hand hygiene during care. Despite these directives, the observed care did not follow the expected sequence of clean-to-dirty care, nor did it include necessary glove changes and hand hygiene at appropriate intervals, as confirmed by both the CNA and the director of nursing (DON) during interviews. Additionally, the facility did not have a system in place to track and trend symptoms of illness among residents who were not on antibiotics. Review of infection control logs revealed that only infections treated with antibiotics were recorded, with no documentation or tracking of viral, fungal, or other illnesses not requiring antibiotic therapy. The infection prevention and control policy referenced surveillance tools for recognizing infections and spotting trends, but did not address the need to track symptoms or illnesses that did not result in antibiotic use. Interviews with the DON confirmed that symptom tracking for potential infections not requiring antibiotics was not maintained in a spreadsheet or log, and infection logs were only completed for identified infections at the end of each month.
Failure to Maintain Odor-Free Environment and Properly Investigate Missing Personal Items
Penalty
Summary
The facility failed to ensure that resident living areas were free from persistent odors, specifically in the rooms of two residents. One resident, with diagnoses including morbid obesity and diabetes, was noted to have a strong, foul odor emanating from his room on multiple occasions. Despite being cognitively intact and generally independent with self-care, this resident often refused staff assistance with personal hygiene, particularly with pericare and cleaning of abdominal folds, which contributed to the ongoing odor. Staff interviews confirmed that the resident's room had a persistent odor, and housekeeping efforts, including deep cleaning and use of odor-blocking products, only temporarily alleviated the issue. The care plan indicated staff were to assist with personal hygiene, but the resident's refusals limited their ability to do so. Another resident, diagnosed with neuromuscular dysfunction of the bladder, spina bifida with hydrocephalus, and morbid obesity, also had a room with a strong urine odor that extended into adjacent areas. This resident, while cognitively intact, required supervision and some assistance with ADLs but often refused staff and housekeeping entry, preferring to manage personal care independently. Staff interviews revealed that the odor had been present for a long time, and the resident's reluctance to allow cleaning or assistance contributed to the problem. The care plan specified assistance with personal hygiene and elimination, but the resident's refusals limited staff intervention, resulting in persistent odors. Additionally, the facility failed to fully investigate and track missing personal items for a resident who reported a missing clothing item for approximately two months. The resident, who was alert and oriented, reported the missing item to housekeeping, but the facility's follow-up was inconsistent. The housekeeping director was initially unaware of the missing item and lacked knowledge of the facility's tracking system and policy for lost items. Although a policy and grievance process existed, it was not consistently followed, and there was no established tracking log in use. The facility's grievance log showed other missing items, some of which were replaced, but the process for investigating and resolving missing items was not systematically implemented.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure that residents received their mail on Saturdays, as required, affecting all 37 residents. During a Resident Council meeting, two residents reported that mail was not delivered to them on Saturdays, and this concern was confirmed by other residents. The mail was delivered by the post office to a locked box outside the facility, but it was not distributed to residents until Monday, as the key was secured and the receptionist position responsible for mail delivery was vacant. The business office manager confirmed that mail was only collected and distributed on Mondays, and there was no current policy addressing Saturday mail delivery. Interviews with facility staff, including the interim administrator and corporate nurse, revealed a lack of awareness regarding the requirement for Saturday mail delivery. The facility initially believed that Saturday delivery was at the discretion of the community, but confirmation from the local Post Master established that mail was indeed delivered to the facility on Saturdays. Despite this, the facility did not provide any additional information or a policy regarding Saturday mail delivery, resulting in a failure to provide residents with reasonable access to their mail.
Failure to Individualize and Document Resident Activity Programs
Penalty
Summary
The facility failed to identify and address the personal activity preferences of all residents reviewed for activities, resulting in a lack of individualized activity care planning and coordination. For five residents, care plans either did not reflect their current interests or lacked evidence of implementation of interventions targeting their stated preferences. Documentation was inconsistent or missing, with activity attendance records not found in the electronic medical record and only handwritten records available upon request. In several cases, residents' care plans listed interests such as crafts, cards/games, and reading, but there was no documentation of participation in these activities, nor evidence that staff facilitated or supported these interests. Residents interviewed expressed dissatisfaction with the activity program, noting a lack of variety, insufficient weekend and evening activities, and limited options beyond watching TV or playing Bingo. Some residents specifically requested additional activities such as exercise or newspaper readings, which were not reflected in the activity calendar or care plans. The activity calendars reviewed lacked scheduled weekend activities, with only 'Independent Leisure' noted, and did not include certain activities that residents had expressed interest in, such as crafts or outings. The activities director confirmed that some activities listed on the calendar, such as virtual reality sessions, were no longer being offered despite being advertised, and that documentation of one-to-one visits and activity participation was not consistently entered into the electronic medical record. For one resident, there was no activity plan of care created at all, despite documented interests in painting, music, and outings. Staff interviews revealed that activity calendars were often copied from previous months with little variety, and that some activities were not communicated to residents in advance or included on the calendar. The facility did not have a policy for activity program development and implementation available for review. These findings demonstrate a systemic failure to assess, plan, and document activities in accordance with residents' individual needs and preferences.
Failure to Complete Self-Administration Assessment and Orders for Bedside Medications
Penalty
Summary
The facility failed to ensure that a complete self-administration of medications (SAM) assessment was performed and appropriate orders were obtained for all medications kept at bedside for one resident. The resident, who was alert, oriented, and largely independent in activities of daily living, was observed with three bottles of over-the-counter (OTC) medications at her bedside, including Hair, Skin, and Nail Vitamins, Elderberry Gummies, and Glucosamine/Chondroitin and MSM supplement. While the care plan and medical record documented a SAM assessment for elderberry chews, there was no assessment or provider order for the other OTC medications at bedside. The care plan directed staff to monitor bedside medication usage and assess the resident's capability to self-administer, but this was only documented for the elderberry chews. The resident had a complex medical history, including chronic pain, osteoporosis, and a recent femur fracture, and was receiving multiple prescribed medications for pain management. The DON confirmed that she was unaware of the additional medications at bedside and acknowledged that each medication kept at bedside required a separate SAM assessment and provider order, as per facility policy. The facility's policy required interdisciplinary team determination and documentation for safe self-administration, with periodic reassessment, but this process was not followed for all medications observed at the resident's bedside.
Failure to Address Resident Council Concerns Regarding Activities
Penalty
Summary
The facility failed to address and resolve concerns raised by residents during resident council meetings in a timely manner. Over several months, meeting minutes documented repeated requests and grievances related to Therapeutic Recreation, including requests for more activities, crafts, games, and the reinstatement of previously offered programs such as Bingocize and exercise sessions. Residents also requested daily newspaper readings and more weekend activities. Despite these ongoing concerns, there was no evidence that the facility provided feedback or resolutions to the residents regarding their requests. Additionally, the activity calendars for March and April showed limited offerings, with several days listing only 'Independent Leisure' and minimal craft activities. During a resident council meeting held during the survey, multiple residents confirmed that their grievances and recommendations had not been addressed or communicated back to them. The facility was unable to provide policies for Therapeutic Program Development or for managing and following through on resident council grievances and recommendations. The lack of documented follow-up and absence of relevant policies contributed to the deficiency, affecting all residents who participated in the council meetings over the past two months.
Failure to Follow Up and Resolve Resident Grievances
Penalty
Summary
The facility failed to follow up and resolve grievances for a resident who had filed multiple complaints over a specified period. Documentation showed that while some grievances had resolution forms completed, there was a lack of follow-through, particularly when the resident indicated dissatisfaction with the outcome. For several grievances, there was no documentation of resolution or follow-up, and some issues were not addressed at all, despite being logged. The facility's grievance log and forms revealed gaps in timely investigation and communication of outcomes to the resident, as required by facility policy. Interviews confirmed that the process for handling grievances was not consistently followed, with the corporate licensed social worker acknowledging that grievances had not been addressed in a timely manner and that some had not been addressed at all. Facility policies required prompt investigation and communication of grievance outcomes, but these procedures were not adhered to, resulting in unresolved concerns and incomplete documentation for several grievances filed by the resident.
Failure to Integrate Hospice Plan of Care with Facility Care Plan
Penalty
Summary
The facility failed to ensure that the hospice plan of care was integrated with the facility care plan for a resident receiving hospice services. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was enrolled in hospice with multiple diagnoses including anemia, hypertension, arthritis, neuropathy, and urinary retention. The facility's care plan noted the resident was on hospice but did not specify what hospice services were being provided or include the hospice plan of care or visit schedule for staff reference. The medical record lacked this essential information, and staff interviews confirmed that the hospice care plan could not be located in the designated binder or within the electronic care plan system. Further review revealed that the hospice nurse described a detailed hospice service plan, including nursing and aide visits, as well as monthly therapy and support services, but this information was not reflected in the facility's documentation. The director of nursing and corporate nurse acknowledged that the hospice care plan was not available as required for staff reference. The facility's agreement with the hospice provider specified that the hospice plan of care should be established, maintained, and accessible, including details on services, frequency, and measurable outcomes, but this was not implemented in practice for the resident in question.
Failure to Ensure Timely and Accurate Dialysis Medication Administration and Communication
Penalty
Summary
The facility failed to consistently communicate with the dialysis department and follow through on specific medication administration instructions for a resident requiring dialysis. The resident, who was cognitively intact and had diagnoses including end stage renal disease, congestive heart failure, diabetes, and recent post-surgical treatment, was admitted following a hospitalization that included complications related to dialysis such as hypotension and hypoglycemia. The care plan identified the need for a diabetic diet and highlighted the risk for dialysis complications, directing staff to send a communication folder with the resident for each dialysis session. Despite these directives, there were lapses in the communication process. The Dialysis Center Communication Record, which was supposed to accompany the resident to and from dialysis, was missing for some sessions, and the facility was unable to account for all records since admission. Additionally, the communication record from the dialysis center specifically instructed that the resident's Midodrine medication be administered one hour before dialysis. However, the medication administration record (MAR) only indicated "AM" dosing without specifying the required timing, leading to confusion among staff. Interviews revealed that staff sometimes gave the medication with breakfast or at the time of departure, rather than the specified one hour prior, and the order was not clearly written to reflect the dialysis center's instructions. Further, the facility lacked a clear policy beyond the undated communication record document, and the process for reviewing and implementing new orders from the dialysis center was not consistently followed. The director of nursing acknowledged that the medication order should have been more precise and that the review process for dialysis communication records was not fully implemented. The care coordination agreement with the dialysis provider required the facility to ensure residents received necessary medications before dialysis, but this was not reliably achieved for this resident.
Failure to Administer Ordered Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the recommended pneumococcal vaccine series as outlined by the Centers for Disease Control (CDC). Specifically, the resident's immunization record showed that she had previously received PPSV23 and PCV13 vaccines, and there was a physician order for the administration of PCV20. However, a review of the medication administration record (MAR) revealed no evidence that the PCV20 vaccine was administered to the resident, despite the vaccine being ordered and delivered to the facility. Further document review and staff interview confirmed that the consent for immunization had been obtained and the vaccine was available, but the administration had not occurred. The facility's own policy required that consent be obtained and the pneumococcal vaccination be administered per physician order, with documentation in the resident's medical record. This process was not completed for the resident in question, resulting in a failure to follow established immunization protocols.
Failure to Monitor Wanderguard, Enforce Smoking Policy, and Supervise Dining Room
Penalty
Summary
The facility failed to implement appropriate monitoring and supervision in several areas, resulting in deficiencies related to accident hazards and resident safety. For one resident with moderate cognitive impairment and a history of elopement, the facility did not provide clear or consistent procedures for monitoring the function and placement of a Wanderguard device. Staff were unclear on how to check the device's function, and documentation lacked specific instructions. The care plan and facility policies did not provide adequate guidance, and the manufacturer's manual was not available. There was also a lapse in interdisciplinary team review documentation for residents at risk of elopement. Another deficiency involved a resident who was permitted to store and use e-cigarettes independently. Despite a care plan and assessment indicating the resident was aware of the rules, the resident was observed using an e-cigarette in her room on multiple occasions, contrary to facility policy requiring use only in designated areas. The resident kept e-cigarettes on her bedside table and admitted to using them indoors due to difficulty moving, indicating a lack of effective monitoring and enforcement of the smoking policy. Additionally, the facility failed to provide adequate supervision in the dining room for a resident with a history of dysphagia and pocketing food, who required a modified diet. The resident was repeatedly observed eating alone without staff present, including while consuming foods not properly prepared according to dietary orders. Staff interviews confirmed that supervision was expected for residents with altered diets due to choking risk, and the facility's policy required dining room supervision during meals, which was not consistently provided.
Failure to Provide Behavioral Health and Social Services for Residents with Odor Issues
Penalty
Summary
The facility failed to provide necessary behavioral health care and social services for two residents whose room odors were significant enough to permeate surrounding halls, affecting other residents, visitors, and staff. For one resident with diagnoses including morbid obesity, alveolar hypoventilation, and type 2 diabetes, there were repeated observations of strong, foul odors emanating from the room. The resident was cognitively intact and required varying levels of assistance with self-care and toileting. Documentation showed a history of refusing care and treatments, and the care plan included psychosocial monitoring and interventions. However, social services progress notes lacked evidence that the social worker was aware of or addressed the odor issue, and there was no documentation of interventions related to this matter until after it was brought to their attention during the survey. Another resident, diagnosed with neuromuscular bladder dysfunction, lumbar spina bifida with hydrocephalus, and morbid obesity, was also found to have a strong urine odor in and around the room. This resident was cognitively intact and required supervision and assistance with ADLs. The resident admitted to soiling the bed and only requesting assistance when necessary, and preferred minimal disturbance. The care plan noted risks related to mood and behavior, with interventions for monitoring and emotional support, but social services documentation did not show awareness of or action on the odor issue. The quarterly care conference also failed to mention the odor, focusing only on routine bathing. Interviews with the corporate and covering licensed social workers revealed that the facility did not have a dedicated social worker or designee at the time, and the two were sharing responsibilities. Both residents had declined certain behavioral health referrals, but there was no evidence of further social services interventions or documentation addressing the ongoing odor issues. Requested policies for social services assessment and intervention were not provided.
Failure to Post Required Survey and Complaint Investigation Results
Penalty
Summary
The facility failed to ensure that both recertification survey results and documentation of complaint investigations were readily available for review by residents, families, visitors, and staff. During the recertification survey, it was observed that the survey binder near the main entrance contained only the recertification surveys from the past three years, but lacked the required CMS 2567 forms for complaint investigations and revisits conducted during those years. Specific complaint investigations and revisits were missing from the binder, including those completed on several dates, and there was no documentation of certain desk audits or revisits. Interviews with the interim administrator and corporate nurse confirmed that the facility was aware of the requirement to post the last three years of all annual survey and complaint investigation results, including the CMS 2567 forms. However, upon review, it was verified that this information was not present in the binder as required. Additionally, the facility did not have a policy in place for the posting of survey results.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented during wound care for a resident with multiple diagnoses, including cancer, anemia, hypertension, renal insufficiency, dementia, multiple sclerosis, and depression. The resident had a physician order and care plan in place requiring EBP, specifically the use of gloves and a gown during high contact care activities such as wound care. During an observed wound care procedure, the DON performed hand hygiene and donned gloves but did not wear a gown as required by the EBP order and care plan. The DON acknowledged this omission immediately after the procedure and confirmed the expectation to follow EBP guidelines. Additionally, the facility was unable to provide a policy for EBP when requested.
Failure to Maintain Cleanliness in Dining and Resident Areas
Penalty
Summary
The facility failed to maintain cleanliness and sanitary conditions in both a resident's room and the dining room, affecting the living environment of the residents. During an observation, brownish stains were found on the floor under a table in the dining room, along with soiled tissues and uncleaned plates with leftover food. A resident expressed discomfort with the cleanliness of the area. The housekeeping supervisor was observed cleaning the stains without wearing gloves and subsequently did not wash hands before interacting with a resident, which is against the facility's training protocols. Additionally, a white powder-like substance was observed scattered on the floor in a resident's room, which was identified by a housekeeper as coming from the resident's skin. The housekeeper admitted to being too busy to clean it up earlier. The Director of Nursing stated that the expectation was for the dining room and resident rooms to be cleaned before and after meals. The facility's policy indicated that housekeeping is assigned to clean these areas daily, but this was not adhered to, leading to unsanitary conditions.
Infection Control Deficiencies in PPE and EBP Usage
Penalty
Summary
The facility failed to ensure proper use of personal protective equipment (PPE) and enhanced barrier precautions (EBP) for residents with indwelling Foley catheters, leading to infection control deficiencies. Resident 1, diagnosed with urinary tract infection and sepsis, had a Foley catheter but lacked EBP signage on her door. Staff did not wear gowns and gloves during high-contact care activities, such as transferring the resident, which was acknowledged by RN-A. Resident 2, with a bladder disorder and neuromuscular dysfunction, also had an indwelling Foley catheter and EBP signage on the door. However, staff were observed not wearing gowns and gloves during transfers and other high-contact activities. Nursing Assistant A admitted to not using PPE and handling soiled linens without gloves, despite being aware of the EBP requirements. Resident 4, diagnosed with acute kidney failure and infection due to an indwelling urethral catheter, did not have EBP signage on the door. Staff failed to wear PPE during transfers and high-contact care, and one nursing assistant touched the Foley catheter without gloves, then proceeded to handle clean items and touch surfaces without washing hands. The Director of Nursing, also the infection preventionist, was unaware of the need for EBP for Resident 1 and acknowledged the lack of PPE use, indicating a need for reeducation on infection control practices.
Medication Communication and E-Kit Utilization Deficiency
Penalty
Summary
The facility failed to ensure that a resident's ordered medications were fully communicated to the pharmacy, resulting in a delay in medication delivery. The resident, who was admitted with diagnoses including acute and chronic congestive heart failure, type 2 diabetes, asthma, and morbid obesity, did not receive several physician-ordered medications immediately following admission. The facility's process involved checking and clarifying orders before entering them into the electronic medication record, but some orders were not communicated effectively to the pharmacy, leading to a delay in medication delivery. The facility also failed to ensure that all licensed staff, including pool agency staff, understood and utilized the emergency medication kit (E-Kit) effectively. The Director of Nursing (DON) and Resident Care Manager (RCM) were aware of the missing medications on the day following the resident's admission and attempted to rectify the situation by contacting the pharmacy. However, the pool agency staff did not have access to the PIXUS medication dispensing system or the refrigerated E-Kit, which contained some of the missing medications, including insulin. This oversight resulted in the resident missing doses of insulin, which were critical for managing their diabetes. The pharmacy confirmed that they had only received part of the medication orders and could have delivered the medications within four hours if a STAT order had been placed. The facility's policy for dealing with missing medications was not effectively communicated to the pool staff, leading to the oversight. Despite the missed doses, the pharmacist and physician assistant did not consider the omission a significant error due to the resident's historically high blood sugar levels and the subsequent clarification and adjustment of insulin orders by the physician assistant.
Failure to Notify Resident's Representative of Condition Change
Penalty
Summary
The facility failed to notify a resident's representative following a change in the resident's condition, which resulted in hospitalization. The resident, who had severe cognitive impairment and multiple medical diagnoses including diabetes, morbid obesity, anemia, edema, heart failure, altered mental status, and end-stage renal disease, experienced a decline in condition. The resident was dependent on staff for daily activities and had multiple pressure ulcers, including two stage 2, three stage 3, and one unstageable ulcer. Despite physician orders for pain management and wound infection treatment, there was no documentation of notification to the resident's responsible party about changes in the resident's condition or treatment on specific dates. Interviews with the resident's family member and facility staff revealed a lack of communication regarding the resident's condition and treatment changes. The family member, who was the primary contact, was unaware of the deterioration of the resident's wounds and the new orders for antibiotics and pain medications until contacted for the interview. Facility staff, including LPNs and RNs, admitted to not notifying the family about medication changes, citing various reasons such as chronic medical issues and unclear policy directives. The facility's policy required sharing changes in a resident's condition or treatment with the resident and/or their representative, but this was not adhered to in this case.
Inadequate Wound Monitoring and Documentation
Penalty
Summary
The facility failed to effectively monitor and communicate the wound status of a resident with severe cognitive impairment and multiple medical conditions, including diabetes, morbid obesity, and end-stage renal disease. The resident had several pressure ulcers, including stage 2, stage 3, and unstageable ulcers. Despite having a care plan that directed staff to monitor and document skin conditions and inform medical professionals of any changes, there was a lack of consistent documentation and communication regarding the resident's wound status. The resident's condition worsened, leading to hospitalization for sepsis due to an infected perianal wound. Interviews with facility staff revealed that while nurses performed wound treatments and visualized the wounds, there was no consistent process for documenting the condition of the wounds unless there were noticeable changes. This lack of documentation made it difficult to track the progression of the wounds and communicate effectively with the wound care agency. The facility's policy required evaluation and documentation of wounds during dressing changes, but this was not consistently followed, contributing to the deficiency in care.
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 104 citations issued within 25 miles in the last 12 months — including the 4 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 Winsted
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Howard Lake | 6.5 mi | ★★★★★ | 10 | 0 |
| The Estates At Delano Llc | 9.4 mi | ★★★★★ | 7 | 0 |
| Cokato Manor | 10.5 mi | ★★★★★ | 5 | 0 |
| Glenfields Living With Care | 14 mi | ★★★★★ | 0 | 0 |
| Lakeside Generations Health Care Center | 14.6 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.