Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Thorne Crest Retirement Center during CMS and state inspections, most recent first.
Failure to assess pressure ulcer care and individualize repositioning plans. Two residents with immobility, incontinence, and other risk factors developed pressure injuries, but the record lacked comprehensive wound assessments, evaluation of intervention effectiveness, and documentation supporting the repositioning intervals used. One resident developed a DTI to the heel and stage 2 ulcers after declining and entering hospice, while the other developed a stage 2 buttock wound while sleeping in a recliner without a pressure-relieving device.
Loose controlled substances were found uncounted in two med carts, and disposed medications were stored in taped boxes in the med room after an overflowing lobby disposal bin could be accessed and intact meds removed. The CP was not involved in the facility’s med reconciliation or disposal process. The facility also delayed a resident’s Eliquis dose because the medication was unavailable, while the DON reported ongoing pharmacy-related medication issues and no formal process to track missed or late doses.
Incomplete QAPI Documentation and Lack of Data-Driven Oversight: The facility failed to show a comprehensive, data-driven QAPI process. QAPI minutes did not document analysis of a medication/treatment trend, root cause review, audits, education, or follow-up, despite leadership stating these issues had been discussed. The DON and administrator acknowledged limited QAPI training, no designated facilitator, and that other resident events, medication availability problems, and long call light wait times were not brought to QAPI for review.
Failure to Complete and Document a Required PIP: The facility failed to show evidence of a PIP within its QAPI program for a high risk or problem-prone area. The DON stated the 2025 PIP was short stay pressure ulcers, but could not provide documentation of data collection, staff feedback, analysis, or a conclusion, and the DON and administrator admitted the PIP had not been completed.
Laundry Handling and Wound Care Infection Control Failures: Staff were observed transporting soiled linens unbagged from resident rooms through hallways and into dirty utility areas, and staff reported this was routine even for linens soiled with urine, stool, and C. diff. The facility also failed to consistently identify residents needing EBP for chronic wounds, post signage, or ensure PPE use during wound care; an RN and the DON were observed providing wound care without proper gown use, with poor glove changes, no hand hygiene at key points, and dirty dressings placed on the floor.
Failure to Track Antibiotic Use and Resistance: The facility did not maintain an effective antibiotic stewardship process within its IPC program. The IPC log tracked resident infection details and current prescriptions, but it did not track culture dates, organisms identified, resistance patterns, antibiotic indications, dosage, duration, or whether antibiotics were stopped timely. The ADON, DON, and RN-D confirmed antibiotic use and resistance were not being monitored, and the facility had no formal antibiotic stewardship process despite a policy requiring tracking of antibiotic starts, lab results, resistance patterns, and antibiotic time-outs.
The facility failed to provide enough nursing staff to meet resident needs, resulting in long call light waits, delayed toileting, missed or delayed breakfast, and delayed evening care. Residents and family members reported waiting 30 minutes to over an hour for help, and staff described frequent call-ins, heavy agency use, and too few NAs and nurses to complete two-person assists, toileting, feeding, and other ADL care in a timely manner. Call light logs showed repeated response times over 20 minutes and multiple calls lasting more than an hour.
Incomplete orientation and competency training for nursing staff: The facility did not ensure agency and employed NAs and RNs received documented orientation before caring for residents. Staff described an informal process that relied on a binder at the nurses' desk and verbal guidance from coworkers, but several agency and employed staff had no orientation documentation, and interviews confirmed there was no comprehensive, leadership-directed training program or competency checklist. The orientation materials reviewed covered general topics, but did not address how to identify residents' individualized care needs.
Persistent urine and bowel odors were observed in a resident hallway and in a resident room, with staff, residents, and a family member reporting the odors were ongoing and strong. A cognitively intact resident with BPH, obstructive uropathy, rheumatoid arthritis, and bladder incontinence had urine-soaked clothing, blankets, linens, and a wheelchair cushion in the room, and staff acknowledged the odor was a known issue. Surveyors also found gray dust and debris on vents in two hallways and a day room, and staff stated common area vents were not on a scheduled cleaning routine.
A resident with diabetes, PVD, dementia, hemiplegia, and edema developed worsening lower-extremity skin issues with redness, warmth, drainage, and open/scabbed areas, but the record did not show timely provider notification or appropriate wound orders. Staff documented an SBAR, yet the DON and clinical leadership could not find evidence the provider was notified, and an LPN was unaware of any dressing orders. In a separate event, a resident with a new skin tear had an SBAR left for the provider, but the RN did not notify the family member, who later reported she first learned of the injury days afterward.
A resident with hemiparesis, wheelchair use, and dependence on dialysis required substantial assistance with personal hygiene, including nail care and handwashing. Care plan directions called for staff help with bathing, washing, and trimming nails, but documentation showed missed or blank hygiene entries and nail care not attempted on some occasions. Surveyors observed dirty hands and fingernails with debris and dried substance, and both the DON and RN confirmed the resident was unclean. The dialysis clinic had also noted ongoing concerns about the resident’s dirty hands, fingernails, and clothing.
Failure to Follow Scheduled Toileting Plan: A resident with Alzheimer’s disease, Parkinson’s disease, severe cognitive impairment, and dependence for ADLs was not toileted according to the care plan, Kardex, and task list. Family reported missed toileting after meals, stool soiling, delayed response to call light requests, and a fall from a wheelchair. Staff gave inconsistent accounts of the toileting routine, and the DON stated she was unaware of the issue and did not monitor adherence to the plan.
The facility failed to provide ordered wound care for a resident with diabetes, PVD, dementia, hemiplegia, cellulitis history, and edema after skin changes were noted, including delayed provider notification, delayed wound orders, and missed dressing care. The facility also failed to complete ordered daily weights, monitor BP, and give PRN hydralazine and torsemide as ordered for a resident with edema and HTN, and failed to carry out daily weights and Ace wrap orders for another resident with CHF and edema. Staff interviews and record review showed missed documentation, missed treatments, and lack of follow-through on provider orders.
Failure to Provide Timely Toileting and Brief Care: A resident with severe cognitive impairment, urinary and bowel incontinence, and dependence for ADLs had a care plan requiring toileting upon rising, before and after meals, at bedtime, midnight, and 4 a.m., but documentation and observations showed these interventions were not consistently provided. Staff interviews indicated the resident had not been toileted for hours, an agency NA was unfamiliar with the resident’s needs, and another NA found dried bowel movement on the brief, while the DON confirmed toileting and refusals were expected to be documented.
Dialysis communication forms were not consistently reviewed, documented, or acted on for a resident receiving HD. A dialysis provider order for Claritin to treat itching was not entered on the MAR until much later, and the resident continued to report itching with scratches on both arms. Staff found dialysis forms in the back pocket of the resident’s wheelchair, agency RNs were not trained on the process, and the DON confirmed the form and order were not addressed in a timely manner.
Incorrect Losartan Dose Administered: A resident with HTN received losartan 50 mg instead of the ordered 25 mg for several months because the pharmacy filled an older order and staff did not verify the medication against the current order. RN identified the discrepancy during med prep, and the DON confirmed the resident had been receiving the wrong dose and that medication reconciliation and audits were not consistently completed.
A resident with a right foot fracture did not receive timely PT after an order was written to begin weight-bearing transfers and start therapy. RN, HUC, DON, and PTA interviews showed the order was not properly entered into the EHR, therapy said the wording was incorrect, and the resident’s daughter reported frustration that PT had still not started so the resident could work on transfers and return home.
A resident with severe cognitive impairment and a history of falls was injured after rolling out of bed and coming into contact with a wall heater that was positioned only 11 inches away, resulting in second-degree burns. Staff had not been consistently educated or auditing bed placement, and maintenance had not documented or continued regular checks to ensure beds were kept at a safe distance from heaters.
A resident with cerebral palsy and an elevated white blood count developed right eye pain, redness, and swelling, which progressed to suspected cellulitis and conjunctivitis. Nursing staff escalated care and new medications were ordered, but the resident's representative was not notified of the change in condition or treatment, as confirmed by staff interviews and record review.
A resident with cerebral palsy and a history of elevated WBC developed an eye infection, but staff failed to consistently monitor and document signs and symptoms of infection after antibiotics were started. Additionally, the resident was transported in a manual wheelchair without a safety assessment and left unattended at an outside appointment, despite being unable to self-mobilize. Communication lapses and lack of clear procedures contributed to the deficiencies.
A resident with a diagnosed eye infection did not receive prescribed oral and ophthalmic antibiotics on the day they were ordered, despite provider instructions for immediate administration. Medication records and staff interviews confirmed the delay, and the error was not communicated to the resident or their representative. Facility policy required timely administration and documentation of medication errors, but the process was not followed, and leadership was unaware of the incident until identified by surveyors.
Staff did not follow standard and contact precautions for a resident with active shingles, including failing to perform hand hygiene and use PPE when entering the room. The required PPE cart was not placed outside the room as expected, and staff interviews revealed a lack of understanding regarding infection control protocols, resulting in improper implementation of precautions.
A resident with severe cognitive impairment and identified as an elopement risk left the facility unsupervised through an unlocked door. The resident was found outside with hypothermia and minor injuries. Staff were unaware of the resident's elopement risk, and the facility's policy on elopement was not effectively communicated or implemented.
A resident with severe cognitive impairment was found to have inadequate hydration due to the water pitcher being placed out of reach, despite being able to drink independently. Observations and staff interviews revealed that the water pitcher was not consistently placed on a bedside table, and there was confusion among staff about the policy for refilling water pitchers. The facility's policy required water pitchers to be within easy reach and refilled each shift, but this was not consistently followed.
A facility failed to protect residents from sexual abuse by a resident with a known history of inappropriate behavior. Despite documented incidents and a care plan that included supervision and checks, these measures were inadequately implemented. Staff were not informed or trained to monitor the resident effectively, and documentation was insufficient, leading to a failure to protect residents from potential harm.
The facility failed to report incidents of inappropriate touching and sexual abuse allegations involving a resident to the State Agency within the required timeframe. Despite staff intervention, the incidents were not documented or reported promptly, as some staff perceived them as harmless. The facility's policy required immediate reporting, but a breakdown in communication and adherence to protocols led to the deficiency.
The facility failed to ensure proper hand hygiene during personal and wound care for two residents. A nursing assistant and a licensed practical nurse did not follow hand hygiene protocols, including changing gloves and washing hands at critical points during care activities, as confirmed by interviews and observations.
Failure to Assess and Individualize Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to comprehensively assess and evaluate pressure ulcer care and failed to develop individualized repositioning programs for two residents who developed pressure injuries. One resident had diagnoses including a left femur fracture, obesity, chronic peripheral venous insufficiency, immobility, and incontinence. That resident’s initial Braden scores were 15 and 16, and the care plan identified incontinence, immobility, and skin integrity risk. Although the care plan later added a two-hour repositioning schedule and pressure-relieving boots, the record did not show a comprehensive assessment supporting that interval or showing that the resident could tolerate two-hour periods without increased skin breakdown risk. Weekly Braden assessments were also missing between admission and the first documented decline in skin status. After the resident’s condition worsened and hospice services began, the record identified pressure injuries including a deep tissue injury to the right heel and a stage 2 pressure ulcer to the coccyx, followed by a left gluteal pressure ulcer. The documentation did not include a comprehensive pressure ulcer assessment with measurements, drainage, or pain for the newly identified wounds, and there was no documented analysis of the causes of the pressure injuries. The record also did not show that the existing interventions were evaluated for effectiveness, that the repositioning program was changed, or that additional interventions were developed to prevent deterioration or new ulcer development. Staff interviews reflected that the resident should have been on a turning and repositioning schedule and heels should have been offloaded before the pressure injuries developed. A second resident had diagnoses including urinary incontinence and coronary artery disease and was identified as being at risk for pressure injuries. The resident’s care plan addressed impaired skin integrity risk related to immobility, edema, and incontinence, and a Braden score of 16 was documented. After a stage 2 pressure wound developed on the left buttock, the record added turning and repositioning every two hours and encouragement to get out of the recliner, but there was no documentation of a comprehensive assessment showing how long the resident could tolerate pressure without increased skin breakdown risk. The resident slept in a recliner most of the time and did not have a pressure-relieving device for the recliner, while staff interviews confirmed the resident’s usual positioning and the absence of a pressure-relieving device in the chair.
Uncounted controlled substances, unsecured disposal storage, and delayed medication reordering
Penalty
Summary
The facility failed to ensure complete narcotic and controlled substance reconciliation for two medication carts. During observation, loose individually packaged tramadol, lorazepam, and oxycodone tablets were found in the drawers of the healthcare medication cart and the transitional care unit medication cart. RN-B stated the medications were in the drawer because a resident refused them or the pharmacy had printed excess medications, and she confirmed they were not counted during narcotic reconciliation at shift change and were not documented in the narcotic log book. RN-A later confirmed the loose narcotics were not counted as part of narcotic reconciliation, and the DON also confirmed that the medications were uncounted and not identified in the narcotic log book. The facility also failed to provide secure storage of disposed medications. Five taped cardboard boxes containing medications were stored in the medication storage room after being removed from the locked disposal container in the lobby. During observation, the disposal container in the lobby was overflowing, and intact medication cards and a medication bottle could be removed from it. The DON stated she was unaware the disposal box was full and could be accessed by anyone in the facility. The local law enforcement officer stated he had not been called for a medication pickup since [DATE]. The consultant pharmacist stated he did not think it was good practice to take medications out of the disposal bin and store them back in the medication room, and he stated he was not aware of the facility’s medication disposal process and was not involved in medication reconciliation as he should have been. The facility also failed to ensure timely re-ordering of physician-ordered medication for a resident with atrial fibrillation. R26’s orders included Eliquis 5 mg twice daily, but a progress note documented the medication was unavailable and RN-I stated the resident was supposed to receive a dose that morning but it was not available. RN-I stated she tried to contact the pharmacy but had difficulty because the room phone did not work and she had other medications to call about. The DON stated the facility had ongoing medication issues with the pharmacy vendor, had no formalized process in place to prevent recurring medication errors, and had no report being used to track missed or late medications. The report also states the facility failed to ensure medications were administered in accordance with prescriber orders when an incorrect dose of losartan was administered for three months for another resident.
Incomplete QAPI Documentation and Lack of Data-Driven Oversight
Penalty
Summary
The facility failed to maintain documentation and demonstrate evidence of a comprehensive, data-driven QAPI program. Survey review found that QAPI meeting minutes from January 2025 through January 2026 did not reflect the identification of a trend from October 2025 involving medications and/or treatments not being administered per physician orders, despite the DON stating that three facility-reported incidents from that period had been discussed in QAPI. The minutes did not show data reporting, root cause analysis, education, audits, or follow-up to confirm resolution, and the meetings were described as grid-format summaries with repeated monthly entries that stayed the same over time. The facility’s QAPI process was described as being driven by corporate-selected agenda topics, with no designated facilitator and process owners only adding summary notes. The administrator, DON, and RN-D acknowledged that the facility lacked training and knowledge in the QAPI process and had not been effectively identifying concerns, analyzing and tracking performance, measuring success, or ensuring improvements were sustained. The DON stated she had no training in QAPI and that the facility did not review medication errors or resident events at QAPI. The administrator also stated that a resident fall with burns had not been brought to QAPI for discussion, and both leaders acknowledged other issues such as medication availability and long call light wait times had not been considered. The QAPI minutes and interviews also showed repeated discussion of topics such as daily nursing expectations, change of condition assessments, onboarding, employee satisfaction, and survey readiness, but the documentation did not show meaningful analysis or sustained follow-up. The facility QAPI policy stated the committee should include representatives from all departments, including pharmacy, and should use multiple data sources, benchmarks, and adverse event tracking; however, the pharmacist’s last documented QAPI attendance was March 2025. The facility also had identified concerns related to medication delivery, orientation, staffing, and mock survey results, but these were not reflected as effective QAPI analysis or documented trend management.
Failure to Complete and Document a Required PIP
Penalty
Summary
The facility failed to have evidence of a Performance Improvement Project (PIP) that focused on a high risk or problem-prone area and included thorough data collection, analysis, and evaluation within the QAPI program. During an interview with the administrator, DON, and RN-B, the DON stated the facility’s 2025 PIP had been short stay pressure ulcers, selected by the previous regional nurse consultant, but also stated there had been no concerns and nothing to improve. The DON could not provide documentation showing that a performance improvement process had been used to reach that conclusion, including no rationale for selecting the PIP, no data gathered, no staff feedback, no analysis, and no conclusion. The DON and administrator admitted that a PIP had not been completed in 2025. The facility’s Quality Assurance/Assessment and Performance Improvement Plan, with a review date of 6/27/25, stated that at least annually a project focused on high risk or problem-prone areas would be addressed through the QAPI program, including PIP development, and that the team would use a systematic approach to determine root cause, contributing factors, and appropriate interventions. The plan also stated that each PIP team would determine the timing of periodic measurements and reviews and continue the PDSA cycle if backsliding occurred.
Laundry Handling and Wound Care Infection Control Failures
Penalty
Summary
The facility failed to ensure laundry was handled, transported, and processed in a manner that prevented the spread of infection. On 1/21/26, a staff member in the utility room stated soiled laundry was routinely gathered from soiled utility rooms on each hallway and placed in laundry carts without being bagged first. The staff member also stated laundry from residents with infections, including C. diff, was not bagged differently and that it was not uncommon to find urine- and bowel-soiled linens transported unbagged. The staff member said this was an ongoing concern that had been brought to leadership and the DON. Later that morning, a hospitality aide was observed removing soiled linens from a resident room and carrying them unbagged down the hallway to the dirty utility room, with the linens held against the aide’s clothing and placed directly into the laundry area without bagging. The aide stated she had not been taught that soiled linens needed to be bagged prior to transport. The facility also failed to follow infection prevention and control practices related to enhanced barrier precautions, wound care, and PPE for a resident with skin concerns and chronic wound issues. The resident’s MDS showed moderate cognitive impairment, dependence for toileting, dressing, and transfers, and diagnoses including diabetes mellitus, PVD, dementia, hemiplegia/hemiparesis, cellulitis of the right lower limb, reduced mobility, muscle weakness, edema, and MASD. The care plan addressed skin breakdown risk, venous ulcer history, right lower extremity edema that sometimes weeps, MASD to the groin, and history of cellulitis. The treatment record showed wound care orders for cleansing both lower extremities, applying collagen to open wound beds, covering with ABD and Kerlix, and applying compression wraps. A progress note documented the left lower leg as warm, red, irritated, with drainage and prior blisters that had scabbed over, and recommended provider evaluation. During wound care, an RN entered the resident’s room without a gown or gloves, and no EBP signage was posted and no PPE was readily available. The RN removed the dressing, placed dirty dressings directly on the floor, went to the bathroom with the same gloves and touched bathroom surfaces including the faucet, then washed the resident’s legs and continued care without performing hand hygiene or changing gloves at the appropriate time. The RN later carried used cloths with bare hands and placed them into a soiled container unbagged in the hallway. The RN stated the resident did not have signage or PPE at the door to indicate EBP. The ADON, who also served as infection preventionist, stated residents with chronic wounds may require EBP, was not aware the resident had a wound, and stated she did not know EBP and contact precautions were different. The ADON confirmed there was no consistent process to identify residents requiring EBP, post signage, or monitor staff compliance. The DON later entered the room to complete wound care for the resident’s weeping, saturated leg dressing with yellow drainage and donned gloves but not a gown, then stated she should have worn a gown and gloves. The DON also confirmed dirty dressings should not be placed on the floor, gloves should be changed during wound care, and hand hygiene should be performed.
Failure to Track Antibiotic Use and Resistance
Penalty
Summary
The facility failed to implement and maintain an effective Infection Prevention and Control Program specific to antibiotic stewardship. Review of the IPC case log dated 1/22/26 showed the log included resident name, room number, onset date, current prescription, prescriber, infection type, infection site, diagnosis, and category, but it did not include the date cultures were obtained, organisms identified from culture results, or whether organisms were resistant to prescribed antibiotics. The log also did not track antibiotic indications for use, dosage, duration, culture results, or whether antibiotics were discontinued timely. On 1/22/26 at 12:10 p.m., the ADON, identified as the infection prevention nurse, stated antibiotic use was not tracked and that the facility did not have a current process for antibiotic stewardship. The ADON stated follow-up of cultures and ensuring residents were prescribed the correct antibiotic was not facility practice, and that providers were responsible for reviewing and tracking culture results. On 1/26/26 at 3:45 p.m., the DON and RN-D verified that infection surveillance related to antibiotic use and resistance was not tracked on the IPC log and confirmed the facility did not have a formal antibiotic stewardship process. The facility policy dated 6/25 stated the facility had an Antibiotic Stewardship Program, including tracking antibiotic starts, monitoring laboratory results, reviewing resistance patterns, and conducting antibiotic time-outs within 48-72 hours, but these elements were not being implemented.
Insufficient Staffing Led to Delayed Care and Long Call Light Waits
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs and to have a licensed nurse in charge on each shift, as shown by repeated delays in care, toileting, transfers, and call light response. Surveyors found that 15 of 47 residents reviewed experienced excessively long call light wait times, missed breakfast, or had delays getting to breakfast or receiving care. The facility assessment described multiple mechanical lifts, multiple residents with behavior issues, heavy hospice care, and 37 residents dependent on staff for ADLs. Staff interviews repeatedly described short staffing, frequent call-ins, high agency use, and difficulty completing required resident care in a timely manner. Several residents and family members reported prolonged waits for assistance. One family member stated a resident’s call light sometimes took over an hour to be answered and that staff would sometimes turn the light off and say they would return but did not. A resident reported waiting about two hours after breakfast to be helped back to his room and said this happened every day, causing him to skip lunch because it took too long to return after meals. Another resident reported waiting almost daily 30 minutes or more for help to get out of bed to use the bathroom, with delays worse around mealtimes. Other residents reported long waits for toileting, bowel incontinence before staff arrived, and delays in evening care. The DON was observed assisting one resident into his room and confirmed evening cares were delayed. Document review showed multiple residents with care plans requiring substantial or total assistance with transfers, toileting, hygiene, and feeding, yet breakfast was missed or delayed for several residents. Records indicated that several residents did not eat breakfast, and staff later confirmed that residents had not yet been gotten up due to staffing shortages. Call light logs documented many response times of 20 minutes to over an hour, including multiple calls over 60 minutes. Staff interviews stated there were not enough NAs or nurses to meet resident needs, that residents were left in bed for long periods, that two-person assists slowed care for others, and that overnight staffing was insufficient. Nursing staff also reported delays in treatments, order processing, toileting, and answering call lights because of workload and staffing shortages.
Incomplete Orientation and Competency Training for Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had appropriate orientation and training before starting their first shifts caring for residents. The report states that 6 of 6 agency staff, including nursing assistants and registered nurses, and 4 of 4 facility staff did not receive documented orientation or training before working with residents. The facility used a large number of agency staff, and multiple staff members stated that agency personnel were often unfamiliar with resident routines, equipment, and individualized care needs. During interviews, the health unit coordinator and assistant director of nursing described an informal process in which floor staff, rather than a designated educator or leadership-directed program, oriented new staff. The process relied on a binder at the nurses' desk and verbal guidance from other staff. The agency orientation materials reviewed included general topics such as resident rights, infection control, HIPAA, documentation, and assignments, but did not include information on how to determine the unique and individualized needs of residents. The facility also did not have orientation documentation available for several agency nurses and nursing assistants, and personnel files showed no orientation documentation for employed nursing assistants and nurses identified in the report. Staff interviews confirmed that orientation was inconsistent and incomplete. An agency nursing assistant stated it was his first day, that he was shown around by another aide, given an assignment, and told how residents transferred, but he was not given a checklist or formal orientation document. Another agency aide stated she had never seen the orientation binder and had not completed an orientation checklist when she started. An employed nurse stated she had never received formal training or a competency checklist, and an employed nursing assistant stated she was still primarily observing during orientation and had not been given a tool to identify training areas. The DON and regional director of clinical services acknowledged there was no comprehensive training process and that the facility lacked a consistent person to provide orientation and training.
Persistent Odors and Dirty Common Area Vents
Penalty
Summary
The facility failed to maintain a clean and sanitary environment free from persistent odors in one resident hallway, where strong and ongoing odors of urine and bowel movements were observed. The report also identified dirty air/heating vents in two resident hallways and one day room. These conditions were observed by surveyors and reported by residents, family, and staff during the survey process. R24 was cognitively intact, used a walker and wheelchair, and required partial assistance with toileting hygiene, personal hygiene, dressing, and toilet transfers. His diagnoses included BPH with obstruction, obstructive uropathy, and rheumatoid arthritis. His care plan indicated he was incontinent of bladder, refused briefs at times, and staff were to assist with incontinence care and encourage/check him every 2 to 3 hours. Survey observations and interviews showed urine-soaked clothing and blankets on the floor, urine stains on linens, a urine-soaked wheelchair cushion, and no laundry basket in the room. Staff and the DON acknowledged the urine odor was a known issue, that urine-soaked items were often left in the room, and that the odor was strong enough to be noticed in the hallway and by others in the facility. The report also documented that common area vents were covered with gray dust and fluffy debris. A housekeeper stated she did not clean common area vents and was unsure who was responsible, while the environmental director stated vent cleaning was not part of the scheduled routine and that he had not been aware of the issue until survey. The administrator stated he would expect vents in common areas to be cleaned on a regular basis. The facility’s routine cleaning and disinfection policy stated it was intended to provide a safe, sanitary environment and prevent infection transmission to the extent possible.
Failure to Notify Provider and Resident Representative of Skin Changes
Penalty
Summary
The facility failed to ensure timely provider notification and appropriate orders were obtained and implemented after a change in condition related to worsening skin integrity for one resident with moderate cognitive impairment, diabetes, peripheral vascular disease, dementia, hemiplegia, cellulitis history, reduced mobility, muscle weakness, and edema. The resident’s record showed ongoing skin concerns, including moisture associated skin damage, a history of venous ulcer to the right lower extremity, and intermittent weeping edema. On 1/15/26, an RN documented that the resident’s left lower leg was warm, red, irritated, and had previously blistered areas that had scabbed over, with drainage occurring on and off and the resident often refusing leg wraps and elevation. The documentation included an SBAR communication noting the left lower leg was red, warm, irritated, and weeping, with open and scabbed areas on both legs, but the record lacked evidence that the provider had been notified of the change in condition. During a later observation, the RN was seen performing wound care and stated she believed the resident’s order had changed because an ABD pad was present, although she did not recall an ABD order. She removed dressings, observed reddened legs with yellowish drainage, applied moisturizer to the lower legs but not to the open areas, and then applied ABD pads directly to both lower legs secured with Coban after stating Kerlix was unavailable. An LPN stated he was unaware of any dressing change orders or open areas and confirmed there was no dressing change order in the EMR. The DON stated she remembered seeing an SBAR and believed the provider had been notified, but she could not find documentation to support that. On follow-up review, the DON and regional clinical services director were unable to locate evidence that the provider had been notified of the skin change. The DON later confirmed the provider should have been notified and stated it was her responsibility to track SBARs submitted to providers. The medical director stated the provider was expected to be notified promptly when skin changes occurred. The facility also failed to notify a resident representative when there was a change in condition for another resident who sustained a full flap loss skin tear to the right shin. The wound was cleansed, covered, wrapped, and an SBAR was left for the provider. The resident’s family member stated she was not informed at the time of the injury and first learned of the skin tear several days later when she saw gauze on the resident’s leg. An RN stated he did not notify the family because it was late, and later learned the family wanted to be notified regardless of the time. The DON acknowledged the family had not been informed and reminded the nurse that family was to be notified in a timely manner when changes occurred.
Failure to Provide Needed Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide assistance with personal hygiene care for one resident who required substantial to maximal assistance with personal hygiene. The resident was cognitively intact, used a wheelchair, and had diagnoses including hemiplegia/hemiparesis, depression, and dependence on renal dialysis. The care plan directed staff to assist with dressing, personal hygiene, and bathing due to immobility related to right-sided hemiparesis, to hand the resident a soapy washcloth and cue him to wash his face, hands, arms, and torso as able, and to trim his fingernails and toenails as needed. Documentation showed multiple blank entries for personal hygiene and that shower/bathe and nail care were not attempted on some scheduled occasions. Surveyor observation and interviews showed the resident’s hands and fingernails were dirty and uncleaned. On observation, the resident had dried red substance on both hands and black and brown debris under all fingernails, and he stated the substance was blood that had been present for several days and that his hands were still sticky from breakfast. The DON and RN both confirmed the hands and fingernails were dirty, and the DON stated staff were expected to assist with handwashing every morning and whenever the hands and fingernails were visibly dirty. The dialysis clinic had also documented ongoing concern about the resident presenting with dirty hands, fingernails, and clothing. A NA stated she assisted with face washing but did not assist with handwashing or provide a washcloth, and stated morning cares were rushed due to agency staff unfamiliar with resident care needs.
Failure to Follow Scheduled Toileting Plan
Penalty
Summary
The facility failed to provide timely toileting for a resident with Alzheimer’s disease and Parkinson’s disease who was dependent on staff for ADLs. The resident’s MDS indicated severe cognitive impairment, dependence for ADLs, and bowel incontinence. The care plan and Kardex directed staff to toilet the resident at 5:00 a.m., upon rising, before and after meals, and at bedtime, with an added direction to toilet him after lunch and then lay him in bed for a nap. Facility staff and the DON later acknowledged they could not verify that toileting was completed at the required intervals, and the DON stated she was unaware of the issue and did not monitor adherence to the resident’s plan of care. Family members described multiple instances in which the toileting plan was not followed. On one occasion, after lunch, a family member turned on the call light to request toileting and bed placement, but after about an hour no staff came; the resident was instead moved to the dayroom and was later found not to have been toileted or laid down as planned. On another occasion, a family member found the resident smelling of bowel movement, reaching behind himself, and covered in stool on his clothing, wheelchair, and back, and stated he likely had been sitting since breakfast without being toileted before lunch. On a third occasion, a family member turned on the call light to request toileting and bed placement, then later learned the resident had fallen from his wheelchair after the call light had been turned on and then shut off. Interviews with nursing staff showed inconsistent understanding and execution of the toileting schedule. An agency NA stated the resident was toileted every two hours, while other agency NAs described toileting at the beginning of shift, after supper, or changing briefs in bed without toileting. During observation, the resident was found in bed all morning with a plump, moderately heavy brief, and staff could not verbalize the toileting frequency listed in the care plan, Kardex, and task list. Facility policies stated residents who are unable to perform ADLs would receive necessary services, including toileting, and that care plan interventions would be monitored and reviewed as necessary.
Failure to Provide Ordered Wound Care, Weights, Blood Pressure Monitoring, and Compression Therapy
Penalty
Summary
The facility failed to ensure necessary wound assessment, treatment, and follow-through for a resident with bilateral lower-extremity skin concerns. The resident had moderate cognitive impairment, diabetes, peripheral vascular disease, dementia, hemiplegia, cellulitis history, reduced mobility, muscle weakness, and edema. The care plan directed staff to inspect skin, monitor for infection, and report changes. On 1/15/26, nursing documented the resident’s left lower leg was warm, red, irritated, and had drained on and off, with prior blisters that had scabbed over. An SBAR also described a red, warm, irritated left lower leg, open/scabbed areas on both legs, weeping, and refusal of wraps and leg elevation. Documentation showed the provider was not notified of the change in skin condition and new wound orders were not obtained and implemented in a timely manner. The record lacked documentation that the provider had been notified until 1/22/26, and the wound orders were not implemented until 1/26/26. During observation on 1/21/26, the RN removed soiled dressings, noted reddened legs with yellow drainage on the left leg, cleaned the legs, applied moisturizer to the lower legs but not the open areas, and then applied ABD pads directly to both lower legs secured with Coban after stating Kerlix was unavailable. Staff interviews showed the LPN was unaware of any dressing change orders or open areas, and the DON later confirmed the provider should have been notified and that the resident went the entire weekend without wound care because no orders had been implemented. The facility also failed to complete and monitor daily weights, monitor blood pressures, and administer medications according to provider parameters for the resident with edema and hypertension. The resident had orders for daily weights, PRN hydralazine for systolic blood pressure greater than 160, and torsemide related to weight gain and blood pressure. The record showed multiple blood pressure readings above 160, but the MAR did not indicate hydralazine was given as ordered. Provider notes stated the resident’s blood pressure had been high, weights had been creeping up, legs were more swollen and weeping, and the resident had not been getting torsemide or hydralazine as often as expected. The DON confirmed weights were not obtained and documented as ordered, medications were not administered as prescribed, and the provider was not notified of the weight increase as expected. The facility also failed to follow physician orders for another resident with CHF and edema. That resident had orders for daily weights and Ace wraps to the lower extremities during the day and off at night. Review of the weight record showed seven missed daily weights over an 18-day period. The MAR showed Ace wraps were not applied on most scheduled occasions, with entries such as not applied, refused without supporting progress note documentation, and not applied on multiple days. Staff interviews showed nursing assistants were not consistently informed which residents needed weights, the new tracking process was not effectively communicated, and the DON stated she did not routinely monitor to ensure physician orders were being carried out.
Failure to Provide Timely Toileting and Brief Care
Penalty
Summary
The facility failed to provide timely toileting for a resident with severe cognitive impairment, delusions, behavioral symptoms, rejection of care, wheelchair use, and frequent urinary incontinence with occasional bowel incontinence. The resident’s care plan directed staff to offer toileting upon rising, before and after meals, at bedtime, midnight, and 4 a.m., and the care conference summary stated the family wanted staff to get the resident to the bathroom after meals and educate staff to ask if she needed the restroom. However, the resident’s task documentation did not consistently reflect toileting at those required times. During observation, the resident was seen seated at meals and in the day room, and staff interviews showed the resident had not been toileted since 9:30 a.m. on the day of observation. An agency nursing assistant stated it was their first day, was unfamiliar with the resident’s care, and expected the resident to notify staff when toileting was needed. Another nursing assistant stated the resident was expected to be toileted every two hours, and a different assistant reported finding dried bowel movement on the brief, suggesting the resident had not been changed for an extended period. Staff also stated the resident was not able to verbalize her needs, and the DON confirmed staff were expected to toilet the resident per the care plan and document toileting and refusals.
Dialysis Communication Forms Not Reviewed or Implemented
Penalty
Summary
The facility failed to ensure dialysis communication forms were consistently reviewed, addressed, and incorporated into the resident’s medical record, and failed to ensure provider orders communicated by the dialysis provider were implemented in a timely manner for one resident who required hemodialysis. The resident was cognitively intact, used a wheelchair, required substantial to maximal assistance with personal hygiene and upper body dressing, and was dependent on staff for toileting hygiene and transfers. Diagnoses included hemiplegia or hemiparesis, depression, and dependence on renal dialysis. The care plan identified the need for hemodialysis related to renal failure and directed staff to encourage attendance at scheduled dialysis appointments with facility-provided transportation. Review of dialysis communication forms from mid-December through late January showed several forms, but the facility could not provide additional forms or documentation of communication from dialysis. A dialysis communication form noted that Claritin had been ordered on 12/29/25 for itching, but the resident’s December MAR did not show the medication, and the January MAR did not show Claritin until 1/20/26. The resident was observed on 1/20/26 lying in bed reporting ongoing itching of the arms for about one month and was noted to have multiple scratches on both arms. Staff interviews showed prior dialysis communication forms had been found in the back pocket of the resident’s wheelchair without being reviewed or addressed, agency nurses were not trained on the expectation to review these forms, and the DON confirmed the form dated 1/16/26 had not been addressed. The DON also confirmed the facility could not locate the dialysis communication form related to the Claritin order and that the medication should have been ordered and administered as directed by the dialysis provider.
Incorrect Losartan Dose Administered
Penalty
Summary
The facility failed to ensure medications were administered according to prescriber orders when R44 received an incorrect dose of losartan for approximately three months. R44’s MDS indicated the resident was cognitively intact, required partial/moderate assistance with personal hygiene, and had diagnoses including hypertension. The care plan identified R44 as at risk for cardiovascular status related to hypertensive heart disease and atherosclerosis of the aorta. A provider note dated 10/8/25 indicated losartan was decreased to 25 mg daily, and the MARs for 10/1/25 through 1/31/26 showed losartan potassium 25 mg daily. During observation on 1/21/26, RN-G identified a discrepancy between the medication order and the pharmacy label for losartan and determined the packet contained 50 mg instead of the ordered 25 mg, so the dose was not administered at that time. The DON stated the pharmacy had been filling an older June 2025 order for losartan 50 mg rather than the current 25 mg order and confirmed that since 10/2025 R44 had been receiving 50 mg instead of the ordered 25 mg. The DON also stated an incident report was not completed, staff were not following the prescriber’s order, medication reconciliation was not completed when medications were dispensed from the pharmacy, the facility did not routinely confirm new or changed orders with the pharmacy, and medication audits had not been completed since December.
Delayed initiation of PT after fracture order
Penalty
Summary
The facility failed to seek clarification and initiate PT timely for a resident with a fracture of the right foot. The resident’s face sheet listed diagnoses including fracture of the right foot, Alzheimer’s disease, and pain related to hand contracture. The care plan indicated restorative nursing and referral to therapy as needed, and the quarterly MDS showed moderately impaired cognition, rejection of care one to three days, lower extremity impairment on one side, wheelchair use, and dependence or substantial assistance with several ADLs. During observation, the resident was in bed with the daughter at bedside, and the daughter stated she expected the resident to return home after therapy and was frustrated that PT had not started despite an order written for PT after the fracture. Documentation showed a clinic sheet and progress note on 12/23/25 stating the resident could begin weight-bearing on the right foot for transfers with assistance and could start PT at that time. However, review of physician orders on 1/21/26 showed no PT order had been entered into the EHR. Staff interviews indicated the order was signed by RN-C, RN-E, and HUC-E, but the order was not activated or entered, and therapy did not receive it promptly. The DON stated therapy needed the order changed and that the provider was contacted later; PTA-I stated the order was received but then said it was written incorrectly and needed to say eval and treat, and no further action occurred until the DON emailed the provider and received the corrected order.
Failure to Maintain Safe Bed Distance from Heater Results in Resident Burns
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's bed was placed a safe distance away from a wall heater, resulting in the resident becoming entrapped and sustaining second-degree burns. The resident involved had severe cognitive impairment, a diagnosis of neurocognitive disorder with Lewy Bodies dementia, anxiety, and a history of falls and self-transfers. The care plan indicated the resident required assistance with transfers and bed mobility, but was independent with rolling in bed. Despite these needs, the bed was positioned too close to the heater, with staff measuring the distance at only 11 inches at the time of the incident. On the morning of the incident, the resident was found between the bed and the heater, having rolled out of bed and come into contact with the heater. The resident sustained burns to the left hip and back, with multiple blistered areas and bruising on both knees. Staff interviews revealed that the bed had been near the heater for an extended period, and that the resident frequently attempted to get out of bed independently. Staff also reported that the heaters felt hot to the touch and that there was no prior education or consistent auditing to ensure beds were kept at a safe distance from the heaters. Documentation and interviews indicated that maintenance had previously performed a visual audit of bed placement but did not document the results or continue regular checks. Nursing staff were not routinely verifying bed distance from heaters, and there was no established policy or education regarding the required minimum distance prior to the incident. The lack of consistent monitoring and clear procedures contributed to the resident's ability to access the hazardous area and sustain injury.
Failure to Notify Resident Representative of Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of a significant change in condition for one resident with a history of cerebral palsy and an elevated white blood count. The resident began experiencing right eye pain, redness, and swelling, which progressed over two days. Nursing staff documented the symptoms, administered acetaminophen, and escalated the concern to the DON, who suspected cellulitis and contacted the nurse practitioner for further evaluation. A telemedicine visit confirmed preseptal cellulitis and conjunctivitis, and new medications were ordered, including oral antibiotics and antibiotic eye drops. Despite these developments, there was no documentation that the resident's representative was notified of the change in condition or the new medical interventions. Interviews with facility staff, including the ADON, LPN, and DON, confirmed that the resident's representative was not informed of the change in condition, and all acknowledged that notification should have occurred and been documented. The resident's representative expressed frustration at not being informed and stated she only learned of the situation during a visit. The resident also indicated a preference for having his representative notified of health changes. Review of the electronic health record and staff interviews confirmed the lack of notification and documentation, and the facility was unable to provide a policy regarding notification of changes in condition.
Failure to Monitor Infection and Ensure Safe Transport for Resident with Mobility Impairments
Penalty
Summary
The facility failed to monitor for signs and symptoms of infection for a resident who was at risk due to refusal of vaccinations and had a history of cerebral palsy and elevated white blood count. The resident developed redness, swelling, and pain in the right eye, which was identified as possible cellulitis. Orders were given for oral and eye drop antibiotics, and staff were instructed to mark the area of redness and monitor for spread. However, there was no consistent daily or shift-based documentation or comprehensive assessment of the infection from the time antibiotics were started through the following week, as confirmed by multiple staff interviews and review of the electronic health record. The lack of monitoring was acknowledged by the LPN, ADON, DON, and the nurse practitioner, all of whom stated that regular assessments should have been performed and documented to detect changes in the resident's condition. Additionally, the facility failed to ensure safe transportation for the same resident to an outside appointment. The resident, who normally used a specialized electric wheelchair due to immobility from cerebral palsy and scoliosis, was transferred to a manual wheelchair for transport because the facility van could not accommodate the electric wheelchair. The resident was left unattended in the manual wheelchair at the clinic for approximately 20 to 25 minutes, during which time he was unable to move himself or seek assistance due to lack of core strength. The family member and staff interviews confirmed that the resident was not assessed for safety in a manual wheelchair prior to transport, and the director of therapy expressed concern about the lack of such an assessment given the resident's physical limitations. Communication failures also contributed to the incident, as the transport driver was not provided with proper paperwork or clear instructions regarding the resident's destination, resulting in the resident being left at the wrong location. The family member was not immediately informed of the resident's whereabouts, and facility staff were unaware that the resident had been left unattended. Facility policies for infection monitoring and safe transport were requested but not provided for review.
Failure to Timely Administer Ordered Antibiotics for Eye Infection
Penalty
Summary
A resident with intact cognition and diagnoses of cerebral palsy and elevated white blood count developed symptoms of an acute right eye infection, including redness, swelling, pain, and discharge. During a telemedicine visit, the provider ordered both oral and ophthalmic antibiotics to be started immediately due to concerns for preseptal cellulitis and conjunctivitis. The provider's orders specified that the medications should be started the same day, and nursing staff were instructed to check the emergency kit for the required eye drops and to monitor the resident for worsening symptoms. Despite these orders, the resident did not receive the prescribed oral or ophthalmic antibiotics on the day they were ordered. Medication administration records showed that both medications were not started until the following day, with missed doses documented for the initial day. Interviews with family members, the resident, and multiple staff confirmed that the medications were not administered as ordered, and the delay was not communicated to the resident or their representative. Nursing staff and leadership acknowledged that this constituted a medication error, as provider orders were not followed and the required medications were not made available or administered as directed. Facility policy required that medications be administered according to provider orders and that any medication errors be documented, assessed, and reported. However, the Director of Nursing was not aware of the error until it was identified by the surveyor, and there was inconsistency in the documentation and reporting process. The facility's medication error policy and forms did not clearly specify requirements for resident or representative notification or documentation of resident assessment following a medication error.
Failure to Follow Contact Precautions and Proper PPE Use
Penalty
Summary
Staff failed to follow standard and transmission-based precautions for a resident who was on contact precautions due to an active shingles infection affecting the right eye. The resident had a history of cerebral palsy and an elevated white blood count, and laboratory results confirmed a positive test for varicella zoster virus. Upon return from the hospital, the resident was placed on contact precautions, with a sign posted on the door indicating the need for hand hygiene and the use of gowns and gloves before entering the room. Despite these precautions, observations revealed that a hospitality aide entered the resident's room to deliver a meal tray without performing hand hygiene or donning the required personal protective equipment (PPE) as indicated by the signage. The aide was unaware of the reason for the contact precautions and could not articulate the need for PPE. Additionally, the PPE cart, which should have been placed outside the resident's room for easy access and to prevent contamination, was instead located inside the room, contrary to best practices and the facility's own infection control expectations. Interviews with staff, including a licensed practical nurse, a nursing assistant, the assistant director of nursing (who also served as the infection control nurse), and the director of nursing, confirmed inconsistent understanding and implementation of infection control protocols. Staff acknowledged the resident was on contact precautions and that hand hygiene and PPE use were required, but the PPE cart was not properly positioned, and staff did not consistently follow hand hygiene or PPE protocols. Facility policies outlined the need for standard and transmission-based precautions, but did not specify PPE cart placement, contributing to the observed deficiencies.
Resident Elopement Due to Inadequate Supervision and Unlocked Door
Penalty
Summary
The facility failed to maintain adequate supervision and safety measures for a resident identified as an elopement risk, leading to the resident leaving the facility unsupervised. The resident, who had severe cognitive impairment and was recently admitted, expressed a desire to go home and was not accepting of the facility placement. Despite being identified as at risk for elopement, no interventions were implemented to prevent the resident from leaving the facility unattended. On the night of the incident, the resident exited the building through an unlocked door to a courtyard without staff awareness. The resident was found outside in the early morning hours, suffering from hypothermia and minor injuries. The staff, including the LPN and nursing assistant on duty, were not aware of the resident's elopement risk and did not provide the necessary supervision or assistance. The facility's policy on elopement and wandering residents was not effectively communicated or implemented, contributing to the incident. Interviews with staff revealed a lack of communication and awareness regarding the resident's risks and needs. The interdisciplinary team did not effectively communicate or develop appropriate interventions to address the resident's elopement risk. The courtyard door was not equipped with a wanderguard system and was left unlocked, allowing the resident to leave the facility unsupervised.
Removal Plan
- The facility locked the courtyard doors.
- Placed all residents on checks until all residents were re-assessed for elopement risk.
- Residents at risk for elopement were placed on checks until individualized interventions were developed and implemented.
- Reviewed all resident care plans.
- Revised the elopement policy.
- Re-educated all staff on the elopement policy and on risk factors to watch for.
- Upon R1's hospital return, the facility re-assessed R1 for elopement and fall risks and implemented interventions to mitigate the risks.
Inadequate Hydration and Accessibility of Water for Resident
Penalty
Summary
The facility failed to ensure adequate hydration for a resident with severe cognitive impairment, who was independent with eating and drinking but required extensive assistance for mobility, transfers, and toileting. The resident's care plan indicated that refreshments should be provided in the afternoon and that the resident could drink water without assistance if it was within reach. However, observations revealed that the resident's water pitcher was consistently placed out of reach, across the room from the bed, and not on a bedside table as required. Interviews with staff confirmed that the resident could not reach the water pitcher while in bed, and there was confusion among staff regarding the policy for refilling water pitchers. Despite the facility's policy stating that water pitchers should be placed within easy reach of residents and refilled each shift, the resident's water pitcher was often not accessible. Staff interviews indicated a lack of awareness or adherence to this policy, with some staff unsure of the procedures for refilling water pitchers. The director of nursing confirmed the existence of a policy requiring fresh water within reach, but observations showed that the resident's water pitcher was not consistently placed within reach, contributing to the resident's complaints of dry mouth and thirst.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to implement appropriate interventions to protect residents from sexual abuse by a resident with a known history of inappropriate sexual behavior. This resident, who had been admitted from another skilled facility, was observed inappropriately touching another resident in the day room. Despite the resident's history of sexual advances towards women, which was documented in physician notes and reported by family members, the facility did not have adequate measures in place to prevent such incidents. The resident's care plan, initiated after previous incidents, included measures such as constant supervision during recreation programs and 15-minute checks. However, these interventions were not effectively implemented or documented. Staff interviews revealed that the 15-minute checks were deemed inadequate, and there was a lack of communication regarding the resident's behaviors and necessary precautions. The facility's documentation was insufficient, failing to record specific incidents and the resident's whereabouts accurately. The facility's abuse policy did not adequately address the protection of residents from abuse, and staff were not informed or trained to monitor the resident effectively. The Director of Nursing was unaware of the resident's history and the severity of the incidents until after they occurred. This lack of awareness and inadequate documentation contributed to the facility's failure to protect residents from potential harm.
Removal Plan
- The facility reviewed and updated their abuse policy and procedure pertaining to resident-to-resident sexual abuse
- R1's care plan was updated with 1:1 to prevent him from having contact with vulnerable females related to his sexual inappropriate touching.
- R1 will have a video monitor on.
- R1 is not to be left by any female residents.
- The facility provided education to all facility staff on the policy and on implementation of individualized care plan and protection measures.
- The facility completed trauma informed care assessments and care plan updated on the residents affected by R1's behaviors.
Failure to Timely Report Abuse Allegations
Penalty
Summary
The facility failed to timely report incidents of inappropriate and unwanted touching, as well as allegations of sexual abuse, to the facility administrator and the State Agency for six residents. The incidents involved a resident, R1, who was observed by a nursing assistant (NA-A) with his hand under another resident's shirt, performing inappropriate actions. Despite immediate intervention by staff, the incident was not reported to the State Agency within the required timeframe. The Assistant Director of Nursing (ADON) was informed but did not have the authority to report to the State Agency, and the Director of Nursing (DON) initially deemed the incident non-reportable. Further interviews revealed that R1 had a history of inappropriate sexual behaviors towards other residents, including R3, R4, and R6. These incidents were either not documented or not reported to supervisors, as some staff perceived them as harmless. R3 recounted uncomfortable encounters with R1, including attempts to hold her hand and inappropriate gestures. Staff interventions were noted, but the lack of documentation and timely reporting contributed to the deficiency. The facility's policy required immediate reporting of abuse allegations, defined as within two hours for serious incidents. However, the DON was unaware of R1's background and did not initiate a report or investigation promptly. The social worker eventually reported the incident to the State Agency and law enforcement after consulting with corporate, highlighting a breakdown in communication and adherence to reporting protocols within the facility.
Failure to Ensure Proper Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene during personal care and wound care for two residents. One resident, diagnosed with dementia, traumatic brain injury, and weakness, required substantial assistance with dressing and grooming. During an observation, a nursing assistant (NA) did not change gloves or perform hand hygiene after providing incontinent care and before assisting the resident with other activities, such as sitting up in bed and moving to a wheelchair. The NA only used hand sanitizer after pushing the resident to the dining room, which was confirmed during an interview with the NA. Another resident, diagnosed with malignant neoplasm of the pancreas and adult failure to thrive, had a stage two pressure injury on the coccyx. During wound care, a licensed practical nurse (LPN) and a trained medication aide (TMA) failed to perform hand hygiene at multiple critical points, including after removing soiled dressings, before applying new gloves, and after scratching the resident's back. The LPN and TMA did not follow the facility's hand hygiene policy, which was confirmed during an interview with the LPN. The facility's policy required hand hygiene immediately before and after resident contact, after contact with blood or body fluids, and after glove removal.
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 59 citations issued within 25 miles in the last 12 months — including the 1 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 Albert Lea
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Johns On Fountain Lake | 2 mi | ★★★★★ | 15 | 0 |
| Good Samaritan Society - Albert Lea | 3 mi | ★★★★★ | 5 | 0 |
| Lutheran Retirement Home | 15.8 mi | ★★★★★ | 8 | 0 |
| New Richland Care Center | 17.7 mi | ★★★★★ | 2 | 0 |
| Sacred Heart Care Center | 18.2 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.