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 Wabasso Restorative Care Center during CMS and state inspections, most recent first.
A resident with a history of alcohol abuse and seizures obtained Super Sani-Cloth wipes containing isopropyl alcohol, mixed them with water, and drank the liquid. Staff found a cup of wipes in the resident’s room and an almost empty container in a drawer, while therapy also had unsecured sanitizing wipes stored in an open room. The resident later had seizures, altered mental status, and acute kidney injury requiring hospital care.
A resident with paraplegia, reduced mobility, and dependence on staff for transfers developed new swelling and edema of the right lower leg, initially denying any known trauma. Nursing staff notified the physician, applied ACE wraps, and later sent the resident to the ED when swelling and vascular concerns worsened, where imaging revealed acute fractures of the right tibia and fibula. Although the injury’s origin was initially unknown and no clear root cause was established, facility leadership did not submit an incident report to the State Agency, relying instead on later documentation suggesting the leg was accidentally hit by a wheelchair.
The facility failed to accurately assess and document mechanical lift sling sizes for two residents who required total assistance with transfers using a Hoyer lift. Manufacturer instructions required sling selection based on both height and weight, but staff and the DON described using primarily weight and did not consistently consider height. For one resident with paraplegia and multiple mobility impairments, the care plan and lift assessment specified use of a full lift with two staff but omitted the resident’s height, weight, and sling size. For another resident with lumbar spondylosis, muscle weakness, and spinal stenosis, the lift assessment contained a weight range inconsistent with the MDS and did not identify sling size, and the care plan did not specify sling size or transfer device. Staff interviews showed confusion about who determined sling size and where this information was documented, with no sling size information found in care plans or the NA binder.
A resident with multiple pain-related conditions, including neuropathy, fracture, and chronic wounds, had care plans and PRN orders for various analgesics and non-pharmacological interventions, but the plan did not specify an acceptable pain level or clearly direct which analgesic to use before wound treatments. Records showed no comprehensive assessment or specific interventions for preventing pain during wound care, and on one morning only aspirin was given despite a documented pain level of 6, with no evidence that other ordered PRN pain medications or non-pharmacological measures were offered. During an observed buttock dressing change, the resident repeatedly yelled and verbalized pain while being turned and treated, and pain medication was not offered before the procedure began. Staff interviews confirmed the resident frequently screamed in pain with repositioning, that PRN medications were often given only if requested or directed, and that the LPN and DON later acknowledged that stronger pain medication and earlier intervention should have been used based on the facility’s pain scales and the resident’s reported pain levels.
Two residents with pressure ulcers received wound care during which an LPN and an RN repeatedly failed to follow the facility’s hand hygiene policy and did not consistently ensure clean work surfaces. For one resident with multiple stage 4 pressure ulcers and enhanced barrier precautions, the LPN did not sanitize the work area before placing wound supplies and repeatedly changed gloves without performing hand hygiene while handling genital areas, shared gauze containers, and open wounds. For another resident with a stage 3 pressure ulcer, the LPN initially placed supplies on an unsanitized overbed table, examined the genital area, cleansed a sacral ulcer, and applied dressings while frequently changing gloves without hand hygiene, and the assisting RN also changed gloves without sanitizing hands. These actions were inconsistent with the facility’s policy that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and after removing gloves and when moving from contaminated to clean body sites.
A resident with DM, peripheral neuropathy, malnutrition, and anxiety, who was independent with ambulation and eating, sustained a significant partial-thickness burn to the right thigh and groin after hot water from a plastic thermal mug spilled when the lid popped off during lunch. The resident reported severe pain, difficulty removing clothing, and a delay before a nurse arrived, while an NA described a large, very red area with a forming blister. Initial nursing documentation noted only redness and use of Vaseline, with later notes identifying a blistered burn and subsequent debridement, and a hospital wound consult later measuring the wound at 15 x 26 x 0.1 cm. Staff interviews revealed that residents had not been assessed for hot liquid safety before the incident, the resident’s care plan lacked hot liquid precautions at the time, and dietary staff acknowledged serving very hot water, with one report that reheated water had been temped at 138°F despite an existing hot liquid safety policy requiring assessment and individualized interventions.
A resident with diabetes, peripheral neuropathy, malnutrition, and anxiety, who was cognitively intact and independent with a walker, spilled hot water on the upper thigh, resulting first in redness and then in a large blistered area requiring wound care and later hospital debridement. Facility documentation showed physician and provider orders for topical treatment and dressings, but the DON and administrator acknowledged that, although they were notified soon after the incident, they did not consider the injury significant at first and did not report the allegation of neglect or serious bodily injury to the State Agency within the required 2-hour timeframe, contrary to the facility’s Abuse, Neglect, and Exploitation Policy.
A resident with paraplegia, chronic infected pressure ulcers, and a history of sepsis developed repeated fevers, low BP, chills, and wound drainage while receiving antibiotics. Staff did not document timely physician notification, a full assessment, or escalation when the resident’s condition worsened, and the resident was later sent to the ER and transferred to the ICU for suspicion of sepsis.
Kitchen sanitation and dumpster closure deficiencies were identified when multiple food prep and storage surfaces were observed with sticky residue, crumbs, grease-like buildup, and food-like debris, including the milk refrigerator, veggie freezer, cooking range, oven doors, countertop, can opener, and steam table. A cook placed gravy into the dirty steam table for lunch service and stated the steam table was cleaned only once per week, not after each meal. The outside dumpster was also observed overflowing and left open with garbage exposed, and the DM agreed the lids should be securely closed at all times.
Unsafe and Poorly Maintained Resident Areas: The facility failed to maintain floor coverings in two shared resident rooms and failed to keep the dining room exterior wall in good repair. One room had 10 broken floor tiles with missing pieces, and another had a hole and fraying in the carpet at the doorway; the residents were unaware of any repair plans. In the dining room, there were 3 holes in the exterior wall, including one open to the outside and another stuffed with a washcloth, which the maintenance director acknowledged had been used for a seasonal AC unit.
Expired meds and supplies were found in a medication room refrigerator, including Vancomycin pumps for a discharged resident, barrier wipes, COVID tests, and bacitracin packets. Staff confirmed the items were expired and should have been removed. Boxes of Ensure were also stored on the floor next to the refrigerator, and the consulting nurse said no items should be stored on the floor and was unaware of the protocol for monitoring expired items and storage.
Infection control practices were not followed when an RN obtained a resident’s BS in the dining room while other residents were seated nearby. The resident had diabetes and moderately impaired cognition, and after the fingerstick the resident had a small amount of blood on the finger and touched the table. The RN then placed the contaminated glucometer in a cart drawer without disinfecting it and later wiped it with a Sani-Cloth wipe without meeting the required 2-minute wet contact time; the glucometer was used by three residents.
Failure to offer or document PCV vaccination status for two residents. Two residents admitted with multiple diagnoses had MDS records showing their PCV status was not up to date, and there was no indication they were offered or declined the vaccine. The IP acknowledged residents were to be assessed on admit and given risk/benefit information and a declination form per CDC guidance, and the facility policy required assessment, offering the PCV vaccine, and documenting consent or refusal.
Failure to Notify Resident Representative of Hospital Transfer: A resident with moderate cognitive impairment, significant ADL assistance needs, and multiple medical diagnoses was transferred to the hospital for SOB, cough, and hypoxia and later hospitalized with pneumonia and kidney injury. The record lacked documentation that the family/emergency representative was notified of the transfer or admission, and RN-C confirmed no such notification was documented.
A resident with multiple psychiatric and medical diagnoses, including paranoid schizophrenia, PTSD, borderline personality disorder, and a history of falls, displayed repeated verbal aggression and intentionally lowered himself to the floor from his wheelchair or bed to get staff attention or to smoke. Observation, interview, and progress notes documented swearing, yelling, and repeated floor-lowering behaviors, but the care plan addressed coping, verbal aggression, and fall risk without including the resident’s intentional placement of himself on the floor. The RN agreed the behavior was not listed in the care plan.
Failure to Investigate Illegal Drug Incident: Staff found a resident very unsteady after a fall and later discovered a crystal-like substance in his room that police field tested as methamphetamine. Law enforcement interviewed the resident, who admitted possession and said another resident gave it to him, and officers also found a pipe and lighters plus additional drugs/paraphernalia near the smoking area. Facility leadership acknowledged no incident report was completed for the drug event and no further investigation was done, despite resident council concerns about drugs and alcohol in the facility.
A resident with severe cognitive impairment and high care needs was physically abused by another resident, who pulled her hair, struck her head, and pushed her wheelchair. The victim reported the incident to several staff and a family member, who contacted law enforcement after being unable to reach the facility. Staff interviews confirmed the abuse was reported, but there was a delay in administrative response and awareness. The aggressor had a history of behavioral issues and recent medication changes. The facility failed to prevent and promptly address the abuse, leading the victim to leave due to fear for her safety.
A resident with severe cognitive impairment reported being physically assaulted by another resident, and although nursing staff were informed immediately and internal monitoring was initiated, the facility did not report the allegation to the State Agency within the required timeframe. The incident was reported to law enforcement by the resident's family before the facility submitted the required report.
A resident with cognitive impairment was unable to locate survey results, and review of the facility's survey binder revealed missing recertification surveys, complaint investigations, and plans of correction. Staff confirmed that not all required documents were available, and no policy for posting survey results was provided, limiting access to important information for all residents, families, and staff.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not honor a resident's right to voice grievances without discrimination or reprisal and failed to establish or follow a grievance policy or make prompt efforts to resolve grievances.
A resident with mental health diagnoses did not receive morning medications as preferred because staff failed to wake her, leading to behavioral escalation. The care plan did not reflect her established preferences for wake-up and medication times, and staff were unaware of these needs until after the incident.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, resulting in a failure to meet individualized care requirements.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A resident with PTSD and cognitive impairment experienced ongoing unwanted sexual advances and explicit notes from another resident, leading to psychosocial harm. Despite multiple reports from residents and staff, the facility did not conduct a comprehensive assessment, update care plans, or implement effective supervision and interventions to ensure safety, resulting in continued distress and a lack of protection for the affected resident.
A resident with severe cognitive impairment and mental health issues, along with several other female residents, reported ongoing sexual harassment, inappropriate advances, and theft by another resident. Despite being aware of these allegations and conducting internal investigations, facility staff did not report the incidents to the State Agency within the required timeframe, failing to follow policy and protect residents.
A resident with severe cognitive impairment and mental health diagnoses reported ongoing sexual harassment and inappropriate advances from another resident, including unwanted letters and verbal behaviors. Multiple residents expressed feeling unsafe, but the facility did not conduct a thorough investigation, failed to document interviews or protective actions, and did not prevent further incidents, despite repeated complaints and its own policy requiring immediate response.
A resident with complex behavioral and mental health needs was transferred to another facility without being given adequate notice, the right to appeal, or the opportunity to remain during the appeal process. The transfer was conducted rapidly, with the resident not signing a discharge agreement, not being allowed to discuss the move with an advocate, and experiencing emotional distress after the move. The facility did not follow its own policies regarding resident rights and discharge procedures.
Two residents with PTSD did not receive trauma-informed care when one was repeatedly harassed and sexually approached by another, despite both having documented trauma histories. The facility failed to update care plans, assess psychosocial harm, or implement effective monitoring and interventions, resulting in ongoing distress and unaddressed triggers for both individuals.
A resident with severe cognitive impairment and psychiatric conditions did not have required physician documentation for routine visits over a 60-90 day period. Although the physician saw the resident and signed orders, no note was entered in the medical record, contrary to facility policy.
Two residents with significant behavioral health needs, including PTSD and cognitive impairment, were not provided with comprehensive assessments or individualized, person-centered interventions. One resident experienced ongoing harassment and triggering of trauma symptoms by another resident, with insufficient safety measures or supportive services implemented. The facility did not follow its trauma-informed care policy or provide evidence of effective behavioral health planning.
The facility did not adequately identify or document the specific care and practices needed for residents with PTSD in its facility-wide assessment, and failed to maintain the required full-time Social Services Designee (SSD) position, instead splitting the SSD's time between two locations. This resulted in insufficient social services support for residents with behavioral health needs, including those with PTSD.
A resident with a history of substance abuse left the facility and was found intoxicated at a bar. The facility lacked protocols to monitor or prevent substance abuse, and the resident's care plan was not updated following the incident. Staff were unaware of how to handle the situation, and there was no documentation of vital signs or assessments upon the resident's return.
A resident with congestive heart failure experienced significant weight gain and symptoms such as shortness of breath and chest pain, but the facility failed to monitor and report these changes to the physician. Despite hospital discharge orders for daily weight monitoring, the facility did not adhere to these instructions, leading to the resident's hospitalization for CHF exacerbation and a heart attack.
The facility failed to provide accurate Ombudsman contact information to residents, as observed during a resident council meeting. Five residents were unaware of how to contact the Ombudsman, and the posted information was outdated. Interviews confirmed the inaccuracy, despite previous requests for updates. The facility's assessment and admission packet indicated residents should be informed of their rights and provided with accurate contact information, which was not effectively implemented.
The facility failed to provide necessary physical therapy (PT) services to residents due to the absence of PT staff since August 2024, affecting residents who required these services. Despite having physician orders for PT, residents did not receive the necessary therapy. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The administrator acknowledged the need to update the facility assessment to reflect the actual services provided.
The facility failed to adequately explain the binding arbitration agreement to 16 residents, leading to a lack of understanding and awareness of their right to refuse signing. Interviews revealed that many residents did not recall receiving an explanation or understanding the agreement, with some feeling pressured to sign without full comprehension. This deficiency affected the residents' rights to make informed decisions about their care and legal options.
A facility failed to implement enhanced barrier precautions for a resident with surgical wounds and a PICC line, as required by CDC guidelines. Observations showed no signage on the resident's door, and staff did not wear gowns during dressing changes. Additionally, the facility's infection control surveillance was inadequate, with critical sections left blank, making it impossible to determine if precautions were implemented timely. The DON, new to her role, admitted to being unsure about necessary precautions, and oversight from a sister facility's IP was minimal.
Two residents in a facility expressed fear of retaliation from staff, feeling intimidated and unable to voice concerns. One resident, admitted with multiple health issues, felt the social services designee was unapproachable and feared being expelled. Another resident, with chronic pain and other conditions, believed the facility misrepresented its services and was denied access to a doctor. During a resident council meeting, several residents shared similar fears. The facility's policy on reporting concerns lacked specific avenues for addressing fears of retaliation from management.
The facility failed to securely store lighters for residents who smoked, leading to potential fire hazards. Residents were observed keeping lighters and cigarettes in unsecured locations, contrary to the facility's policy. Staff reported challenges in enforcing the policy, as residents often kept lighters in their possession. The facility's smoking policy did not explicitly address the secure storage of lighters, contributing to inconsistent enforcement and increased fire risk.
A facility failed to ensure nursing staff were competent in identifying and responding to an emergent change in condition for a resident with congestive heart failure, leading to a delay in emergency medical evaluation. The resident experienced significant weight gain, shortness of breath, and chest pain, but staff did not notify the physician or send the resident to the emergency department. Interviews revealed a lack of timely updates to the physician and insufficient staff training on recognizing changes in condition.
The facility failed to maintain adequate staffing levels on weekends as per their assessment, with only one licensed nurse on the day shift for 12 out of 26 weekend days. The administrator was unaware of the staffing requirements and questioned the accuracy of data submitted to CMS.
A resident with intact cognition and a history of stroke, heart failure, renal insufficiency, and diabetes mellitus reported missing personal items to the Social Service Director (SSD). Despite the report, the SSD did not recall the grievance, and no documentation was found in the facility's grievance log. The facility also failed to provide a grievance policy, indicating a lack of follow-up and documentation.
A facility failed to ensure a resident could communicate with their county care coordinator (CC), resulting in multiple unsuccessful contact attempts by the CC. The social services designee (SSD) instructed the CC to direct communication needs to her, but the CC faced difficulties reaching the SSD and the resident was not informed of the calls. Interviews revealed no directive to forward calls to the SSD, and residents could take calls privately. The resident was unaware of the CC's attempts, indicating a communication breakdown.
A facility failed to accurately code the MDS for a resident with a non-pressure chronic ulcer and other medical conditions. Despite medical records confirming the presence of a skin ulcer, the MDS did not reflect this, leading to discrepancies in the resident's care documentation. Interviews revealed that the resident was aware of ongoing wound care, but staff were not consistent in coding practices, and the DON was unaware of the MDS coding process.
The facility failed to revise care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked monitoring for behaviors associated with anti-anxiety medication and did not address potential adverse reactions or signs of increased depression. Another resident's care plan did not include daily weight monitoring as ordered, resulting in significant weight gain and hospital readmission with congestive heart failure.
The facility failed to assess and document target behaviors and non-pharmacological interventions for residents on psychotropic medications. One resident with severe cognitive impairment and worsening behaviors lacked a care plan with specific target behaviors. Another resident's care plan did not include non-pharmacological interventions for anxiety and depression. A third resident's care plan failed to document target behaviors or side effects of medications. The DON acknowledged these deficiencies, which were not in line with the facility's psychotropic medication policy.
The facility failed to label two opened vials of Tuberculin (TB) PPD solution with an open date, as required by the manufacturer's guidelines. The vials were found in the medication room refrigerator without an open date, despite being dispensed on a specific date. An LPN confirmed the absence of an open date, and the DON expected medications to be dated and initialed upon opening. A policy on medication labeling and storage was not provided.
A resident with intact cognition and multiple health conditions, including stroke and diabetes, repeatedly requested a dental appointment due to missing molars. Despite oral assessments documenting these requests, the facility failed to schedule the necessary dental services. The Social Service Director did not recall the request and missed an email notification from the RN responsible for oral assessments.
Two residents at the facility did not receive physician-ordered physical therapy (PT) services due to the unavailability of PT providers. One resident, admitted to regain strength and return to independent living, did not receive PT after August 2024. Another resident, with moderate cognitive impairment and requiring assistance with daily activities, also did not receive PT as ordered. The facility lacked a plan to provide PT services in the interim, and no policy on skilled therapy services was available.
Unsecured alcohol wipes accessible to resident with alcohol abuse history
Penalty
Summary
The facility failed to ensure alcohol sanitizing wipes were stored safely out of resident reach for one resident with a known history of alcohol abuse. The resident’s face sheet identified diagnoses including alcohol abuse, ADHD, major depressive disorder, and seizures. Her care plan directed staff to assure she did not have access to alcohol-based products and to check her bags when she returned from outings for alcohol-based items. Her quarterly MDS identified intact cognition, no behaviors or rejection of care, and independent mobility with a walker. On 5/17/26, staff found the resident with a cup containing sanitizing wipes and water, and she admitted placing the wipes in the cup and drinking the liquid. Nursing staff also found an almost empty container of Super Sani-Cloth Germicidal Wipes in her drawer. Staff interviews indicated the resident had a history of drinking hand sanitizer and was supposed to be kept from access to alcohol-containing products, but the resident was able to obtain the wipes and ingest them. The resident later had grand mal seizures and was sent to the emergency department for evaluation. Hospital records documented altered mental status after ingestion of alcohol wipes mixed with water, with poison control involved in the evaluation. The resident reported attempting suicide by consuming the liquid from the sanitizing wipes, and the hospital noted acute kidney injury with creatinine elevated to 2.32 from a baseline of 1.07. The therapy department was also observed with an unsecured room and a container of sanitizing germicidal wipes stored on a shelf, not locked in a cabinet, and the occupational therapist stated the wipes were not locked up and that residents did not know they were there.
Failure to Timely Report Injury of Unknown Origin Involving Lower Extremity Fractures
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin to the State Agency within the required two-hour timeframe for one resident with fractures of the right tibia and fibula. The resident had paraplegia, reduced mobility, weakness, adult failure to thrive, neuralgia, neuritis, and a history of right tibia and fibula fractures with routine healing. The resident required staff assistance with dressing, turning, and transfers using a mechanical lift, and used a wheelchair for mobility. On the morning of 4/14, the night nurse reported new edema of the resident’s right lower leg; the resident denied hitting his leg on anything. The physician was notified and ordered ACE wraps and observation, with an x-ray to be obtained if the condition did not improve. Later that night, due to increased swelling, +3 pitting edema, and poor capillary refill, the on-call physician was notified and the resident was sent to the emergency department for suspected fracture. In the emergency department, imaging showed an acute oblique longitudinal fracture of the distal tibial shaft with a lateral cortical step-off and a mildly displaced distal fibular shaft fracture. The ED documentation noted that swelling had started one to two days earlier, there were no recent falls or notable injury, and it was reported that the resident accidentally hit his right lower leg in a wheelchair. The resident returned to the facility with a diagnosis of closed fractures of the right tibia and fibula, and the DON was notified. No incident report related to these fractures was submitted to the State Agency. During interview, the DON acknowledged that the incident was not reported and that, prior to hospital transfer, the resident did not know how the injury occurred. The admissions director stated that, because hospital paperwork later attributed the injury to the wheelchair, they determined it did not meet criteria for reporting, even though the origin of the injury was initially unknown and a definitive root cause could not be established.
Failure to Accurately Assess and Document Mechanical Lift Sling Sizes for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate, comprehensive assessments and care planning for full body mechanical lift sling sizing according to the manufacturer’s guidelines for two residents. The manufacturer’s Sling Selection Guide required sling size selection based on both height and weight, emphasizing the importance of using the correct size and proper fit prior to lifting. Despite this, facility staff and leadership described sling selection practices that relied primarily on resident weight and did not consistently incorporate height, and there was no clear, documented process in the care plans or other nursing documents specifying sling sizes for individual residents. One resident (R2) had paraplegia, fractures of the right tibia and fibula with routine healing, reduced mobility, weakness, and adult failure to thrive. R2’s MDS showed no cognitive issues, bilateral lower extremity impairment, dependence on staff for dressing, turning, and transfers, and use of a wheelchair, with a recorded weight of 235 lbs and height of 69 inches. R2’s ADL care plan identified total dependence of two staff with a Hoyer lift for transfers but did not specify the sling size to be used. The Lift Mobility Status assessment for R2 documented that the resident could not stand, pivot, or walk and would continue to use a full lift with two staff assist, but it did not include the resident’s height, weight, or required sling size. Another resident (R4) had diagnoses including lumbar spondylosis without myelopathy or radiculopathy, muscle weakness, unsteadiness on feet, and spinal stenosis. R4’s MDS indicated no cognitive issues, substantial assistance needed for bed mobility and sitting/standing transitions, and dependence on staff for transfers, with a recorded weight of 220 lbs and height of 71 inches. R4’s Lift Mobility Status assessment stated the resident could not stand, pivot, or walk, could tolerate a semi-reclined position, and required a Hoyer lift, but it inaccurately listed the resident’s weight as between 376–420 lbs and did not identify the sling size. R4’s ADL care plan documented dependence for transfers but did not specify sling size or transfer device. Staff interviews revealed inconsistent understanding of who determined sling size and how it was documented, with NAs and the DON indicating reliance on weight alone and reference to a sling size guide in a storage closet, while the DON confirmed that sling sizes were not in care plans or the NA binder.
Failure to Individualize and Provide Adequate Pain Management During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement an individualized pain management plan for a resident with multiple pain-related diagnoses, particularly in relation to wound treatments and repositioning. The resident had documented conditions including polyneuropathy, a left femur neck fracture, polyosteoarthritis, chronic pain related to absence of toes on both feet, and gastroesophageal reflux disease. The admission MDS showed mild cognitive impairment, verbal behaviors, and rejection of care on some days. Care plans identified use of aspirin therapy and opioid pain medication related to fracture, with goals to avoid discomfort and adverse side effects, and interventions to administer analgesics as ordered, monitor side effects and effectiveness, and assess pain on a 0–10 scale. However, the care plan did not identify the resident’s acceptable level of pain, and while a pressure wound care plan stated to treat pain per orders prior to treatment/turning, there was no corresponding physician order specifying which analgesic to use or when to administer it before wound care. The resident’s physician orders included aspirin 81 mg daily, PRN acetaminophen 1,000 mg every 6 hours for moderate pain, PRN gabapentin 600 mg every 8 hours for pain, and PRN oxycodone 5 mg every 4 hours for severe pain, with a maximum daily dose. The MAR listed non-pharmacological interventions such as ice, distraction, and rest, with instructions to document effectiveness and non-pharmacological measures used alongside medications. Record review showed no comprehensive assessment, treatment orders, or care plan interventions specifically addressing pain prevention during wound treatments. On one morning, the MAR documented administration of aspirin with a recorded pain level of 6, but there was no indication that non-pharmacological interventions were offered or that PRN acetaminophen, gabapentin, or oxycodone were offered or administered at that time. During an observed dressing change to the resident’s buttocks, the resident repeatedly yelled out, stated he was cold and hurting, and vocalized pain while being turned and while the wound was cleaned, using exclamations and profanity. The LPN performing the dressing change did not offer pain medication before starting the procedure and acknowledged that the dressing change had already begun and that pain medication should perhaps have been given beforehand, noting the resident was in pain every time he was turned. Staff interviews indicated the resident screamed in pain whenever turned or repositioned, and that this was reported to nurses and TMAs. A TMA reported she only administered PRN pain medication if a resident asked or a nurse instructed her, and during the morning pass she gave aspirin and recorded a pain level of 6 without notifying the LPN; the resident did not request additional pain medication at that time. The LPN later stated that, based on the resident’s pain level and the facility’s FACES and numeric pain scales, oxycodone should have been used for severe pain, and the DON stated the resident should have been offered pain medication when pain was identified at 6 and that the dressing change should have been stopped when the resident voiced pain. These findings show the facility did not individualize and implement pain management for wound care and did not provide adequate pain control during the observed treatment.
Failure to Perform Hand Hygiene and Maintain Clean Surfaces During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper hand hygiene and clean work surfaces during wound care for two residents with pressure ulcers. One resident had paraplegia and multiple stage 4 pressure ulcers on the right and left buttocks and sacral region, required assistance with mobility and personal care, and was on enhanced barrier precautions due to open wounds, colostomy, and urinary catheter. During an observed wound care session, the LPN entered the room wearing enhanced barrier precautions but did not sanitize the work surface before placing or using wound supplies. Throughout the wound care procedure for this resident, the LPN repeatedly removed and reapplied gloves without performing hand hygiene in between glove changes. The LPN examined the resident’s genital area, handled gauze from a shared container, applied barrier cream, removed and replaced dressings on three pressure ulcers, cleansed the wounds, and applied Calcium Alginate and Mepilex dressings, all while frequently changing gloves but not sanitizing hands between glove removals and reapplications. The LPN also reached into the gauze container multiple times after contact with contaminated areas, and only washed hands after leaving the room and disposing of the garbage. For the second resident, who had a stage 3 pressure ulcer and no cognitive impairment, the LPN again entered wearing enhanced barrier precautions and brought wound supplies into the room, initially placing them on an overbed table that had not yet been sanitized. The LPN examined the resident’s enlarged testicles and genital area with gloved hands, used gauze from a container to cleanse the area, and repeatedly removed and reapplied gloves without hand hygiene. After lifting the wound supplies to wipe down the overbed table, the LPN continued the dressing change, including cleansing a sacral ulcer and applying Calcium Alginate and Mepilex, again changing gloves multiple times without sanitizing hands. An RN who assisted with the procedure also examined the genital area, applied cream, and changed gloves without performing hand hygiene between glove changes. The facility’s hand hygiene policy stated that glove use does not replace hand hygiene and that hand hygiene must be performed before donning and immediately after removing gloves, and when moving from a contaminated to a clean body site, which was not followed in these observed instances.
Failure to Assess and Protect Resident From Hot Liquid Burn
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents related to hot liquids and to have an effective system to assess residents’ safety with hot liquids. A cognitively intact resident with diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety was independently ambulatory with a walker and independent with eating. The resident’s care plan initially identified independence with eating, and only after the incident was a revision made to specify that staff should ensure the lid was on and secure for hot liquids. At the time of the incident, there was no documented individualized assessment or care plan intervention addressing the resident’s ability to safely handle hot liquids despite her peripheral neuropathy and other comorbidities. On the day of the incident, the resident was having lunch when hot water from a plastic thermal mug spilled onto her upper right thigh. The resident later reported that the lid was not sitting correctly on the mug and popped off, causing hot water to splash onto her hand, startling her and leading her to jerk, which caused the remaining hot water to spill onto her right thigh. She stated that the hot water soaked through her sweatpants and into her incontinent brief, burning most of the top of her right thigh and the right groin fold. The resident reported experiencing horrible pain and stated it took 20–30 minutes for a nurse to come while she struggled to remove her clothing. A nursing assistant confirmed being notified by dietary staff that the resident had spilled hot water, immediately taking her back to her room, and then leaving to find the charge nurse, describing the resident’s leg as a large, very red area with a forming blister and noting the resident’s significant pain and frustration. Clinical documentation following the incident showed that the initial nursing note described visible redness to the upper thigh, with education provided to the resident to be careful with hot liquids and to ask for help. The physician ordered Vaseline and pain medication. The following day, documentation identified a reddened area with a blister approximately five inches by three inches, and orders were obtained for Xeroform and dressings. A subsequent wound note documented a partial thickness burn acquired in the facility, but the measurements recorded were later verified as incorrect. The resident’s primary care provider’s visit note from the day after the incident did not mention the thigh burn, describing the skin as warm and dry with no rashes or lesions on exposed skin. Later documentation identified the burn as a stage 2 burn site requiring debridement and daily wound care. A hospital wound care consult subsequently measured the burn at 15 x 26 x 0.1 cm and described it as a partial thickness burn that was blistered, fragile, bleeding, and erythematous. Staff interviews revealed that prior to this incident, the facility had not been conducting hot water assessments on residents, and there was inconsistency in staff accounts regarding the existence and implementation of a hot liquid policy and temperature monitoring at the time the resident was burned. Additional staff interviews highlighted issues related to hot liquid temperatures and supervision. The dining specialist stated that all hot water and coffee were served from the kitchen and that the water was too hot, noting that on the day of the interview the temperature was being turned down. She reported being on duty when the resident was burned but did not know who provided the hot water, and she assumed, based on the severity of the burn, that the water had been way too hot. The certified dietary manager reported that a dietary staff member reheated the water in the microwave and stated that the water was reportedly 138°F when checked, with staff expected to log temperatures. The facility’s hot liquid safety policy, implemented prior to the incident, required assessment of all residents for their ability to handle containers and consume hot liquids, with individualized interventions on the care plan, and described the time–temperature relationship for serious burns, including that at 133°F a third-degree burn could occur in 15 seconds and at 140°F in 5 seconds. Despite this policy, interviews and documentation showed that residents had not been systematically assessed for hot liquid safety and that the resident involved in the incident did not have appropriate hot liquid precautions in place at the time of the burn.
Failure to Timely Report Significant Burn Injury as Alleged Neglect
Penalty
Summary
The facility failed to immediately report an allegation of neglect involving a resident who sustained a significant burn injury from hot liquid. The resident, who had intact cognition, ambulated independently with a walker, and was independent with eating, had diagnoses including diabetes, peripheral neuropathy, malnutrition, and anxiety. Progress notes documented that the resident spilled hot water on the right upper thigh, resulting in visible redness, and was educated to be careful with hot liquids and to ask for help when needed. A physician ordered Vaseline to the affected area and pain medication. The following day, documentation showed a reddened area with a blister approximately five inches by three inches, and the provider ordered Xeroform dressings, ABD pad, Kerlix, and added the resident to wound rounds. Despite these findings and the development of a large blistered area, the facility did not report the incident to the State Agency within the required two-hour timeframe for events involving alleged abuse or resulting in serious bodily injury, as required by its Abuse, Neglect, and Exploitation Policy. A later hospital wound care consult identified a partial thickness burn on the resident’s right thigh measuring 15 x 26 x 0.1 cm, described as blistered, fragile, bleeding, and erythematous, and requiring chemical and mechanical debridement. The DON stated she was notified of the burn on the date of occurrence but did not consider it significant until several days later and confirmed the burn was not reported to the State Agency. The administrator also confirmed that although staff notified him immediately after the incident, it was not reported to the State Agency, and there was no evidence the facility assessed residents for mitigation of hazards related to hot liquids prior to this event.
Failure to Respond to Worsening Infection and Change in Condition
Penalty
Summary
The facility failed to appropriately identify, assess, and intervene for a resident with a change in condition when signs and symptoms of worsening infection developed. The resident had paraplegia, a history of sepsis, and an infected wound with a Stage 3 and Stage 4 unhealed pressure ulcer present on admission. He was admitted for wound care and antibiotic therapy, and the hospital discharge summary later documented that he was transferred to the ICU for fever, feeling unwell, and purulent drainage from the buttock wound, with empiric antibiotic therapy started and brief vasopressor use. Progress notes showed repeated episodes of fever and low blood pressure over several days. The resident had temperatures of 102 F, 102.3 F, 102.2 F, and 104 F, along with blood pressures as low as 91/59 mm/hg and 93/48 mm/hg, and he also complained of chills. On one date, bloody drainage was noted from the left buttock wound and minimal discharge from the navel area. The record did not show that the nurse practitioner was contacted when the resident first showed increased signs and symptoms of potential worsening infection, and there was no documentation of a full set of vital signs or a full nursing assessment when the fever and other symptoms continued. The nurse practitioner eventually saw the resident and ordered labs to be collected 3 days later, but there was no indication staff questioned the delayed workup or consulted the medical director when the resident continued to show signs of worsening infection. The resident was not sent to the hospital until he developed a fever of 104 F and was then transferred by ambulance to the ER, where he was subsequently moved to the ICU for suspicion of sepsis. Interviews with nursing and medical staff confirmed expectations that the physician should have been notified at the first change in condition and that a full assessment and earlier evaluation would have been expected.
Kitchen Sanitation and Dumpster Closure Deficiencies
Penalty
Summary
The facility failed to ensure the kitchen and dining area were clean and sanitary to prevent cross contamination during food preparation and service. During observation of the kitchen with the dietary manager present, the milk refrigerator had an unknown wet, sticky substance and crumb-like debris on the bottom shelf. The veggie freezer had sticky residue and fingerprints on the doors and handles, drip marks on the lower half of the doors, white and orange food-like particles inside on the bottom shelf, a cardboard box stuck to the bottom, and a screw on the shelf. The cooking range had food crumbs and grease-like residue on the burners and flat surface, the control dials were covered in dirt and grease-like debris, and the oven doors had residue dripping down the front. A stainless-steel countertop had wet food on the mounted can opener and three personal drink tumblers with straws. The steam table had a yellowish thick substance smeared across one well lid and the flat surface between the wells, along with other unknown substances and food-like crumbs. Cook-A was observed placing gravy into the dirty steam table for lunch service and stated the yellow smeared substance was from eggs served earlier that morning; she was not certain what the other debris was from. She also stated the steam table was cleaned only once per week and not after each meal service. The facility also failed to ensure the outside garbage dumpster was securely closed to prevent attracting pests and rodents. The dumpster was observed overflowing, which prevented the lids from being closed securely, and garbage was visible from the road. Later, the dumpster lids remained open even after the dumpster had been emptied, with three bags of garbage visible inside and exposed to pest and rodent contamination. The dietary manager agreed the dumpster lids should be securely closed at all times and stated she had concerns about kitchen cleanliness and expected all surfaces to be wiped down as needed and the steam table to be cleaned after each meal. She also stated she had completed training and provided sign-off sheets for staff tasks, but had not completed documented audits to ensure staff were completing the tasks correctly.
Unsafe and Poorly Maintained Resident Areas
Penalty
Summary
The facility failed to maintain floor coverings in 2 of 2 resident-shared rooms and failed to maintain the exterior wall in 1 of 1 dining room in good condition. In one shared room occupied by two residents, observation identified 10 broken floor tiles, some with large missing pieces and others with smaller missing pieces. Both residents stated they were not aware of any facility plans to repair the tile and said the condition had been present for a long time. The maintenance director stated he knew about the broken tiles, explained that the tiles were 9 x 9 and replacements could not be obtained, and said the entire room floor would need to be replaced when the room became empty. In the second shared room occupied by two residents, observation identified a hole in the carpet at the doorway seam between the hall carpet and the room carpet, measuring approximately 3 inches wide by 12 inches long, with fraying strings. One resident used a walker and the other walked independently, and neither resident was aware of any plan to repair the carpet. The maintenance director stated he had already trimmed the loose frayed strings once and had not yet repaired it because he had been busy with a new shower project, though he said he would order a trim piece that day. In the dining room, observation identified a quarter-sized hole in the west exterior wall open to the outside, a second hole covered by unfinished wood, and another silver dollar-sized hole stuffed with a washcloth. The dietary manager stated the washcloth was a temporary fix, and the maintenance director acknowledged there were 3 holes in the wall used for a summertime air conditioning unit and agreed the condition could cause a problem with pest control.
Expired Medications and Improper Storage in Medication Room
Penalty
Summary
The facility failed to monitor for expired items and to store items in a sanitary manner in 1 of 1 medication rooms. During observation and interview, the medication room refrigerator contained 3 pre-filled elastomeric pumps of Vancomycin for a resident who had already discharged, along with 9 boxes of barrier wipes, 4 boxes of 4-pack COVID tests, and 6 boxes of bacitracin packets that had all expired. The RN confirmed the items were expired and stated they should have been removed once expired. In addition, 4 boxes of Ensure were observed sitting on the floor next to the refrigerator and 3 more boxes of Ensure were inside a plastic box on the floor next to the refrigerator; the RN stated no items should be stored on the floor. The consulting nurse reported being unaware of the protocol for monitoring expired items and storage in the medication room, and the facility’s Medication Storage policy stated the consultant pharmacist routinely inspected for outdated, discontinued, defective, or deteriorated medications with missing or illegible labels.
Infection Control Failure During Blood Sugar Testing and Glucometer Disinfection
Penalty
Summary
The facility failed to follow appropriate infection control practices when obtaining a blood sugar level for one resident while the resident was seated in the dining room with other residents present. The resident had a diagnosis of diabetes, hypertension, GERD, and depression, and the accepted MDS assessment identified moderately impaired cognition and the need for substantial assistance from staff for cares. The resident had an order for blood glucose monitoring before meals and at bedtime related to diabetes management. During observation, a registered nurse entered the dining room, put on gloves, set up the glucometer, and used a lancet to prick the resident’s finger and obtain a blood sample at the table in front of other residents. After the test, the resident had a small amount of blood on the tip of the finger and touched the bloody finger on the top of the table. The same nurse then returned to the medication cart and placed the contaminated glucometer into a drawer without disinfecting it. When the glucometer was later removed, the nurse wiped it with a Sani-Cloth wipe but did not ensure the surface remained wet for the required contact time. The infection preventionist stated the Assure glucometer should be cleaned first and then disinfected with a 2-minute wet contact time and air-dried, and that the machine was used by three residents. The nurse stated she believed she had disinfected the glucometer per facility protocol but was unaware the Sani-Wipes required a 2-minute wet-contact time. Facility policies stated blood glucose testing should be performed per manufacturer instructions, with privacy provided, and glucometers cleaned and disinfected after each use according to manufacturer instructions.
Failure to Offer or Document Pneumococcal Vaccination Status
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on interview and document review, the facility failed to ensure 2 of 5 sampled residents, R16 and R21, were offered and/or provided updated pneumococcal vaccinations in accordance with CDC guidance. Review of the CDC pneumococcal vaccine recommendations identified that adults 65 years or older may receive PCV20 or PCV21 based on shared clinical decision-making, including those who previously received PCV13 and PPSV23 under specified conditions. R16 was admitted to the facility in October 2025, was [AGE] years old, and had diagnoses including spinal fusion, MDRO, substance abuse, and a pressure ulcer of the sacral region. The comprehensive MDS identified R16's PCV vaccine status was not up to date, and R16 had received PPSV-23 on 12/19/11, with no indication that the vaccine was offered or declined. R21 was admitted to the facility in October 2025, was [AGE] years old, and had diagnoses of depression, alcohol dependence, PTSD, and C-diff. The comprehensive MDS identified R21's PCV vaccine status was not up to date, and there was no indication that the vaccine was offered or declined. During a callback interview on 1/14/2026, the infection preventionist agreed residents were to be assessed for vaccine status upon admission and/or provided risk and benefit information and a declination form for PCV vaccines according to CDC guidelines. The facility's October 2024 pneumococcal vaccine policy stated the facility was to follow state or local guidance, assess resident status upon admission, offer the PCV vaccine, and document consent or refusal in the medical record.
Failure to Notify Resident Representative of Hospital Transfer
Penalty
Summary
The facility failed to notify the responsible party of a resident’s transfer to the hospital for 1 of 4 sampled residents reviewed for hospitalizations. The resident had moderate cognitive impairment, required moderate assistance with activities of daily living, used a wheelchair for mobility, and needed extensive staff assistance with toileting, dressing, and grooming. She also had diagnoses including generalized weakness, psychoactive substance abuse, acute respiratory failure with hypoxia, adult failure to thrive, bipolar disorder, anxiety disorder, and Buerger’s disease, and she received scheduled and PRN pain medication for frequent severe pain that interfered with day-to-day activities. The resident was transferred to the hospital for shortness of breath, cough, and hypoxia and was hospitalized with pneumonia and kidney injury. Review of the progress note for the transfer showed no documentation that the family member had been notified of the hospital transfer, and there was no documentation that the resident’s representative was notified of the transfer and admission to the hospital. RN-C confirmed there was no documentation of notification to the resident’s family/emergency representative. The facility policy was to notify the provider, ombudsman, and family/emergency representative when a resident was transferred from the facility, and the interim DON stated the expectation was that the policy be followed with documentation of appropriate notifications.
Care Plan Not Revised for Resident’s Intentional Floor-Lowering and Behavioral Symptoms
Penalty
Summary
The facility failed to revise 1 of 12 sampled resident care plans for behaviors. The resident’s 10/31/25 MDS showed intact cognition with verbal behavioral symptoms directed toward others 1 to 3 days during the assessment period, substantial assistance needed for cares and transfers, use of pain medication as needed, a history of falls with minor injury, and use of an antipsychotic, antidepressant, antibiotic, and anticonvulsant. The resident also had multiple diagnoses including paranoid schizophrenia, borderline personality disorder, generalized anxiety disorder, PTSD, schizoaffective disorder, major depressive disorder with psychotic symptoms, cognitive communication deficit, dysphagia, abnormal posture, difficulty walking, muscle weakness, and a history of falling. Observation and interview showed the resident seated in a wheelchair, hunched over due to neck pain, with disheveled hair from rubbing his hands through it. He stated he would fall out of his wheelchair and bed on purpose because he did not like his wheelchair and would do it when he wanted to get out of bed. He also stated he did not like where he was seated in the dining room and made repeated negative comments about staff, saying they were dirty, rotten scoundrels and that they avoided his room even when he used the call light. Additional observations showed him swearing at staff and other residents while in the hall and going toward the smoking area. Progress notes documented repeated behaviors including lowering himself to the floor from his wheelchair, doing so to get staff attention, yelling and swearing, being agitated when he could not smoke, and voluntarily slipping or laying himself on the floor multiple times. The 10/17/25 care plan addressed ineffective coping, verbal aggression, withdrawal, irrational thoughts, and fall risk, but it did not mention that the resident intentionally placed himself on the floor from his wheelchair or bed. During interview, the RN agreed the care plan did not include that behavior, while an NA stated the resident would put himself on the floor when staff did not respond immediately or when he wanted attention or help getting to the smoking area.
Failure to Investigate Illegal Drug Incident
Penalty
Summary
The facility failed to investigate a potential crime involving illegal drugs for one resident who was found after a fall to be very unsteady and later had a crystal-like substance discovered in his room. On 1/4/26, nursing staff responded after the resident called for help and found he had fallen and gotten himself up without injury. Staff documented that he was very unsteady and seemed off, but the fall report did not mention suspicion of drug or alcohol use. During the same event, nursing assistants observed the resident focused on a Walmart bag, and after he quickly shoved it into a nightstand drawer, they found a small zip-lock bag containing a crystal-like substance. The bag was secured in the medication room and law enforcement was contacted. Law enforcement arrived, interviewed the resident and staff, field tested the substance as presumptive positive for methamphetamine, and reported that the resident admitted possession and said another resident had given it to him. Officers also confiscated a blue glass pipe and two lighters that staff identified as having been thrown over the fence surrounding the outdoor smoking area. Additional officers with a K-9 searched the resident rooms and the smoking area and found additional drugs and/or paraphernalia outside the fence. The resident had diagnoses including alcohol-induced chronic pancreatitis, anxiety disorder, alcohol use, and alcoholic hepatitis, and his admission MDS identified intact cognition and independence with ADLs. Facility staff and leadership acknowledged that no incident report was completed for the illegal drug event and that no further investigation was done by the facility. Resident council members later reported concerns that drugs and alcohol were being brought into the facility, that the social worker had been made aware, and that there had been no action or investigation into those concerns. The resident council meeting minutes did not document those concerns, although the ombudsman stated residents discussed drug and alcohol use at a meeting. The facility policy stated illegal substance use was not allowed and staff should recognize signs of use and notify law enforcement if a resident may have access to illegal substances, but the policy did not address investigating how the substances entered the facility or whether other residents were at risk.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with severe cognitive impairment and significant physical care needs was subjected to physical abuse by another resident. The incident occurred in the facility's smoking area, where the aggressor pulled the victim's hair, struck her in the back of the head, and pushed her wheelchair into a fence. The victim immediately experienced pain and reported the incident to several nursing staff, though she could not recall exactly whom she told. The victim also contacted a family member, expressing fear for her safety, especially after the aggressor threatened her the following day. The family member attempted to reach the facility but, unable to get a response, contacted the Sheriff's department to conduct a welfare check. Multiple staff interviews confirmed that the victim reported the abuse shortly after it occurred, with several nursing assistants recalling the resident's complaints of being hit and having her hair pulled. The aggressor admitted to grabbing the victim by the hair and shaking her during a verbal altercation. Documentation showed that the victim had a pain level of ten and required medication for her symptoms. The aggressor had a history of behavioral issues, including previous verbal altercations and threats, and had recently experienced a medication change that increased his discomfort and irritability. Despite the victim's immediate reports to staff, there was a delay in administrative awareness and response. The charge nurse on duty did not recall the incident, and the director of nursing was not informed until the following day. The facility's policy required protections against abuse, but the events indicate a failure to prevent and promptly address resident-to-resident physical abuse, resulting in the victim's decision to leave the facility against medical advice due to ongoing fear and lack of perceived safety.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse in a timely manner to the State Agency (SA) as required by policy. An incident occurred in which one resident, who had severe cognitive impairment and required substantial assistance with activities of daily living, reported that another resident pulled her hair, struck her in the back of the head, and pushed her wheelchair while outside in the smoking area. The incident was reported by the affected resident to nursing staff immediately after it happened, and the nursing assistant informed both the assistant director of nursing and the charge nurse. The residents involved were placed on 15-minute checks following the report. Despite the immediate internal notification, the facility did not submit the Facility Reported Incident (FRI) to the SA until approximately 25.5 hours after the event, exceeding the required reporting timeframe of no later than 2 hours for allegations involving abuse. The administrator confirmed that the FRI was submitted late, as she was not aware of the full details of the incident until the following day. Additionally, law enforcement was contacted by the resident's family member, and a welfare check was conducted prior to the FRI being submitted to the SA. Facility policy required immediate reporting of all alleged violations to the administrator, state agency, and other authorities within specified timeframes, which was not followed in this case.
Failure to Provide Complete and Accessible Survey Results
Penalty
Summary
The facility failed to ensure that survey results, including recertification surveys, complaint investigations, and facility plans of correction, were readily available for review by residents, family, visitors, and staff. During interviews and document review, it was found that a resident with moderately impaired cognition expressed a desire to view the results of state agency surveys but was unable to locate them. Upon inspection, the binder labeled as containing facility survey results was found behind other documents and was missing several required survey reports and plans of correction. Specifically, recertification surveys from certain dates and multiple complaint investigations, as well as associated plans of correction, were not present in the binder. Further interviews with facility staff confirmed that the survey results are considered public knowledge and should be accessible, but the binder did not contain all required documents. The administrator acknowledged difficulty in maintaining the availability of these documents, stating that they often go missing. No facility policy regarding the posting of survey results was provided when requested. This deficiency had the potential to affect all residents, family members, visitors, and staff by limiting access to important regulatory information.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as mandated by regulations.
Failure to Honor Resident Grievance Rights
Penalty
Summary
The facility failed to honor the resident's right to voice grievances without discrimination or reprisal. The facility did not establish or follow a grievance policy and did not make prompt efforts to resolve grievances as required. This deficiency was identified based on the facility's actions and inactions regarding the handling of resident grievances.
Failure to Update Care Plan for Medication Administration Preferences
Penalty
Summary
The facility failed to revise and update the care plan for a resident with anxiety disorder, borderline personality disorder, and delusional disorder, who exhibited new behaviors when her medications were not administered according to her preferences. The resident, who typically wakes up around 9:00 to 9:30 a.m. but sometimes sleeps later, relies on staff to wake her for morning medications. On the day of the incident, staff attempted to administer her medications but did not wake her, resulting in the medications being marked as not given. When the resident later requested her medications, she became visibly upset, raising her voice, pacing, and repeatedly returning to the medication cart. The situation was only resolved after the clinical registered nurse consultant contacted the on-call physician and obtained an order to administer the medications outside the usual time frame. Review of the resident's care plan revealed it did not address her preferences for wake-up times or being woken for medication administration, despite staff and the resident confirming this was her usual routine. Interviews with staff indicated a lack of awareness and documentation regarding the resident's preferences, and the care plan was not updated to reflect these needs until after the incident occurred. The facility's policy requires a comprehensive, person-centered care plan based on the resident's assessment and preferences, which was not followed in this case.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with established directives or the expressed wishes and objectives of the resident, resulting in noncompliance with required standards for individualized care.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Prevent and Assess Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to ensure adequate supervision and a comprehensive assessment to prevent resident-to-resident sexual abuse. A resident with a history of PTSD and cognitive impairment reported receiving unwanted, sexually explicit notes and advances from another resident over a period of months. Multiple residents expressed feeling unsafe due to the behaviors of the resident delivering the notes, and several staff members, including the DON and social worker, were made aware of the situation through direct reports, grievances, and resident council meetings. Despite these reports, the facility did not complete a comprehensive assessment of the affected resident for psychosocial harm, nor did it implement effective interventions or monitoring systems to ensure her safety and well-being. The affected resident had a documented history of childhood sexual abuse, PTSD, anxiety, depression, and cognitive impairment. Her care plan identified a need for a safe environment and support for coping with trauma, but interventions were limited to general reassurances and reminders, without specific measures to address the ongoing harassment. The resident repeatedly reported feeling unsafe, experiencing increased PTSD symptoms, and having trouble sleeping due to the unwanted attention and fear of further abuse. Other residents and staff corroborated the ongoing nature of the harassment, including the delivery of sexually explicit notes and unwanted advances in unsupervised areas such as the smoking area. The facility's response to the reports was inadequate, as staff primarily addressed the issue by speaking to the resident delivering the notes and advising the affected resident to avoid him. There was no evidence of a thorough assessment of the affected resident's psychosocial harm, no clear documentation of interventions to ensure her safety, and no updates to the care plan of the resident exhibiting the inappropriate behaviors. The facility also failed to monitor or restrict interactions effectively, and did not promptly report the abuse to the State Agency as required. The lack of comprehensive assessment, supervision, and timely intervention resulted in ongoing psychosocial harm to the affected resident and a failure to protect her and others from further abuse.
Failure to Timely Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to timely report multiple allegations of abuse, neglect, and theft involving a resident with severe cognitive impairment and a history of mental health issues. Over a period of several weeks, the resident and other female residents reported feeling unsafe due to another resident's sexually inappropriate behavior, harassment, and theft. Specific incidents included unwanted letters, verbal advances, and being followed to common areas, as well as reports of items being stolen. Despite these ongoing concerns, the facility did not report the allegations to the State Agency within the required timeframe. Documentation and interviews revealed that staff, including the DON and social services, were aware of the inappropriate behaviors and the residents' discomfort. The DON acknowledged receiving complaints and conducting internal investigations but chose not to report the incidents, citing a belief that the resident involved was capable of consenting to the interactions. However, there was no clear determination of the resident's capacity to consent, and the facility's own assessments indicated the resident was at risk for abuse due to cognitive impairment and other vulnerabilities. The facility's policy required immediate reporting of all alleged violations, including abuse and neglect, to the administrator, state agency, and other authorities. Despite this, the allegations were not reported until well after the incidents occurred, and some staff members were unaware of all the events. The delay in reporting and lack of timely action failed to provide the required protections for the residents involved.
Failure to Investigate and Protect Residents After Sexual Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate and protect residents following allegations of sexual abuse and harassment involving a resident with severe cognitive impairment and a history of mental health issues. Multiple reports were made by female residents, including one who reported feeling unsafe due to another resident's sexually inappropriate behavior, unwanted advances, and persistent letter writing. Despite these reports, the facility did not provide documentation of a comprehensive investigation, nor did it demonstrate that effective measures were taken to prevent further abuse or address the concerns raised by the residents. Documentation shows that the resident with severe cognitive impairment, along with other female residents, repeatedly expressed discomfort and fear regarding the behavior of another resident, who had a documented history of verbal and behavioral symptoms. The facility's response included minimal actions such as speaking to the alleged perpetrator and providing education, but there was no evidence of a thorough investigation, interviews, or protective interventions. The affected resident continued to receive inappropriate letters even after submitting a grievance, and staff interviews revealed a lack of documentation and uncertainty about the steps taken to ensure resident safety. The facility's own policy requires immediate and thorough investigation of abuse allegations, including interviews, documentation, and protective measures for residents. However, the facility was unable to provide requested investigation records, timelines, or evidence of actions taken to protect residents from further harm. Reports from staff, social services, and law enforcement indicated ongoing issues with harassment and a lack of effective response, further highlighting the facility's failure to meet its investigative and protective obligations.
Failure to Provide Resident Rights and Proper Discharge Process During Transfer
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate choices and rights during a transfer/discharge process. The resident, who had a history of emotional lability, alcohol use, cognitive communication deficits, depression, anxiety disorder, and osteonecrosis, was identified as having moderately impaired cognition and required staff assistance for mobility and daily activities. The care plan noted ineffective coping, a history of trauma, and a preference for female caregivers. The resident also exhibited behavioral issues, including negative statements, isolation, and anxiety, and was on 15-minute safety checks due to recent incidents involving other residents. Despite these complex needs, the facility did not provide the resident with adequate notice or options regarding the transfer. The discharge notice was completed on the same day as the transfer, and the resident was moved to a sister facility within a short timeframe, reportedly without being given the opportunity to discuss the decision with an advocate or to appeal the transfer. The Ombudsman was not notified until several days after the transfer, and the resident did not sign a discharge agreement. Interviews revealed that the resident felt rushed, was not allowed to process the discharge, and experienced emotional distress following the move. The facility's own policies require that residents be given notice, the right to appeal, and the opportunity to remain during the appeal process, none of which were followed in this case. Staff interviews indicated confusion about who initiated the discharge and whether the interdisciplinary team had discussed the transfer. The resident expressed a desire to return to the original facility and reported feeling isolated and depressed at the new location. The transfer was described as sudden, with the resident's belongings hastily packed and some personal items discarded. The facility did not document that the resident's mental health and substance use history were considered in the decision-making process, nor did they ensure the resident was prepared for a safe and supported transition.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to implement trauma-informed care for two residents diagnosed with post-traumatic stress disorder (PTSD). One resident had a history of childhood molestation and was identified as having severe cognitive impairment, depression, anxiety, and PTSD. Despite documentation of her trauma history and potential triggers, her care plan was not updated to address current PTSD-related symptoms or triggers. When this resident reported feeling unsafe due to harassment and sexual advances from another resident, the facility's response was limited to offering an alternative smoking area and notifying law enforcement, without comprehensive assessment or ongoing monitoring for psychosocial harm or exacerbation of PTSD symptoms. The second resident, also with a history of childhood sexual abuse and other mental health diagnoses, exhibited behaviors such as writing sexual notes and following female residents, including the first resident, to unsupervised areas. Although his care plan noted a preference for female caregivers and a history of trauma, it did not address his sexual behaviors toward others or include updated interventions. Reports from multiple residents about his inappropriate behavior were met with education for the resident, but there was no evidence of behavior management, supervision, or monitoring to mitigate the risk of re-triggering PTSD in other residents. Interviews with the affected resident and her family revealed ongoing distress, including increased PTSD symptoms, trouble sleeping, and feelings of being unsafe, despite repeated reports to staff. The facility's trauma-informed care policy required identification of triggers, individualized interventions, and ongoing evaluation with resident and family input, but these steps were not followed. The lack of comprehensive assessment, care plan updates, and effective interventions contributed to the deficiency in providing trauma-informed care.
Lack of Physician Documentation for Routine Visits
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and multiple psychiatric diagnoses had proper physician documentation for routine visits as required by facility policy. The resident's medical record showed physician visits occurred on several dates, but there was a lack of documentation for routine 60-90 day visits between two specific dates. During an interview, the DON confirmed that the physician had seen the resident and signed orders but did not document a note for the visit, and the physician could not recall the reason for this omission. The facility's policy requires residents to be seen by a physician within 30 days of admission, every 30 days for the first 90 days, and at least every 60 days thereafter, with documentation of these visits in the medical record.
Failure to Provide Comprehensive Behavioral Health Assessment and Person-Centered Planning
Penalty
Summary
The facility failed to implement comprehensive assessment and person-centered planning to ensure that the individualized behavioral health needs of two residents were met. One resident, with diagnoses including alcoholic encephalopathy, PTSD, anxiety, depression, and a history of childhood trauma, was admitted under a court commitment order and required multiple therapies and substance abuse treatment. Despite documented cognitive impairment and a history of trauma, the care plan lacked evidence that the facility identified the resident's responses to stressors or utilized person-centered interventions developed by the interdisciplinary team (IDT). The care plan was not reviewed or revised when interventions were ineffective or when the resident experienced a change in condition related to ongoing abuse. The resident reported feeling unsafe due to harassment and inappropriate sexual advances from another resident, including receiving disturbing notes and being followed in unsupervised areas. These incidents triggered the resident's PTSD symptoms, leading to increased anxiety, sleep disturbances, and emotional distress. The facility's records did not indicate that a comprehensive assessment was completed to determine psychosocial harm, nor were there clear interventions or monitoring systems implemented to ensure the resident's safety or provide supportive services. Family members also expressed concerns about the lack of follow-through on safety plans and the ongoing nature of the harassment. The second resident involved had a history of emotional lability, alcohol use, depression, and anxiety, and was reported by multiple female residents for inappropriate behavior, including writing notes and following them. Staff responses included educating the resident and checking on the affected resident during smoking breaks, but there was no evidence of a comprehensive behavioral health assessment or effective interventions. The facility's trauma-informed care policy outlined the need for individualized interventions and ongoing evaluation, but there was no documentation that these practices were followed in these cases. The facility did not provide additional policies related to behavioral health services.
Failure to Identify PTSD Care Needs and Maintain Social Services Staffing
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment (FA) that accurately identified the specific care and practices necessary to meet the needs of residents with post-traumatic stress disorder (PTSD). The assessment did not sufficiently address the requirements for managing PTSD, despite the presence of residents with this diagnosis or history. The FA was intended to use evidence-based, data-driven methods to evaluate the care needs of the resident population, including behavioral health and psychiatric conditions, but did not specify the interventions or resources required for PTSD care. Additionally, the facility did not maintain the identified number of staff required to provide social services, as the Social Services Designee (SSD) position was split between two facilities, resulting in only part-time coverage at each location. The administrator believed the SSD's time at the facility was sufficient, but the documented staffing plan called for one full-time SSD. This staffing shortfall had the potential to affect all residents with behavioral health needs, including those with PTSD, as the facility did not ensure adequate social services support as outlined in their own assessment and policy.
Failure to Monitor and Prevent Substance Abuse in Resident
Penalty
Summary
The facility failed to adequately assess and monitor a resident with a known history of substance use/abuse, leading to a deficiency in preventing and managing substance abuse incidents. The resident, who was wheelchair-bound and had a history of opioid, cocaine, and other stimulant abuse, left the facility and was later found intoxicated at a bar. Despite being aware of the resident's condition, the facility staff did not have protocols in place to monitor or prevent substance abuse, nor did they update the resident's care plan following the incident. Upon returning to the facility, the resident was found to be intoxicated and asleep, but there was no documentation of vital signs being taken or assessments performed to monitor the resident's condition. Interviews with staff revealed a lack of awareness and protocols for handling residents under the influence of alcohol or drugs. The charge nurse on duty was not informed of the resident's departure from the facility, and there was no clear guidance on how long to monitor the resident or what interventions to implement. The facility's existing care plan for the resident did not include specific interventions to prevent substance abuse or monitor for signs of intoxication. The facility's policy on safety for residents with substance use disorder did not address specific interventions for potential or actual substance abuse, highlighting a gap in the facility's preparedness to handle such situations. This lack of assessment, monitoring, and protocol contributed to the deficiency identified in the report.
Failure to Monitor and Report CHF Symptoms
Penalty
Summary
The facility failed to identify a significant change in condition and provide timely medical intervention for a resident with congestive heart failure (CHF), resulting in actual harm. The resident, who had a history of CHF, hypertension, diabetes, and coronary artery disease, experienced a significant weight gain of 61.8 pounds over a period of approximately five weeks. Despite the hospital discharge orders to monitor daily weights and report significant weight changes, the facility did not adhere to these instructions, and the resident's weight gain was not reported to the physician in a timely manner. The resident's medical records indicated multiple instances of shortness of breath, chest pain, and edema, yet there was a lack of documentation showing that the physician was notified of these symptoms or the significant weight gain. The facility's staff failed to follow the hospital's discharge orders and the medical director's modified orders for daily weights, which were only followed for one week. The resident continued to gain weight, and despite complaints of shortness of breath and chest pain, the facility did not seek immediate medical evaluation or treatment. Interviews with facility staff, including the RN, physician, and director of nursing, revealed that the facility did not have adequate procedures or training in place to recognize and act on changes in a resident's condition. The facility lacked a policy on identifying and responding to changes in condition, and there was no evidence of training for the majority of the nursing staff on this issue. The resident was eventually admitted to the hospital with CHF exacerbation and a heart attack, where she was treated with IV diuretics, resulting in a 20-pound weight loss before being discharged back to the facility.
Failure to Provide Accurate Ombudsman Contact Information
Penalty
Summary
The facility failed to provide accurate and accessible information regarding Ombudsman services to residents, as observed during a resident council group meeting. Five residents attending the meeting were unaware of how to contact the Ombudsman, and there was no mention of this information in the resident council minutes from June to November 2024. Although Ombudsman contact information was posted near the main entrance, it was outdated and incorrect, listing a former employee who no longer represented the facility. Interviews with the Ombudsman, the administrator, and the social service designee confirmed the inaccuracy of the posted information. The Ombudsman had previously requested updates to her contact details, but these were not made. The facility's August 2024 assessment and admission packet indicated that residents should be informed of their rights and provided with accurate contact information for relevant agencies, including the Ombudsman. However, this was not effectively implemented, leading to a deficiency in ensuring residents' rights to access advocacy services.
Deficiency in Physical Therapy Services and Staffing
Penalty
Summary
The facility failed to implement a comprehensive facility-wide assessment to ensure adequate resources and staffing were available to meet the needs of residents, particularly in the area of physical therapy (PT) services. The report highlights that the facility did not have PT services available from the end of August 2024, affecting residents who required these services. Despite having physician orders for PT, residents R20 and R37 did not receive the necessary therapy due to the absence of PT staff. Interviews with staff, including the Speech Therapist, Director of Nursing, and Registered Nurse, confirmed the lack of PT services and the absence of a plan to address this gap. Resident R37, who had intact cognition and was independent with activities of daily living, was dependent on staff for emotional, intellectual, physical, and social needs due to physical limitations. Despite having orders for PT, the facility did not provide these services, which were crucial for his mobility and strengthening. Similarly, Resident R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was not seen by a physical therapist despite having orders for PT and OT evaluations and treatments. The facility's failure to provide PT services as ordered had the potential to affect all 32 residents. Additionally, the facility's staffing plan was not adhered to, particularly on weekends, where the number of staff scheduled was less than required. The facility assessment identified the need for two licensed nurses on the day shift, but this was not implemented. The administrator acknowledged the discrepancy in the staffing plan and the need to update the facility assessment to reflect the actual services provided. The lack of PT services and inadequate staffing were significant deficiencies identified in the report.
Failure to Explain Arbitration Agreement
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was fully explained to 16 out of 32 residents and/or their representatives, leading to a lack of understanding and awareness of their right to refuse signing the agreement. The social service designee (SSD) was responsible for explaining the arbitration agreement during the admission process, but interviews with residents revealed that many did not recall receiving an explanation or understanding the agreement. Some residents, such as R148 and R10, reported not being aware of signing any agreement, while others, like R32, did not remember any discussion about the arbitration agreement. During a resident council meeting, several residents expressed that they were unaware of signing an arbitration agreement upon admission and did not understand what it entailed. The SSD had informed residents that the arbitration agreement was not a precondition for admission, but failed to ensure that residents comprehended the implications of signing the agreement. This lack of communication and understanding was further highlighted by R37, who initially claimed to understand the agreement but later admitted to feeling intimidated and unaware of what he had signed. The report also noted that some residents, such as R40, felt pressured to sign the documents without fully understanding them, fearing retaliation from staff. The SSD's failure to adequately explain the arbitration agreement and ensure residents' comprehension resulted in a significant deficiency, affecting the residents' rights to make informed decisions about their care and legal options.
Failure to Implement Enhanced Barrier Precautions and Inadequate Infection Surveillance
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for a resident with surgical wounds and a PICC line, as required by CDC guidelines. The resident, who was a new admission, had undergone multiple surgeries due to frostbite, resulting in amputations and the placement of an orthopedic pin. Despite the care plan identifying the need for EBP, observations revealed that there was no signage on the resident's door to indicate these precautions, and staff did not wear gowns during dressing changes. Interviews with staff confirmed the lack of awareness and implementation of EBP, with reliance on door signage that was absent. Additionally, the facility's infection control surveillance was inadequate, failing to monitor infections through to resolution over a three-month period. The Director of Nursing (DON), who was new to her role as both DON and Infection Preventionist (IP), admitted to being unsure about the necessary transmission-based precautions and acknowledged gaps in the surveillance process. Critical sections of the surveillance records, such as isolation status and resolution dates, were often left blank, making it impossible to determine if precautions were implemented timely or at all. The facility's infection surveillance policy required comprehensive tracking and analysis of infection-related data, but this was not effectively carried out. The DON had limited time to devote to infection control, and oversight from a sister facility's IP was minimal due to their absence. The administrator recognized the need for extensive oversight and improvement in the surveillance tracking system to prevent the potential spread of infection.
Fear of Retaliation Among Residents
Penalty
Summary
The facility failed to implement policies to ensure residents could voice concerns without fear of retaliation. Two residents, identified as R37 and R40, expressed fear of being retaliated against by facility staff. R37, who was admitted following an acute hospitalization for various diagnoses including metabolic encephalopathy and alcohol abuse, reported feeling intimidated by the social services designee (SSD) and feared being kicked out of the facility. He admitted to lying about understanding an arbitration agreement due to this fear. R37 also felt that the SSD was unapproachable and dismissive when he sought assistance with his concerns about housing and employment. R40, who was admitted with conditions such as vertebrogenic low back pain and sheltered homelessness, also reported fear of retaliation. She believed that the facility would expel residents who raised concerns, yet did not address issues with problematic residents. R40 felt that the facility misrepresented the services they could provide and was denied a request to see the MD by the DON. The facility administrator, when interviewed, stated that retaliation did not occur and expected concerns to be reported to her, although she was unaware of any such issues. Additionally, during a resident council meeting, several residents expressed discomfort in voicing concerns to the SSD due to fear of retaliation. The facility's Abuse, Neglect, and Exploitation policy outlined procedures for reporting concerns without fear of retaliation but lacked specific avenues for addressing fears of retaliation from management. The admission packet provided information on residents' rights and procedures for filing complaints without fear of reprisal, but the residents did not feel comfortable utilizing these resources.
Failure to Securely Store Lighters for Smoking Residents
Penalty
Summary
The facility failed to ensure that lighters were stored securely away from residents, leading to potential fire hazards for several residents who smoked. Observations and interviews revealed that residents were keeping their smoking materials, including lighters, in their rooms or on their person, contrary to the facility's policy. The policy required lighters to be stored at the nurse's station, but staff reported difficulty in enforcing this rule as residents often purchased additional lighters and kept them in their possession. Several residents, including those with cognitive impairments and various medical conditions, were observed keeping lighters and cigarettes in unsecured locations such as unlocked drawers or bedside tables. Despite the facility having an automatic wall-mounted lighter in the designated smoking area, residents continued to use personal lighters. Interviews with staff and residents indicated a lack of consistent enforcement of the smoking materials policy, with some residents never being asked to turn in their lighters. The facility's smoking policy outlined safety measures for the designated smoking area but did not explicitly mention the secure storage of lighters. Staff interviews highlighted challenges in managing residents' compliance with the policy, as they were unable to search residents' rooms or forcibly take lighters from them. This lack of enforcement and secure storage of lighters posed a risk of fire hazards within the facility.
Failure to Identify and Respond to Emergent Change in Condition
Penalty
Summary
The facility failed to ensure that five out of six nursing staff were competent in identifying an emergent change in condition and the need for hospital transfer for emergency medical evaluation for a resident with a history of congestive heart failure, hypertension, diabetes mellitus, and coronary artery disease. The resident experienced significant weight gain, shortness of breath, and chest pain, which are indicative of a potential heart attack or acute heart failure. Despite these symptoms, the staff did not follow the facility's assessment or develop policies and procedures to ensure staff had demonstrated competencies to perform care for residents. The resident's care plan required staff to monitor for signs and symptoms of congestive heart failure and report any significant changes, such as weight gain or shortness of breath. However, the facility did not complete the hospital discharge order to obtain a baseline weight, and the resident experienced a weight gain of 61.8 pounds since re-admission. Multiple nursing progress notes documented the resident's complaints of shortness of breath, chest pain, and significant weight gain, yet there was no indication that the physician or discharging hospital was notified, or that the resident was sent to the emergency department for further evaluation and treatment. Interviews with the facility's medical director, attending physician, and director of nursing revealed that the facility did not update the physician with the resident's weight changes in a timely manner. The facility lacked a policy on identifying and acting on a change in condition, and there was no professional reference for nursing staff to utilize. Only one of the five licensed nurses on staff had received training on recognizing and communicating resident changes in condition. The facility's failure to ensure staff competency and adherence to care plans resulted in a delay in emergency medical evaluation and treatment for the resident.
Inadequate Weekend Staffing Levels
Penalty
Summary
The facility failed to ensure adequate staffing levels on weekends as determined by their facility assessment. The Payroll Based Journal (PBJ) Report for quarter 3 identified excessively low weekend staffing, which triggered a deficiency. The facility assessment indicated that the day shift required two licensed nurses and three direct care staff, while the night shift required one licensed nurse and two direct care staff. However, a review of working schedules and timecards revealed that for 12 out of 26 weekend days, the day shift was staffed with only one licensed nurse, contrary to the facility's assessment requirements. Interviews with the administrator revealed a lack of awareness regarding the facility assessment's staffing requirements. The administrator reported that the low weekend staffing was attributed to the census and that the facility no longer cut hours since COVID. Despite the administrator's expectation for staffing to align with the facility assessment, she was unaware that the assessment required two licensed nurses on the day shift. The administrator also expressed uncertainty about the accuracy of the data submitted to CMS, as she believed there was a discrepancy in the reported staffing levels. The facility's policy required the submission of complete and accurate staffing information to CMS, verified by the administrator, HR director, and director of nursing, but this was not adhered to, leading to the deficiency.
Failure to Address Resident Grievance
Penalty
Summary
The facility failed to address a verbal grievance reported by a resident, identified as R5, who had intact cognition and a medical history including stroke, heart failure, renal insufficiency, and diabetes mellitus. R5 reported to the Social Service Director (SSD) that his gel pens, a key to his locked drawer, and a stylist were missing. Despite R5's report, the SSD did not recall the grievance and no documentation was found in the facility's grievance log from May to November 2024. Additionally, the facility did not provide a grievance policy by the end of the survey, indicating a failure to follow up on the resident's complaint and to maintain proper grievance documentation.
Failure to Facilitate Resident Communication with Care Coordinator
Penalty
Summary
The facility failed to ensure that a resident was provided with communication access to their county care coordinator (CC) and did not discourage or obstruct these communications. The CC made multiple attempts to contact the resident, R18, without success. On one occasion, the CC left contact information with an unidentified charge nurse, but the resident was not informed of the call. The social services designee (SSD) instructed the CC to direct all communication needs to her, citing the nurses' busy schedules. Despite this, the CC experienced difficulty reaching the SSD and was unable to contact R18, leading to a personal visit to the facility. During this visit, R18 reported not receiving any messages from the CC, indicating a breakdown in communication. Interviews with facility staff, including a trained medication aid (TMA) and a licensed practical nurse (LPN), revealed that there was no directive to forward calls to the SSD, and residents could take calls in a private room. The SSD confirmed that residents had the right to receive phone calls and that calls could be forwarded to her if necessary. However, the CC's repeated attempts to contact R18 were unsuccessful, and the resident was unaware of the attempts made to reach him. This situation suggests a failure in the facility's communication process, preventing the resident from accessing necessary services.
Inaccurate MDS Coding for Resident with Wounds
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set (MDS) for a resident, identified as R26, who was reviewed for wounds. R26 was admitted in September 2023 with medical conditions including an abscess on the buttocks, a non-pressure chronic ulcer with fat layer exposed, protein-calorie malnutrition, and end-stage renal disease. Despite these conditions, the MDS completed on 9/21/24 did not mention the non-pressure skin ulcer, although it noted the application of a nonsurgical dressing. Subsequent medical records, including a history and physical on 9/29/23 and a wound care progress note on 10/09/24, confirmed the presence of a left buttock abscess and a skin ulcer with fat layer exposed, respectively. Interviews conducted with the resident and staff revealed discrepancies in the MDS coding process. The resident was aware of daily wound dressing changes but was unsure why the wound had not healed over nine months. A registered nurse confirmed the presence of a non-pressure ulcer and acknowledged that the wound was previously coded under surgical wounds in the MDS. The Director of Nursing was unaware of the MDS coding process, and the MDS Coordinator's job description emphasized the need for accurate assessments and compliance with regulations. The facility's MDS 3.0 Completion policy required accurate assessment and identification of care needs, which was not adhered to in this case.
Failure to Revise Care Plans for Two Residents
Penalty
Summary
The facility failed to revise the care plans for two residents, R33 and R40, leading to deficiencies in their care. For R40, the care plan did not include target behaviors to be monitored despite her receiving anti-anxiety medication. Additionally, the care plan failed to identify potential adverse reactions to the antidepressant medication and did not address signs of increased depression or suicidal ideation, despite R40's history of suicidal thoughts. R40's medical conditions included vertebrogenic low back pain, muscle spasm, and a history of substance abuse, and she required both medication and non-medication interventions for pain management. For R33, the facility did not follow hospital discharge orders to obtain a baseline weight the morning after discharge and failed to conduct daily weight monitoring as required. The care plan did not include instructions for daily weights or when to report significant weight changes to the physician. This oversight resulted in a 60-pound weight gain over a month, leading to R33's readmission to the hospital with congestive heart failure and other complications. The facility delayed adding the physician's order for daily weights to the administration record, and the care plan was not updated to reflect these critical monitoring requirements.
Failure to Document Target Behaviors and Non-Pharmacological Interventions
Penalty
Summary
The facility failed to comprehensively assess and identify target behaviors and non-pharmacological interventions for residents receiving psychotropic medications. For one resident, identified as R8, the Minimum Data Set (MDS) assessment indicated severely impaired cognition and worsening behaviors, including hallucinations and intrusiveness. Despite being on multiple psychotropic medications, R8's care plan lacked specific target behaviors to monitor, and there was no mention of non-pharmacological interventions. The Director of Nursing (DON) acknowledged these deficiencies during an interview. Another resident, R246, was diagnosed with anxiety and major depressive disorder and was on antidepressant and anti-anxiety medications. The care plan for R246 did not specify non-pharmacological interventions, and the DON agreed that these should have been included upon admission. The care plan was updated only after surveyors pointed out the deficiencies. For resident R42, who had anxiety, depression, and PTSD, the care plan failed to identify specific target behaviors or side effects of the prescribed medications. Interviews with staff revealed a lack of documentation on target behaviors and side effects in the care plan. The DON was unaware of the side effects related to psychotropic medication use and planned to collaborate with the nursing team to address this issue. The facility's psychotropic medication policy required documentation of residents' responses to medications, including symptoms and therapeutic goals, which was not adhered to in these cases.
Failure to Label Opened PPD Vials
Penalty
Summary
The facility failed to ensure that two opened vials of Tuberculin (TB) purified protein derivative (PPD) solution were labeled according to the manufacturer's guidelines with an open date. During an observation, two open vials of PPD solution were found in the medication room refrigerator, with the pharmacy-labeled bag dated as dispensed on 9/28/24. However, neither vial was dated to indicate when they had been opened. The pharmacy list indicated that the solution was good for 30 days from the date opened. An LPN confirmed that medications were supposed to be dated when opened and acknowledged the absence of an open date on the vials. The DON stated that her expectation was for medications to be dated and initialed on the date of opening. A policy on medication labeling and storage was requested but not provided by the time of exit.
Failure to Provide Scheduled Dental Services
Penalty
Summary
The facility failed to provide scheduled routine dental services upon request for a resident, identified as R5. R5's quarterly Minimum Data Set (MDS) assessment indicated that his cognition was intact, and he had diagnoses of stroke, heart failure, renal insufficiency, and diabetes mellitus. During interviews conducted on two separate occasions, R5 reported that he had requested a dental appointment when he was first admitted to the facility, as he was missing all his molars and believed he would benefit from a partial denture. Observations confirmed that R5 was missing all but one upper molar. Additionally, oral assessments conducted on three different dates by RN-A documented R5's requests for a dental appointment. RN-A, who conducted the oral assessments, stated that she always asks residents if they would like a dental appointment and communicates their requests to the Social Service Director (SSD) either verbally or via email. An email dated June 4, 2024, from RN-A to the SSD confirmed that R5 had requested a dental appointment, noting that he had several cavities but no pain or difficulty chewing at the time. However, the SSD claimed she did not recall R5's request and acknowledged that she must have missed the email notification. This oversight resulted in the facility's failure to arrange the necessary dental services for R5.
Failure to Provide Physical Therapy Services
Penalty
Summary
The facility failed to provide physician-ordered physical therapy (PT) services for two residents, R20 and R37, due to the unavailability of PT services. R37, who had intact cognition and was independent with activities of daily living, was admitted to the facility following hospitalization with the goal of regaining strength and returning to independent living. Despite having orders for PT services, R37 did not receive PT after the end of August 2024, as the facility no longer had PT services available. Interviews with staff, including the director of nursing and the administrator, confirmed that PT services were not provided due to the lack of a PT provider. R20, who had moderate cognitive impairment and required substantial assistance with daily activities, was also affected by the lack of PT services. R20 had medical diagnoses including an artificial knee joint and osteoporosis, and was supposed to receive PT and occupational therapy (OT) as per physician orders. However, the facility could not provide documented evidence that R20 had been seen by a physical therapist. Interviews with the occupational therapist and the administrator revealed that the facility had been without a PT provider since the end of August 2024, and there was no interim plan to ensure PT services were provided. The facility's failure to provide PT services was further highlighted by the absence of a policy on the provision of skilled therapy services, which was requested but not provided by the end of the survey. The facility's August 2024 assessment indicated that it would provide ancillary services, including PT, but the lack of a PT provider and the absence of a plan to address this gap resulted in the deficiency noted in the report.
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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.
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Nursing homes near Wabasso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| River Valley Health And Rehabilitation Center Llc | 12 mi | ★★★★★ | 8 | 0 |
| Valley View Manor Hcc | 12.4 mi | ★★★★★ | 13 | 2 |
| Gil-mor Manor | 16.4 mi | ★★★★★ | 3 | 0 |
| St John Lutheran Home | 18.2 mi | ★★★★★ | 10 | 0 |
| Franklin Restorative Care Center | 19.9 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.