Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Woodlyn Heights Healthcare Center during CMS and state inspections, most recent first.
Insufficient staffing led to missed restorative care, incomplete ADL assistance, and delayed call light response. A resident ordered to receive daily passive ROM often did not get it because NAs said they lacked time, while another resident had dirty, untrimmed nails and a third resident remained unshaven despite stating he wanted daily shaving. Multiple residents reported waiting 30 minutes to several hours for help with toileting, transfers, and brief changes, and device reports showed many call light responses over 15 minutes, with some over an hour or two. Staff and the DON acknowledged they could not always complete resident care because there were not enough staff.
Improper dishwasher sanitizer testing was observed when dietary staff used test strips in ways that did not match manufacturer instructions. A dietary aide placed chlorine test paper on a rack and ran it through the machine, but the strip was lost or came out clear, and the aide stated this was her usual method. The DM then used chlorine and quat test papers in a manner that included leaving a strip in water on a plate and reported results of about 25 PPM and 300 to 400 PPM, while the facility policy and dishwasher data plate required 50 PPM available chlorine.
An unattended care sheet was left on top of a medication cart in a hallway, exposing personal and medical information for 11 residents, including names, room numbers, bath days, diets, hospice provider information, and details about dialysis, urinary catheter use, and blood sugars. Staff, residents, and visitors passed by the exposed information multiple times, and an RN later confirmed the sheet should not have been left unattended. The DON stated staff were expected to follow HIPAA and keep resident information from being exposed.
The facility failed to keep multiple resident rooms within the required temperature range, and residents with intact cognition reported being cold, wearing extra layers, hats, gloves, and multiple blankets while surveyors measured room temperatures below 71°F. The facility also served meals on hard plastic trays in the dining room, and a resident said the practice made meals feel like a hospital experience; dietary staff said it was their usual, quicker routine.
Failure to document informed consent for antipsychotic meds. A resident with moderately impaired cognition and delusions was receiving risperidone and Seroquel for psychosis/delirium, but the EMR had no signed consent for either medication. RN and DON stated psychotropic consents were to be obtained before starting or increasing meds, and the guardian said they were told about a new med for agitation but were not informed of the name, risks, or benefits and never signed a consent reviewing those details.
A resident with dementia, orthostatic hypotension, syncope, and impaired mobility received risperidone and Seroquel for psychosis/delirium, but the chart lacked orders or evidence of orthostatic BP monitoring. Staff interviews showed nurses were responsible for orthostatic BP checks, and the DON verified they had not been obtained despite ongoing antipsychotic use.
Failure to provide routine personal hygiene for two dependent residents. One resident who needed help with grooming and shaving said staff only shaved him on shower days even though he wanted daily shaving with morning cares; he was repeatedly observed with unshaven facial hair, and staff said shaving should be part of morning cares but was not completed. Another resident who required full assistance with personal hygiene had long, dirty fingernails and toenails that were not cleaned or trimmed on weekly audits, despite saying she had asked staff to do it and staff confirming nail care should be done on bath/shower days and as needed.
Failure to consistently provide daily passive ROM for a resident with impaired ROM in both lower extremities. The resident’s MDS, therapy referral, care plan, and task list all directed daily passive ROM to the hips, knees, and ankles, but the task record showed refusals, incomplete documentation, and missed entries. The resident said staff were supposed to do ROM daily but never did it, and NAs said they often could not complete it because they did not have enough time. The DON acknowledged staff should be completing ROM daily.
Failure to provide ordered eating assistance and supervision: A resident with dysphagia and hemiplegia had care plan interventions and MD orders for a mechanical soft diet, upright positioning, small bites/sips, and total feeding assistance, but was observed eating and drinking in bed and later in the dining room without staff sitting with him. An RN stated the resident was supposed to have someone with him to help ensure safe eating, and the DON stated staff should have been in the room or sitting with him during meals.
Failure to Enter Increased Nutritional Supplement Order: A resident with severely impaired nutrition, dysphagia, and hemiplegia had a care plan for supplements per provider order, but the EMR only reflected a house nutritional supplement once daily. The dietitian documented weight loss likely related to inadequate intake and requested the supplement be increased to TID between meals, yet staff interviews showed the resident continued to receive it once daily and the increased order had not been entered into the EMR.
Pharmacist recommendations were not acted on timely for a resident reviewed for unnecessary medication use. The resident was receiving risperidone and Seroquel, and pharmacy notes included concerns about the antipsychotic diagnosis, reducing poly-pharmacy, and gradual dose reduction. One pharmacy review was missing from the record, and the DON confirmed it had not been provided at the time of review. The facility policy required medication regimen review documents to be maintained in the resident medical record.
Failure to Document and Provide Pneumococcal Vaccination Status: The DON and MD verified that one resident's EMR lacked any pneumococcal immunization status or evidence the vaccine was offered or declined, and two other residents had prior pneumococcal vaccines documented but no evidence of shared clinical decision making for updated PCV dosing per CDC guidance. The facility policy required assessment of pneumococcal vaccination status on admission and that residents be offered and encouraged to receive pneumococcal vaccines.
The facility failed to ensure 3 of 3 staff reviewed were offered and/or provided education on the benefits and potential risks of the COVID-19 vaccine. The HR director stated there was no documentation that an offer or education had been provided to an LPN and a housekeeper, and the DON was unaware whether employees had been offered the vaccine. The MD stated staff should be educated on risks and benefits and offered the vaccine when available, consistent with the facility policy requiring documentation of the offer and education.
The facility failed to serve meals at a warm and palatable temperature, impacting residents' quality of life and nutritional intake. Observations showed that meal trays were not maintained at the expected temperature, with pancakes and oatmeal served cooler than required. Residents expressed dissatisfaction with the food temperature and quality, and the facility's In-Room Dining policy was not followed.
The facility failed to monitor and remove expired food from storage, risking foodborne illness. During a tour, the DD found opened bags of sliced ham and turkey without proper date marking, and an expired bag of turkey. The DD admitted to not expecting staff to date quickly used deli meat and was unable to explain the process for ensuring thawed food was safe. The facility's policy required date marking on high-risk foods.
The facility failed to consistently implement enhanced barrier precautions (EBP) for three residents, leading to potential infection risks. A staff member assisted a resident with an indwelling catheter without wearing a gown, despite EBP signage. Another resident with a PICC line for MRSA treatment was attended by a nurse who did not follow EBP guidelines. Additionally, staff did not use gowns or gloves for a resident with a pressure ulcer, misunderstanding the necessity of EBP. These lapses highlight a failure to adhere to CDC guidelines for infection control.
A facility failed to manage constipation for a resident on narcotics, inadequately addressed a resident's Darier's disease by not providing necessary supplies and consistent care, and neglected to manage a PICC line for a resident on IV antibiotics, lacking orders and documentation for dressing changes and infection monitoring.
A resident's POLST indicating DNR status conflicted with the EMR showing 'Full Code' in a facility. The resident confirmed their DNR preference, but staff acknowledged the inconsistency, which posed a risk of unwanted resuscitation. The facility's policy required matching documentation, but lacked guidance on ensuring consistency.
A resident was observed receiving peri-care with the window blinds open, exposing them to the outside parking lot. The staff member providing care did not close the blinds, which was later acknowledged as an oversight. The resident expressed a preference for the blinds to be closed during care. The DON confirmed that staff are trained to ensure privacy, but recent audits on privacy had not been conducted.
A resident's motorized wheelchair was found to be dirty, with dust, food particles, and stains, indicating a failure to maintain a clean and safe environment. Staff interviews revealed confusion over cleaning responsibilities, and the resident expressed dissatisfaction with the unclean state of the wheelchair. The facility lacked a policy on wheelchair cleaning, and the DON acknowledged the potential infection control and dignity issues.
A resident with multiple medical conditions, including diabetes, did not receive proper nail care from staff, despite being dependent on them for personal care. Observations showed the resident's nails were long and dirty, and staff failed to trim them despite requests. The facility's protocol required weekly nail trimming, especially for diabetic residents, but this was not adhered to.
The facility failed to reassess and document the participation of two residents in their ROM programs. One resident received ROM exercises only four times in 28 days, with refusals and lack of documentation noted. Another resident refused exercises 12 times in 30 days, with similar documentation issues. Staff were often too busy to perform exercises, and refusals were not communicated to the nurse manager. The facility lacked a policy on ROM, contributing to the deficiency.
A resident with intact cognition and multiple medical conditions attempted to order alcohol via a mobile delivery service, but the facility failed to assess and develop interventions to ensure safety. Staff were unaware of the behavior, and the care plan lacked necessary monitoring or interventions. The facility's policy on alcohol consumption was not provided.
A resident experienced significant weight gain in less than 10 months, but the facility failed to assess and implement interventions for weight management. Despite the resident's desire to lose weight and reports of unhealthy eating habits, the care plan and EMR lacked recommendations or education. Staff interviews revealed a lack of awareness and communication regarding the resident's weight management needs.
A facility failed to attempt a gradual dose reduction (GDR) or document a clinical rationale for not doing so for a resident on psychotropic medications. The resident, with anxiety and depression, was prescribed aripiprazole and duloxetine. Despite the pharmacist's recommendation to switch to a less stimulating antidepressant, the prescriber declined the GDR, citing the resident's refusal and ongoing psychiatric care. The director of nursing confirmed no GDR was attempted since admission.
The facility did not ensure adequate surety bond coverage for resident personal fund accounts, affecting 20 residents with positive balances totaling $27,953.42. The existing bond covered only up to $25,000, as acknowledged by the administrator, who noted that the corporate office managed the bond. No updated bond evidence was provided, despite the facility's policy requiring sufficient coverage.
The facility lacked a qualified therapeutic recreation director (TRD) to oversee the activities program, as the current TRD had no prior healthcare recreation experience and had not completed the required certification. A resident expressed dissatisfaction with the lack of weekend activities, leading to boredom. The TRD had not been recording residents' attendance at activities, and the facility's job description did not specify the need for state-approved certification, as required.
The facility did not accurately post nurse staffing information, failing to display the total number and actual hours worked by LPNs separately. Instead, LPN hours were incorrectly included in RN staffing hours due to a computer program error. The staffing coordinator confirmed the issue, and no policy on posting nurse staffing information was provided.
The facility failed to reconcile narcotic and controlled substances on two medication carts as per policy, with numerous unsigned spaces on count records indicating incomplete shift counts. This affected six residents with active orders for controlled substances, raising concerns about medication security amid a possible drug diversion incident.
A resident with multiple diagnoses, including COPD and bronchiectasis, was admitted to a facility with orders for respiratory chest physiotherapy, which was not provided. The resident also received oxygen therapy without a physician's order. Interviews and records indicated a lack of consistent treatment, contributing to the resident's death from severe sepsis and pneumonia.
The facility failed to maintain a homelike environment for two residents due to another resident playing loud music, which disturbed their ability to hear their own music or television. Despite the facility's aim to manage noise levels, the DON was unaware of any complaints, and no policy for a homelike environment was provided.
A resident with complex medical needs, including dialysis and respiratory concerns, did not have a comprehensive care plan addressing these issues. Interviews with staff revealed a lack of coordination in care planning, and the facility's policy on person-centered care was not followed, leading to significant omissions in the resident's care plan.
A resident with multiple health issues, including a gastrostomy-jejunostomy, was not properly monitored for hydration status by the facility staff, leading to severe dehydration and hospitalization. The facility's staff, including the DON and dietitian, failed to communicate and assess the resident's hydration needs, and no policy on hydration assessment was provided.
A resident with end-stage renal disease and dependence on dialysis did not receive the required pre-and-post dialysis assessments at a facility. Despite orders for regular monitoring, only three assessments were completed. Interviews with staff revealed a lack of consistent monitoring and absence of a formal policy, contributing to the deficiency.
A resident with a complex medical history, including sepsis and COPD, required pre-and-post dialysis assessments, which were not consistently documented by the facility. Vital signs were inaccurately recorded, and staff interviews revealed a lack of awareness regarding the resident's respiratory status and condition. This deficiency highlights lapses in documentation and monitoring of the resident's health needs.
The facility failed to ensure a neutral and fair arbitration process by not allowing residents or their representatives to agree on the selection of a neutral arbitrator and a convenient venue. Interviews revealed that residents were unaware of the implications of signing the arbitration agreement, and staff acknowledged the importance of neutrality but had no input or training on the agreement's contents.
The facility failed to disinfect community use glucometers between patient use and did not keep a wound vac machine off the floor, posing significant infection control issues. Staff acknowledged the importance of these practices but did not adhere to them, contrary to the facility's policies and guidelines.
The facility failed to assess and supervise two residents for self-administration of medications. One resident was self-administering creams without a SAM assessment, while another resident with cognitive impairment was found self-administering oral medications and using a nebulizer unsupervised, despite being deemed inappropriate for SAM.
The facility failed to ensure Level II PASARRs were conducted, documented, and retained for two residents with significant mental health diagnoses. Despite initial screenings indicating the need for further evaluation, the facility did not follow up with the lead agency, and the medical records clerk admitted to giving up on the process. The administrator confirmed the expectation for staff to complete PASARRs but did not ensure this was done.
The facility failed to implement proper infection control techniques during wound care for two residents and did not comprehensively assess, monitor, or provide necessary care for a resident with an intrathecal baclofen pump. Staff used uncleaned medical equipment and surfaces, and were unaware of the baclofen pump's existence and required monitoring.
A resident with moderate cognitive impairment and multiple diagnoses was not assisted with her bilateral hearing aids, despite care plans indicating their necessity. Staff were unaware of the hearing aids' location and had not been helping the resident with them, leading to potential communication and isolation issues.
The facility failed to ensure appropriate administration of oxygen and CPAP therapy for a resident with COPD and obstructive sleep apnea. The resident received oxygen at a higher rate than prescribed without proper documentation or notification to the NP. Additionally, the facility did not follow up on the resident's need for a new CPAP machine, despite recommendations from the hospital and the resident's request for information.
A resident with severe cognitive impairment and on psychotropic medications did not receive appropriate side effect monitoring, orthostatic blood pressure checks, or non-pharmacological interventions. The care plan and MAR lacked documentation of these essential monitoring activities, as confirmed by the nurse manager and director of nursing.
A resident did not receive prescribed medications for hypertension and high cholesterol for 30 days. The facility's medical orders and Medication Administration Record lacked documentation of these medications, and interviews confirmed the oversight. The facility's policy on medication management was requested but not provided.
A resident with heart failure, diabetes, and depression required dental extractions due to pain and fractured teeth. Despite a recommendation from a dentist, the facility failed to schedule an appointment with an oral surgeon, leaving the resident in pain and with difficulty eating. Interviews revealed a lapse in the process for setting up out-of-facility appointments.
The facility failed to maintain accurate medical records and ensure proper monitoring for two residents, leading to discrepancies in medication lists and lack of monitoring for an intrathecal baclofen pump. The nurse manager and director of nursing confirmed these issues, highlighting deficiencies in medication management and record-keeping practices.
The facility failed to ensure that binding arbitration agreements were clearly communicated and understood by two residents before signing. Both residents, despite having intact cognition, could not recall being informed that signing the agreement was not a condition of admission or having the agreement explained in a manner they understood. The social worker and administrator confirmed that the arbitration paperwork was provided by corporate and that they had limited roles in its explanation.
The facility failed to post nurse staffing information on the weekend and in a timely manner at the start of the shift. The displayed information was outdated, and no postings were available for several days. The staffing coordinator admitted to errors in posting dates, and the director of nursing and administrator emphasized the importance of accurate postings. A facility policy for staff posting was not provided.
The facility failed to accurately record and account for thirty morphine tablets ordered for a resident, resulting in the medication being unavailable when needed. Staff interviews revealed a lack of proper procedures for ensuring the medication was received and logged, and the facility's policy did not provide clear guidance on actions to take if medication was not received.
Insufficient Nursing Staffing Led to Missed Care and Delayed Call Light Response
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet resident needs, and survey findings showed missed restorative care, incomplete ADL assistance, and repeated delays in responding to call lights. The report identified that the lack of staffing had the potential to affect all 46 residents in the facility. Facility staff, including the DON, NA-F, NA-E, NA-H, NA-B, NA-C, and NA-D, stated that they often did not have enough time to complete required resident care tasks during their shifts. For restorative nursing, R29 had intact cognition, impaired ROM in both lower extremities, and required maximum assistance with bed mobility and lower body dressing. Therapy and the care plan directed staff to provide passive ROM to both hips, knees, and ankles daily. The task record showed multiple refusals, completed entries, entries marked not applicable without further documentation, and several dates with no entry at all. R29 stated staff were supposed to complete ROM daily but never did it. NA-D stated she rarely refused to do ROM when she had time, but often did not have enough time to complete everything on her shift. NA-B stated it was often hard to complete everything needed during the shift and that ROM often did not get done. The report also documented incomplete ADL care for R43 and R44. R43 had intact cognition and required full assistance with personal hygiene, including grooming. R43 was observed with long, dirty fingernails, and family trimmed some nails because staff had not done so. Staff stated nail care was usually done on bath or shower days, while the DON stated nail care was expected on bath/shower days and as needed, including when a resident requested it. R44 had intact cognition and required moderate assistance with personal hygiene, including shaving. R44 stated he preferred to be shaved daily and that staff only shaved him on shower days. He was repeatedly observed with unshaven facial hair, and staff acknowledged they had not shaved him because they were multitasking and could not get to the small tasks. The record lacked evidence that R44 was offered and refused shaving. Resident interviews and device activity reports showed repeated long waits for assistance. Residents reported waiting 30 minutes to several hours for call lights to be answered, help with toileting, transfers, and brief changes. Device reports documented numerous call light response times over 15 minutes, including response times over an hour and, for some residents, over two hours. During observation, one resident’s call light remained on for 39 minutes before staff responded. Staff stated there was not enough staff to complete showers, ROM, shaving, and other resident care, and that one aide per hallway was not enough. The DON acknowledged that longer call light times were not acceptable and that staff had told her they were not able to complete their work and care for residents.
Improper Dishwasher Sanitizer Testing
Penalty
Summary
The facility failed to perform adequate testing, per the manufacturer’s instructions, to ensure proper sanitization of dishware used for meal preparation and meal service when using a low-temperature dishwashing machine. The NSF data plate for dishwasher Model ADC-44 indicated that when chemical sanitizer was used, the required level was 50 parts per million (PPM) of available chlorine. The facility’s Cleaning Dishes/Dish Machine policy also stated that proper chemical concentrations and machine function should be verified before machine use and that the sanitization level should reach 50 PPM. During observation and interview, a dietary aide was seen using an Ecolab Chlorine Test Paper by placing it on a rack and running it through the dishwasher, but the strip could not be located after the cycle. The aide then repeated the process with another strip, which was found but was clear, and stated this was how she always tested the machine and that she had not tested it yet that day. The dietary manager then used Hydrion Chlorine test paper by placing it on a rack and later leaving it in water that had accumulated on a plate for about 30 seconds; the result was about 25 PPM, which she stated was not acceptable. The dietary manager also used Hydrion QT-10 test paper and stated the result was 300 to 400 PPM, which she considered acceptable, despite the manufacturer instructions and the facility policy indicating a 50 PPM chlorine sanitization level.
Unattended Care Sheet Exposed Resident Information
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when an unattended care sheet was left on top of a mobile medication cart in the hallway corridor of the long-term care unit. During continuous observation, the care sheet titled Nurse/TMA contained personal information for 11 residents, including names, room numbers, bath days, diets, hospice provider information, and details regarding dialysis, urinary catheter use, and blood sugars. Staff, residents, and visitors walked or were wheeled past the unattended care sheet 17 times while it remained exposed. RN-B later verified that the unattended care sheet belonged to RN-A and should not have been left unattended, and the DON stated that staff were expected to follow HIPAA and ensure personal information was not exposed or unattended. The facility policy titled Notice of Privacy Practices/HIPAA, revised September 23, 2013, identified the requirement to appropriately safeguard resident information.
Cold Resident Rooms and Non-Homelike Dining Service
Penalty
Summary
The facility failed to maintain resident rooms at a comfortable temperature between 71 and 81 degrees Fahrenheit for 7 of 7 residents reviewed who reported their rooms were cold. Residents with intact cognition and varied diagnoses, including type 2 diabetes with circulatory complications, spinal stenosis, osteomyelitis, failure to thrive, traumatic brain injury, metabolic encephalopathy, chronic respiratory failure, cellulitis, and alcoholic cirrhosis, described being cold in their rooms and were observed wearing multiple layers, hats, gloves, shawls, and several blankets. Surveyor temperature checks found room temperatures below the required range, including readings such as 70.5, 69.5, 66.6, 67.4, 58, 64.4, 69.5, and 69.1 degrees Fahrenheit, with some window or bathroom areas even colder. Residents described ongoing discomfort, including cold rooms every day, freezing overnight, and no heat in bathrooms. One resident stated the whole building was cold and that staff layered their clothes too. Another resident reported the room was cold especially at night, and another said the plastic on the windows stayed up all year. The maintenance director stated the facility did not have room thermometers or thermostats, used a laser thermometer to check temperatures, and explained that hallway sensors, shut vents, single-pane windows, and wind through improperly shut windows affected heat distribution. The facility also failed to provide a homelike dining experience for a resident who was independent with eating. During observation in the main dining room, residents were seated at tables but were served meals on hard plastic trays with plates, cutlery, and drinks left on top of them. No staff were observed removing the trays or placing items directly on the tables. The resident stated meals were normally served this way and that it made the dining experience feel like being in a hospital. Dietary staff stated the practice was used because it was easier and quicker, and the dietary manager confirmed it had been their routine practice.
Failure to Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to obtain and document informed consent, including an explanation of the risks and benefits, for a resident who was receiving antipsychotic medications. The resident had a quarterly MDS assessment showing moderately impaired cognition with delusions, and during interview was observed lying in bed, waking from a nap, pleasant, and confused in some responses. The resident’s medication records showed orders for risperidone 0.5 mg twice daily for psychosis and Seroquel for delirium, with Seroquel administered under two different order periods in December. Review of the resident’s EMR found no signed consent for either antipsychotic medication. RN-B stated that consent for psychotropic medications was obtained by floor nurses before administration and, if the resident could not consent, the family, guardian, or POA would be contacted; the signed form would then be uploaded to the EMR. The DON stated that consents were expected to be completed before starting or increasing psychotropic medications, but the consents for the resident’s risperidone and Seroquel could not be located. The resident’s guardian confirmed giving consent for a new medication for agitation but stated they were not told the medication name or the risks and benefits and had never signed a consent reviewing those details.
Failure to Monitor Orthostatic Blood Pressure With Antipsychotic Use
Penalty
Summary
The facility failed to provide appropriate side effect monitoring for a resident receiving antipsychotic medications. The resident had moderately impaired cognition with delusions, no hallucinations, no behaviors, wandering, or rejection of care, and was diagnosed with orthostatic hypotension, dementia, syncope and collapse, and myocardial infarction. The resident used a walker and wheelchair and required supervision for chair-to-bed transfers. The resident’s medication orders included risperidone 0.5 mg twice daily for psychosis and Seroquel 50 mg twice daily for delirium, and the medication administration record showed the medications were administered throughout December. The resident’s order summary, MAR, and blood pressure summary report lacked orders or evidence that orthostatic blood pressures were obtained, and the progress notes did not show the resident refused them. During observation, the resident was able to transfer from bed to wheelchair with supervision and the RN confirmed the resident was able to stand. Staff interviews showed nurses were responsible for obtaining orthostatic blood pressures, but they were not automatically done for residents on antipsychotic medications unless ordered or otherwise indicated. The DON stated the expectation was that orthostatic blood pressures would be obtained when a resident started an antipsychotic medication and monthly thereafter, and verified they had not been obtained for this resident despite current antipsychotic use.
Failure to Provide Routine Personal Hygiene
Penalty
Summary
The facility failed to ensure routine personal hygiene was provided for two residents who were dependent on staff for ADL care. One resident, who had intact cognition and required moderate assistance with personal hygiene including shaving, stated he did not like facial hair because it became itchy and said he had told staff this before. He reported staff only shaved him on shower days, while his preference was to be shaved daily with morning cares. He was observed multiple times with approximately a quarter-inch beard and mustache, and later continued to have unshaven facial hair. Staff interviews confirmed shaving should be included with morning cares and could be done anytime, but one NA stated she had not shaved him because she could not get to all the small tasks and another NA stated shaving should have been offered with morning cares but was not because she had to multitask. The resident’s care plan did not identify the level of assistance needed for personal hygiene such as shaving, and progress notes lacked evidence that he was offered and refused shaving. A second resident, who had intact cognition and required full assistance with personal hygiene cares, had weekly body audits showing her fingers and toenails were not cleaned or trimmed. During observation, she stated her nails were long and dirty and said she had asked staff to clean and trim them, but it was not done. Her fingernails were observed to be about 1/4 inch long with brown substance under them, and her toenails were also about 1/4 inch long. A family member trimmed two fingernails on one hand during the survey. Staff stated nail care was usually done on bath or shower days, and the DON stated nail care was expected on bath/shower days and as needed, including when a resident asked for it. The resident’s care plan identified a grooming ADL deficit and need for staff assistance, but the weekly audits documented that nail care had not been completed.
Failure to Consistently Provide Daily Passive ROM
Penalty
Summary
The facility failed to consistently implement a restorative nursing program to maintain or improve range of motion for one resident with impaired ROM in both lower extremities. The resident’s quarterly MDS indicated intact cognition, no rejection of care behaviors during the look-back period, impaired ROM in both lower extremities, and a need for maximum assistance with bed mobility and lower body dressing. A therapy referral for a maintenance program directed staff to provide passive ROM to both hips, knees, and ankles daily, and the resident’s care plan and task list also directed daily passive ROM to those joints. The task list for the month showed the ROM task was refused five times, completed 17 times, charted as not applicable five times without any further entry showing it was completed or refused that day, and had no entry on three dates. During interview, the resident stated staff were supposed to complete ROM daily but never did it. Nursing assistants stated they often did not complete ROM because they did not have enough time during their shifts, and one stated she would rarely refuse to complete ROM when she had time. The DON stated staff should be completing ROM daily and acknowledged the NAs had reported difficulty finding enough time to complete it; the facility was looking to get a restorative aide, but it had not yet happened.
Failure to Provide Ordered Eating Assistance and Supervision
Penalty
Summary
The facility failed to follow developed interventions for eating assistance for one resident with dysphagia and hemiplegia. The resident’s quarterly MDS indicated severely impaired nutrition, moderate assistance with transfers and personal hygiene, and independence with eating. However, the care plan dated 9/13/25 stated the resident required setup help for eating, should be encouraged to get out of bed for all meals, had a history of dysphagia and hemiplegia, and had a goal of having no choking episodes when eating or drinking through the review date. The resident’s order summary dated 11/5/25 directed that he receive a mechanical soft diet, be upright in a chair or bed while eating and drinking, be given small bites and sips, and require total assistance with feeding. During observation, the resident was seen lying in bed with a meal tray and beverage in front of him and no staff in the room, and later was seen in the dining room eating and drinking without staff at the table while an RN stood at the medication cart at one end of the dining room. The resident drank coffee and ate toast without signs of choking or coughing. During interview, the RN stated the resident was supposed to have someone sitting with him to help ensure safe eating, and the DON stated staff should either be in the resident’s room or sitting with him in the dining room while he was eating to ensure he was safe.
Failure to Enter Increased Nutritional Supplement Order
Penalty
Summary
The facility failed to ensure ordered nutritional interventions were provided to support weight gain for one resident who had severely impaired nutrition on the quarterly MDS. The resident’s care plan identified a potential nutritional problem related to dysphagia and hemiplegia and stated the resident would receive supplements per provider order. The order summary showed a house nutritional supplement once daily for nutritional support, but it did not include the increased frequency of three times daily that the dietitian later requested. The dietitian documented weight loss likely related to inadequate intake and noted the house nutritional supplement should be increased to three times a day between meals. The resident’s weight decreased from 140 lbs to 137 lbs, a 2.14% loss. During interviews, the dietitian stated she sent the increased supplement order to the nurse manager and DON to be entered into the EMR, the RN stated the resident was receiving the supplement once daily after breakfast, and the DON stated the email from the dietitian had been received but the order had not been entered because it was the nurse manager’s responsibility.
Pharmacist Recommendations Not Timely Addressed
Penalty
Summary
The facility failed to ensure that pharmacist recommendations were acted upon timely for one resident, R9, who was reviewed for unnecessary medication use. The pharmacist’s recommendation records from July 2025 through December 2025 showed several reviews, including a recommendation on 8/17/25 that Seroquel, an antipsychotic medication, needed an appropriate diagnosis, which was signed by the provider on 8/20/25; a 9/23/25 recommendation to consider a trial discontinuation of agents to reduce poly-pharmacy because R9 was receiving risperidone 0.5 mg twice daily and Seroquel three times daily, with the prescriber not responding until 12/18/25 to change Seroquel to twice daily and plan to discontinue if possible; and a 12/16/25 recommendation for gradual dose reduction, with the provider responding that GDR was being completed. The November 2025 pharmacist recommendation was not provided. During interview, the DON stated she believed she had the November 2025 pharmacy review for R9 but verified it had not been provided at the time and would be provided when located. The facility policy stated that all medication regimen review documents would be maintained in the resident medical record.
Failure to Document and Provide Pneumococcal Vaccination Status
Penalty
Summary
The facility failed to ensure recommended pneumococcal vaccinations were offered and/or provided in a timely manner for one resident, R4, whose electronic medical record lacked information on pneumococcal immunization status. During interview and record review, the DON verified there was no documentation to support that R4 had been offered or had declined the vaccine, and the medical director stated R4's record lacked evidence that pneumococcal immunization was offered or administered at any time. The facility also failed to document shared clinical decision making for two residents, R16 and R27, who were identified as needing or being offered updated pneumococcal immunizations per CDC guidance. R16's record showed prior pneumococcal vaccines, including Pneumovax 23 doses in 2019 and 2022, and the DON verified CDC guidance indicated a dose of PCV15, PCV20, or PCV21 was due at least one year after the last PPSV23 dose, but it was not done. R27's record showed Prevnar 13 in 2018 and Pneumovax 23 in 2019, and the DON verified CDC guidance indicated one dose of PCV20 or PCV21 at least five years after the last pneumococcal vaccine dose applied, but this was not done. The DON and medical director both stated there was no documentation or evidence that shared decision making occurred for R16 or R27, despite the facility policy requiring assessment of pneumococcal vaccination status upon admission and providing residents the opportunity and encouragement to receive pneumococcal vaccinations.
Failure to Offer and Document COVID-19 Vaccine Education for Staff
Penalty
Summary
The facility failed to ensure staff were offered and/or provided education regarding the benefits and potential risks associated with COVID-19 vaccination for 3 of 3 staff reviewed: LPN-A, LPN-B, and HSK-A. Review of CDC Clinical Guidance for COVID-19 Vaccination indicated an updated COVID-19 vaccine was recommended for most adults ages 18 years and older, including people who live and work in LTC settings. During interview, the HR director stated the facility did not have documentation that COVID-19 vaccine education or an offer of vaccination had been provided to LPN-A, LPN-B, or HSK-A. The DON stated she was unaware if employees were offered the COVID-19 vaccine, and the MD stated her expectation was that the facility would ensure staff were educated on the risks and benefits and offered the vaccine when available. The facility policy stated each staff member would be offered the vaccine and provided education regarding its benefits, risks, and potential side effects, and that documentation of this education and offer would be maintained.
Failure to Serve Meals at Appropriate Temperature
Penalty
Summary
The facility failed to ensure that meals were served at a warm and palatable temperature, affecting the quality of life and nutritional intake for residents. Observations revealed that meal trays, including hot cereal and pancakes, were not maintained at the expected temperature of approximately 155 to 165 degrees Fahrenheit. Instead, the pancakes were measured at 108 degrees Fahrenheit, and the oatmeal at 119 degrees Fahrenheit. The dietary staff, including Cook-A, acknowledged the difficulty in keeping the food warm due to the lack of assistance from nursing assistants, who were occupied with resident care tasks. Interviews with residents revealed dissatisfaction with the temperature and quality of the food served. One resident reported not eating breakfast anymore because it was always served cold, while another expressed reluctance to ask staff to reheat meals due to perceived annoyance from the staff. Another resident mentioned that although meals served in the dining room were better, room-trays were often served cooler, and staff would only reheat food upon request. The facility's In-Room Dining policy, which mandates that hot food must be served hot, was not adhered to, contributing to the deficiency.
Failure to Monitor and Remove Expired Food
Penalty
Summary
The facility failed to ensure proper monitoring and timely removal of food stored in refrigerators and freezers, which could lead to foodborne illness. During an initial tour with the dietary director (DD), it was observed that the walk-in cooler contained two opened plastic bags of sliced ham dated nearly a month prior, two opened undated bags of sliced turkey, and an unopened bag of sliced turkey with an expiration date that had passed. The DD admitted that the deli meat was used quickly, so staff were not expected to date it, and was unable to explain the process for ensuring thawed food was not kept past its safe consumption date. In a follow-up interview, the DD acknowledged that deli meat should be discarded after seven days of opening to prevent illness. The facility's Food Storage policy required date marking on high-risk foods to indicate when they should be consumed, sold, or discarded.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure staff consistently implemented enhanced barrier precautions (EBP) in accordance with CDC guidelines to reduce the risk of infection spread among residents. This deficiency was observed in three residents, each residing on different wings of the care center. For one resident, identified as R4, a staff member was observed providing peri-care without wearing a gown, despite the presence of signage indicating the need for EBP due to the resident's use of an indwelling catheter. The staff member admitted to not using the gown due to being in a hurry, although they were aware of the EBP requirements. Another resident, R28, who had a PICC line and was receiving IV antibiotic therapy for MRSA, also experienced a lapse in EBP. A registered nurse entered the resident's room without wearing a gown and only put on gloves after entering, failing to adhere to the EBP guidelines. The nurse acknowledged the mistake and recognized the potential risk of infection spread due to not following the proper precautions. For resident R12, who had an unstageable pressure ulcer, staff were observed not wearing gowns or gloves while assisting with transfers, despite the presence of EBP signage on the door. One nursing assistant believed the signage was inaccurate, while another did not think a gown was necessary unless performing wound care. The director of nursing confirmed that staff were expected to follow the EBP signs and utilize additional PPE during personal care activities.
Deficiencies in Bowel Management, Skin Condition Care, and PICC Line Management
Penalty
Summary
The facility failed to adequately assess and manage constipation for a resident with moderate cognitive impairment who was on multiple medications, including narcotics. Despite the resident expressing feelings of constipation and a change in bowel movement patterns, the care plan lacked comprehensive interventions beyond medication administration. The facility's documentation did not reflect any evaluation or intervention to address the resident's constipation, and the last continence evaluation was completed two years prior. Another deficiency involved the inadequate management of a resident's non-pressure skin condition, Darier's disease. The resident's care plan did not include specific interventions for this condition, and there were inconsistencies in wound care and shower schedules. The resident reported sitting in dirty bandages and not receiving the necessary supplies, such as Aquaphor and a mesh vest, to manage her skin condition effectively. The facility's documentation lacked comprehensive assessments or reassessments of the resident's wound care needs and preferences. The facility also failed to manage a PICC line for a resident receiving IV antibiotic therapy. There were no orders or documentation regarding the changing of the PICC line dressing or monitoring the insertion site for infection. The dressing was not changed since insertion, and the nurse verified the lack of orders and documentation. The facility's policy on PICC line care was requested but not provided, indicating a lack of adherence to professional standards of care.
Discrepancy in Resident's Code Status Documentation
Penalty
Summary
The facility failed to ensure that a resident's Physician Orders for Life Sustaining Treatment (POLST) matched the code status information in the electronic medical record (EMR). The resident, identified as R112, had a POLST indicating a Do Not Attempt Resuscitation (DNR) status, which was signed by both the resident and a nurse practitioner. However, the EMR displayed a conflicting 'Full Code' status. This discrepancy was discovered during a review of the resident's medical records and interviews with staff, including a registered nurse (RN) and the director of nursing (DON). The resident, R112, had a medical history that included suicidal ideation, opioid use, sleep apnea, diabetes mellitus, and acute kidney failure. During an interview, R112 confirmed their wish for a DNR status, as outlined in the POLST. The RN responsible for R112's care acknowledged the conflict between the EMR and the POLST and expressed concern about the risk of performing unwanted resuscitation. The DON and a registered nurse unit manager confirmed the expectation that the EMR and POLST should match to ensure resident wishes are honored. The facility's policy required a physician order for either DNR or Full Code in all medical records, but it lacked guidance on ensuring consistency between the EMR and POLST.
Failure to Ensure Privacy During Personal Care
Penalty
Summary
The facility failed to maintain privacy during the provision of personal care for a resident, identified as R4, who was observed receiving peri-care with the window blinds open to the outside parking lot. The incident occurred in the early morning when a staff member, dressed in dark-blue scrubs, was assisting R4, whose legs and peri-area were exposed and visible from the sidewalk. The staff member, identified as NA-B, was observed wiping R4's peri-area without closing the blinds, which allowed visibility from outside. Upon being alerted by a surveyor, NA-B acknowledged the oversight and closed the blinds. R4, who had intact cognition and no delusional thinking, later confirmed that staff did not always close the blinds during care and expressed a preference for them to be closed. The Director of Nursing (DON) stated that staff receive training on ensuring privacy during care, which includes closing blinds and doors, but acknowledged that recent audits on privacy had not been conducted. The facility was unable to provide a policy on privacy with care when requested.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to maintain a clean and safe environment for a resident, identified as R39, who was observed using a motorized wheelchair that was visibly dirty. The wheelchair had dust, food particles, and stains on various parts, including the joystick controller, armrests, foot pedal, and frame. Despite the resident's cognitive intactness and independence in using the wheelchair, the lack of cleanliness was evident during multiple observations over several days. Interviews with nursing assistants and housekeeping staff revealed confusion and inconsistency regarding the responsibility for cleaning motorized wheelchairs, with some staff believing it was the responsibility of housekeeping and others thinking it was the nursing assistants' duty. The resident expressed dissatisfaction with the state of her wheelchair, highlighting that it remained unclean despite her frequent outings. The registered nurse/nurse manager acknowledged the issue, noting the potential for disease or infections due to the unclean condition of the wheelchair. The director of nursing emphasized the importance of maintaining clean wheelchairs to prevent infection and uphold the resident's dignity. However, the facility was unable to provide a policy on wheelchair cleaning, indicating a lack of established procedures for ensuring the cleanliness of residents' mobility aids.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
The facility failed to ensure proper nail care for a resident who was dependent on staff for personal care. The resident, who was cognitively intact and did not refuse care, had several medical conditions including post-polio syndrome, morbid obesity, Type 2 diabetes, and functional quadriplegia, which made him reliant on staff for activities of daily living. Observations revealed that the resident's fingernails were excessively long and had a light brown substance underneath. Despite the resident's requests for nail trimming, staff members repeatedly failed to provide this care. Interviews with the resident and staff confirmed that the resident's nails were not trimmed as expected. The resident reported receiving three bed baths a week, during which nurses were supposed to trim his nails due to his diabetic condition. However, the nurses did not fulfill this responsibility until after the issue was raised by a surveyor. The Director of Nursing stated that the facility's protocol required weekly nail trimming, especially for diabetic residents, but a specific policy on nail care was not provided when requested.
Failure to Reassess and Document ROM Program Participation
Penalty
Summary
The facility failed to comprehensively reassess and develop interventions for two residents, R9 and R39, who were part of a range of motion (ROM) program. R9, who was cognitively intact and had multiple diagnoses including post-polio syndrome and functional quadriplegia, was supposed to receive passive ROM exercises daily. However, documentation showed that R9 only received ROM four times over a 28-day period, refused six times, and there was no documentation for 18 days. Interviews revealed that nursing assistants were often too busy to perform the exercises, and there was a lack of communication about refusals to the nurse manager. R39, also cognitively intact, had diagnoses including cerebral palsy and functional quadriplegia. R39's ROM program included several specific exercises to be performed daily. However, documentation indicated that R39 refused ROM 12 times, participated on four days, and there was no documentation for 14 out of 30 days. Interviews with staff confirmed that R39 often refused the exercises, but these refusals were not communicated to the nurse manager. The facility's director of nursing stated that ROM programs are crucial for maintaining mobility and preventing contractures, and expected follow-up with therapy after several refusals. However, the nurse manager had not been informed of the refusals or lack of participation, and there was no facility policy on ROM provided. This lack of reassessment and communication contributed to the deficiency in maintaining the residents' ROM programs.
Failure to Address Resident's Alcohol Ordering Behavior
Penalty
Summary
The facility failed to comprehensively assess and develop interventions to promote safety and reduce the risk of injury for a resident who attempted to order alcohol via a mobile delivery service. The resident, who had intact cognition and several medical conditions including asthma, a history of seizure disorder, and diabetes mellitus, was found to have ordered alcohol on multiple occasions. Despite this behavior being documented in progress notes, the resident's care plan and medication administration records lacked any interventions or monitoring related to alcohol consumption. Interviews with staff revealed a lack of awareness and direction regarding the resident's attempts to obtain alcohol. Nursing assistants and registered nurses were not informed about the resident's behavior and were unsure of the facility's protocols for handling such situations. The director of nursing and a registered nurse unit manager were also unaware of the resident's actions until informed by the surveyor, indicating a failure to assess or act upon the situation in a timely manner. The facility's policy on alcohol consumption was requested but not provided, further highlighting the deficiency in addressing the resident's safety and care needs.
Failure to Address Significant Weight Gain in Resident
Penalty
Summary
The facility failed to comprehensively assess and care plan appropriate interventions for a resident who experienced significant weight gain. The resident, who was cognitively intact and independent with most activities of daily living, was admitted to the facility weighing 210.6 pounds and gained 78.3 pounds in less than 10 months. Despite being assessed multiple times for significant weight gain, the facility did not implement any interventions or provide education to the resident on healthy choices. The resident expressed a desire to lose weight and reported snacking on unhealthy foods, but the facility's dietary progress notes lacked any recommendations or education on weight management. Interviews with staff revealed a lack of awareness and communication regarding the resident's weight management needs. The resident's care plan and electronic medical record did not include any interventions or discussions about weight loss goals. The dietary director and dietitian had only spoken with the resident once and were focused on residents with significant weight loss. The director of nursing confirmed the absence of care-planned recommendations and staff education to support the resident's weight loss goals. The facility's inaction and lack of communication contributed to the deficiency in addressing the resident's nutritional needs.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medication
Penalty
Summary
The facility failed to attempt a gradual dose reduction (GDR) or document a clinical rationale for not attempting it for a resident reviewed for unnecessary medications. The resident, who was cognitively intact and independent with most activities of daily living, was admitted with diagnoses including unspecified personality disorder, generalized anxiety disorder, and major depressive disorder. The resident was prescribed aripiprazole and duloxetine for anxiety and depression. The pharmacist recommended a GDR for duloxetine, suggesting it could worsen anxiety, and proposed switching to an SSRI. However, the prescriber did not forward this recommendation to the resident's psychiatrist and declined the GDR, citing the resident's ongoing work with a psychiatrist and refusal to change medications. The pharmacist consultant reiterated the GDR recommendation three months later, but it was again declined by the prescriber, who stated the resident refused changes and was followed by psychiatry. The director of nursing confirmed that no GDR had been attempted since the resident's admission. The pharmacist expressed concerns about the use of a stimulating antidepressant like duloxetine for a resident with anxiety, noting better outcomes with less stimulating alternatives. Despite these recommendations, the facility did not document a clinical rationale for not attempting a GDR, leading to the deficiency finding.
Inadequate Surety Bond Coverage for Resident Personal Funds
Penalty
Summary
The facility failed to ensure that resident personal fund accounts were adequately insured with a surety bond to cover the total account balance. An undated resident fund account record, received on December 3, 2024, identified 20 residents with positive balances totaling $27,953.42. However, a Continuation Certificate dated April 2, 2024, indicated that the facility's surety bond only covered up to $25,000. During an interview on December 4, 2024, the administrator acknowledged that the surety bond was insufficient to cover the residents' personal fund accounts and mentioned that the corporate office oversaw the surety bond. The administrator intended to reach out to see if an updated version was available, but no evidence of an updated surety bond was received. The facility's Resident Trust Funds policy, dated December 2023, stated that a surety bond would be purchased by the Home Office to ensure the security of all resident trust funds deposited into the account.
Unqualified Activities Director and Lack of Weekend Programs
Penalty
Summary
The facility failed to have a qualified therapeutic recreation director (TRD) to oversee the activities program, which is a requirement to ensure competent assessment and implementation of activities programming. The current TRD, who had been in the role for approximately three months, had a background in elementary education and lacked prior experience in a healthcare recreation program. The TRD had not completed the necessary certification course for activities programming in a nursing home, having only partially completed the first module of a self-paced online course. Additionally, the TRD had not been recording residents' attendance at activities, which is a critical component of assessing and planning activities for residents. A resident with intact cognition expressed dissatisfaction with the lack of activities on weekends, stating that they often became bored and wandered around to find people to converse with. The facility's job description for the Life Enrichment Coordinator did not specify the need for state-approved certification or occupational therapy credentials, which are required under F680. The administrator acknowledged the TRD's lack of credentials and the importance of having a credentialed activity director to ensure quality care for residents.
Inaccurate Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted nurse staffing information accurately displayed the total number and actual hours worked by licensed staff for each shift on a daily basis. Specifically, the daily staff postings from November 19, 2024, through December 2, 2024, included a row for Licensed Practical Nurses (LPNs) but did not include the total number or actual hours worked by LPNs, unlike the rows for Registered Nurses (RNs) and Certified Nursing Assistants (CNAs). The facility's staffing schedules indicated that LPNs worked on several days during this period. During an interview, the staffing coordinator acknowledged that the LPN hours were not being separately categorized as required and were instead being included in the RN staffing hours. The coordinator attributed this issue to a computer program that was incorrectly pulling the staffing data for the postings. The facility did not provide a policy regarding the posting of nurse staffing information.
Failure to Reconcile Controlled Substances
Penalty
Summary
The facility failed to ensure proper reconciliation of narcotic and controlled substances on two of the three medication carts reviewed, as per their established policies and procedures. This deficiency was identified during a facility-reported incident investigation for possible drug diversion. The facility's Controlled Substances policy required that narcotic records be reconciled by a physical count at the change of each shift by the oncoming and outgoing licensed nurse, with signatures verifying the count. However, numerous instances of unsigned spaces on the Controlled Drug Count Records were observed, indicating that the required counts were not consistently performed. During the investigation, it was found that the 500-hall medication cart had multiple days where the required signatures were missing, with some days having all spaces left blank. Similarly, the hall one medication cart also showed numerous unsigned spaces across several days. Interviews with registered nurses revealed that the counting of controlled substances was supposed to occur at each shift change, but the blanks on the flow sheets indicated that this process was not consistently followed. The Director of Nursing acknowledged that the facility's policy was not being adhered to, as the controlled substances record was not signed for every shift. This lapse in procedure had the potential to affect six residents who had active orders for narcotic and/or controlled substances on the reviewed medication carts. The failure to follow the policy raised concerns about the accountability and security of controlled medications, especially in light of the reported incident of possible drug diversion.
Failure to Provide Ordered Respiratory Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide the ordered respiratory care for a resident, leading to significant harm. The resident was admitted with a primary diagnosis of sepsis and additional diagnoses including bronchiectasis, dysphagia, obstructive sleep apnea, and COPD. The resident was supposed to receive respiratory chest physiotherapy three times a day, but this therapy was not provided. Additionally, the resident received oxygen therapy without a physician's order. The lack of proper respiratory care contributed to the resident's death. The resident's medical records indicated that the facility did not document the administration of the chest physiotherapy vest or obtain the necessary orders for its use. Despite recommendations from respiratory therapy for the use of DuoNebs and hypertonic saline nebulizers in conjunction with chest physiotherapy, these treatments were not consistently administered. The facility's treatment administration record showed incomplete assessments and a lack of documentation regarding the resident's respiratory treatments. Interviews with facility staff and family members revealed that the resident did not consistently receive the prescribed vest therapy. The resident's family expressed concerns about the lack of treatment, and the facility's director of nursing acknowledged that the vest treatment order was missed. The resident's condition deteriorated, leading to hospitalization for acute respiratory failure, and ultimately, the resident passed away due to severe sepsis and pneumonia.
Failure to Maintain a Homelike Environment Due to Loud Music
Penalty
Summary
The facility failed to provide a homelike environment for two residents, R2 and R3, due to the loud music played by another resident, R4. Observations on the 600 hallway revealed that R4 played explicit music loudly with his door open, which could be heard from the front entrance and other hallways. R2 and R3, both cognitively intact, expressed their inability to hear their own music or television due to R4's loud music. R2 reported the issue to her nurse, but was unsure if any investigation was conducted. R3 also mentioned that the loud music had been a problem for about a week. R4 admitted to playing his music loudly to retaliate against other residents who were playing their music and television loudly. He stated that he usually used headphones but felt entitled to play his music loudly since he paid to live there. The DON stated that the facility aims to create a homelike environment by maintaining cleanliness and ensuring noise levels do not disturb other residents. However, the DON was unaware of any complaints regarding loud music. The administrator mentioned that concerns about noise would typically be addressed through discussions with the involved residents, but no policy for a homelike environment was provided upon request.
Failure to Develop Comprehensive Care Plan for Resident with Complex Needs
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as R1, who had multiple complex medical needs. R1 was admitted with a primary diagnosis of sepsis and had a history of various other conditions, including end-stage renal disease, congestive heart failure, and chronic obstructive pulmonary disease. Despite these significant health issues, the care plan did not address critical areas such as dialysis, tube feeding, respiratory therapy, and risk factors for urinary tract infections. Interviews with facility staff, including the Director of Nursing (DON), nursing assistants, and MDS coordinators, revealed a lack of coordination and communication in creating and updating the care plan. The DON acknowledged that essential elements like dialysis treatment and COPD management should have been included in the care plan. The MDS coordinators also expressed concerns about missing information related to tube feeding and dialysis, indicating that these omissions were not in line with their expectations for comprehensive care planning. The facility's policy on person-centered care planning emphasized the need for a detailed and individualized approach, including measurable objectives and timeframes to meet residents' needs. However, the care plan for R1 lacked specific interventions, preferences, and risk assessments, which were necessary to address the resident's complex medical conditions. This deficiency in care planning was identified through a combination of record reviews and staff interviews, highlighting a significant gap in the facility's adherence to its own policies and procedures.
Failure to Monitor Resident Hydration Status
Penalty
Summary
The facility failed to adequately monitor and assess the hydration status of a resident who was receiving tube feedings. The resident, who had a history of sepsis, hypokalemia, moderate protein-calorie malnutrition, bronchiectasis, dysphagia, COPD, gout, and lymphedema, was admitted with a gastrostomy-jejunostomy and was on a Novasource Renal diet. The treatment administration record indicated that the resident was to receive tube feeding with specific water flushes, which were to be adjusted based on hydration status. However, the facility staff did not monitor or assess the resident's hydration status as required, leading to the resident being severely dehydrated and requiring hospitalization. Interviews with facility staff, including the DON and the dietitian, revealed a lack of communication and responsibility regarding the resident's hydration needs. The dietitian believed the resident was meeting nutritional needs and relied on nursing staff to report any necessary adjustments, while the DON expected the dietitian and facility provider to determine hydration needs. The resident's guardian reported that the resident was so dehydrated during a dialysis session that an ambulance was called. The facility did not provide a policy on assessing hydration status when requested, indicating a systemic issue in monitoring and managing the resident's hydration needs.
Failure to Conduct Pre-and-Post Dialysis Assessments
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services. The resident, who had a history of sepsis, kidney transplant, anemia in chronic kidney disease, end-stage renal disease, and dependence on renal dialysis, was admitted to the facility with specific orders for pre-and-post dialysis assessments. These assessments were to be conducted on Mondays, Wednesdays, and Fridays, and included checking vital signs, level of consciousness, and other symptoms such as muscle cramping, itching, and pain. However, the facility only completed three such assessments from the time of the resident's admission, despite the requirement for regular monitoring. Interviews with the facility's RN and DON revealed that the assessments were not consistently performed as required. The RN acknowledged that the assessments should have been conducted before and after each dialysis session, while the DON expressed concern over the lack of completed assessments. Additionally, there was no contract between the facility and the dialysis center, and the facility failed to provide a dialysis assessment policy and procedure when requested. This lack of consistent monitoring and absence of a formal policy contributed to the deficiency in care for the resident.
Failure to Document Vital Signs and Assessments
Penalty
Summary
The facility failed to accurately document vital signs and assessments for a resident who required pre-and-post dialysis assessments three times a week. The treatment administration record (TAR) indicated that these assessments were not completed on all but three occasions during the resident's stay. Additionally, vital signs were recorded while the resident was not present in the facility, indicating a lapse in proper documentation and monitoring. The resident had a complex medical history, including sepsis, bronchiectasis, dysphagia, obstructive sleep apnea, and chronic obstructive pulmonary disease (COPD). The resident was admitted to the facility with a primary diagnosis of sepsis and required skilled nursing care, including respiratory therapy and scheduled dialysis. Despite these needs, the facility's records showed inconsistencies in documenting the resident's respiratory status and vital signs, which were crucial for monitoring the resident's condition. Interviews with facility staff revealed a lack of awareness and recall regarding the resident's condition and the completion of required assessments. The registered nurse responsible for the resident on a specific date could not remember the vital sign readings and did not notice any concerns with the resident's appearance. The nurse manager and other staff members also failed to identify respiratory issues, despite the resident's known history of lung problems and the need for continuous oxygen. This lack of documentation and awareness contributed to the deficiency identified in the report.
Failure to Ensure Neutral and Fair Arbitration Process
Penalty
Summary
The facility failed to offer a neutral and fair arbitration process by ensuring both the resident or their representative and the facility agree on the selection of a neutral arbitrator and that the venue is convenient to both parties. This deficiency was identified for 11 of 17 residents reviewed for binding arbitration. The arbitration agreements indicated that the arbitration would be administered by the American Health Lawyers Association (AHLA) and conducted at a site selected by the facility. Interviews with residents and staff revealed that residents were not aware they were giving up their right to litigation in a court proceeding and that the arbitrator and location were decided by the facility. Staff members, including the social worker and business office manager, acknowledged the importance of having a neutral arbitrator and a mutually agreed-upon site but stated that the arbitration agreement was provided by corporate and they had no input or training regarding its contents. One resident, who had intact cognition and diagnoses of heart failure, diabetes, and depression, stated she did not understand the implications of signing the arbitration agreement. The social worker and business office manager both expressed concerns about the lack of neutrality in the arbitration process and the potential stress caused by the facility-selected site. The facility's policy on voluntary binding arbitration agreements directed that the facility should provide for the selection of a neutral arbitrator agreed upon by both parties and a venue convenient for both parties. However, the facility's practice did not align with this policy, leading to the identified deficiency.
Infection Control Deficiencies in Glucometer Use and Wound Vac Placement
Penalty
Summary
The facility failed to ensure community use glucometers were properly cleaned and disinfected between patient use for four residents. During observations, a registered nurse (RN) was seen using the same glucometer for multiple residents without disinfecting it between uses, despite the manufacturer's guidelines requiring cleaning and disinfecting with Medline Micro-Kill+ disinfecting wipes. The RN acknowledged the importance of disinfecting the glucometer but admitted to not doing so between uses. Another RN also confirmed that the glucometer should be cleaned between uses but was observed wrapping it in a sani-cloth instead of following proper disinfection procedures. The Director of Nursing (DON) and the facility's policy both emphasized the need for cleaning the glucometer between uses to prevent infection spread, but this was not adhered to during the observations. Additionally, the facility failed to ensure a wound vac machine was kept off the floor for a resident reviewed for wound care. The resident had a stage 4 pressure ulcer and required a wound vac machine, which was observed on the floor next to the resident's bed. The RN verified that the wound vac should not be on the floor due to the risk of bacteria traveling up to the wound. The nurse manager and the infection preventionist/DON both stated that the wound vac should be kept in a bag and hung away from the floor to prevent infection. The facility's policies on infection prevention and control, as well as surveillance and monitoring, were not followed in these instances. The failure to disinfect the glucometer between uses and to keep the wound vac machine off the floor posed significant infection control issues, as confirmed by multiple staff members and the facility's own guidelines.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
The facility failed to assess the ability of two residents to self-administer medications (SAM). Resident R27, who was cognitively intact and had multiple medical diagnoses including multiple sclerosis, psychosis, and diabetes, was found to be self-administering Calazinc and diclofenac creams without a SAM assessment. The resident had been receiving these medications via mail and applying them as needed, with the nurses providing the creams without proper documentation or assessment. The Director of Nursing confirmed that a SAM assessment was necessary but had not been completed for R27. Resident R10, who had moderate cognitive impairment and multiple medical conditions including chronic obstructive pulmonary disease and heart failure, was observed self-administering oral medications and using a nebulizer without supervision. Despite a SAM assessment indicating that R10 was not appropriate for self-administration, the resident was found with medications on her bedside table and a nebulizer set up for unsupervised use. Interviews with nursing staff confirmed that R10 required supervision for medication administration and should not have been left alone with her medications. The facility's failure to conduct proper SAM assessments and ensure appropriate supervision for medication administration led to these deficiencies. The Director of Nursing acknowledged the need for assessments and supervision but did not provide a facility policy on self-administration of medication when requested by the surveyors.
Failure to Complete and Document PASARR for Two Residents
Penalty
Summary
The facility failed to ensure a Level II Pre-Admission Screening and Resident Review (PASARR) was conducted, documented, and retained for two residents reviewed for PASARR. Resident R4, who was admitted on 3/10/21, had diagnoses including bipolar disorder, depression, diabetes, and delusional disorder. Despite an initial Pre-Admission Screening (PAS) indicating the need for further evaluation by the county or managed care program, R4's medical record lacked evidence of a final determination. The medical records clerk acknowledged the incomplete status of the Level II PASARR and admitted to giving up on following up after a few attempts. The administrator confirmed the expectation for staff to complete and follow up on PASARRs but did not ensure this was done for R4. Similarly, Resident R27, who had diagnoses including multiple sclerosis, unspecified psychosis, polyneuropathy, generalized anxiety, major depression, and personality disorder, also lacked evidence of a final determination for the Level II PASARR. The initial PAS indicated a referral for mental illness OBRA Level II to the lead agency, but the facility did not follow up on the results. The medical records clerk confirmed the lack of follow-up, and the administrator stated it was the clerk's responsibility to ensure the PASARR was completed. A policy on PASARR was requested but not received, indicating a possible lack of formal procedures in place to ensure compliance.
Infection Control and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure appropriate infection control techniques during wound care for two residents. For one resident, the registered nurse (RN) used uncleaned medical scissors and a single towel for wound care on both legs, and placed medical tape on unclean surfaces before using it on the resident. The RN admitted to not cleaning the scissors between uses and acknowledged the improper handling of medical tape. The Director of Nursing (DON) expressed disappointment in the staff's failure to follow proper infection control protocols, especially given the residents' vulnerability to infections. Another resident also received wound care with improper infection control techniques. The RN placed medical tape on an uncleaned drawer before using it on the resident's wound dressing. The RN admitted to not knowing if the drawer was clean and acknowledged that the tape should not have been placed on an unclean surface. The DON reiterated the importance of proper infection control techniques and expressed concern over the staff's actions. Additionally, the facility failed to comprehensively assess, monitor, and provide necessary care for a resident with an intrathecal baclofen pump. The resident's medical records lacked documentation of the pump's placement, dose, and rate of medication. Staff members, including a registered nurse and a nurse manager, were unaware of the pump's existence and did not monitor it. The DON confirmed the lack of monitoring and documentation for the baclofen pump, emphasizing the importance of staff awareness and proper monitoring of such devices.
Failure to Assist Resident with Hearing Aids
Penalty
Summary
The facility failed to provide assistance for hearing appliances for a resident (R17) who had bilateral hearing aids. R17, who had moderate cognitive impairment and several diagnoses including Parkinson's, encephalopathy, chronic pain, anxiety, dementia, diabetes, and depression, was observed multiple times without her hearing aids. Despite the care plan and Kardex indicating that R17 required bilateral hearing aids, staff members were unaware of the location of the hearing aids and had not been assisting R17 with them. R17 expressed that she did not know where her hearing aids were, and staff members, including a registered nurse and nursing assistants, confirmed that they had not been putting the hearing aids in for her or were unaware of their existence. R17's family member also confirmed that the hearing aids were necessary for her to understand conversations and avoid feelings of isolation, but noted that the hearing aids were never in her ears during visits. During interviews, staff members indicated that they expected information about hearing aids to be on the Kardex and that they would be responsible for putting them in if they were aware. However, multiple staff members, including nursing assistants who had worked with R17 for an extended period, stated they had never seen the hearing aids. The Director of Nursing acknowledged the importance of hearing for R17's quality of life. The facility's policy on hearing aids was requested but not provided, indicating a potential gap in policy adherence or availability.
Failure to Administer Appropriate Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate administration of oxygen therapy and CPAP therapy for a resident with multiple respiratory conditions. The resident, who had intact cognition and required assistance with daily activities, was observed receiving oxygen at a rate higher than prescribed without proper documentation or notification to the nurse practitioner. The resident's medical records indicated a history of obstructive sleep apnea, COPD, and heart failure, and the hospital discharge summary recommended the use of a CPAP machine, which the resident had not used since admission to the facility in 2021 due to a misplaced machine. The resident's oxygen levels were inconsistently monitored, with several missed assessments and instances where oxygen was administered at a rate of three liters per minute, contrary to the prescribed one liter per minute. The resident reported shortness of breath to an aide, leading to an increase in oxygen, but this change was not communicated to the nurse practitioner or documented in the progress notes. The nurse manager and floor nurse were unaware of the increased oxygen rate, and the nurse practitioner expressed concern about the potential adverse effects of excessive oxygen on the resident's health. The facility also failed to follow up on the resident's need for a new CPAP machine. Despite the resident's request for information about obtaining a new CPAP and the importance of CPAP therapy for her health, no steps were taken to schedule a sleep apnea test or update the CPAP settings. The director of nursing acknowledged that the facility was unaware of the resident's need for a CPAP machine and emphasized the importance of reviewing hospital notes to ensure appropriate respiratory care for residents.
Failure to Monitor Side Effects of Psychotropic Medications
Penalty
Summary
The facility failed to provide appropriate side effect monitoring for a resident (R24) who was on psychotropic medications. R24 had severe cognitive impairment and was dependent on assistance with activities for daily living. The resident's care plan included the use of antipsychotic and antidepressant medications, but there was no evidence of monitoring for side effects, orthostatic blood pressures, or non-pharmacological interventions for sleep or behaviors. The medication administration record (MAR) for March lacked documentation of these essential monitoring activities. R24's care plan identified the need for monitoring side effects of psychotropic medications and listed specific interventions, such as observing and recording target behaviors and documenting abnormal findings. However, the care plan lacked evidence of non-pharmacological interventions attempted and their effectiveness. Additionally, the progress notes for the last 90 days and the vital signs summary lacked evidence of orthostatic blood pressure monitoring, which is crucial for patients on psychotropic medications. Interviews with the nurse manager and the director of nursing confirmed that side effect monitoring should be documented in the MAR, but they were unable to locate such documentation for R24. The director of nursing verified that R24 had not been receiving orthostatic blood pressure monitoring and that there were no non-pharmacological interventions in place. The facility's policy on PRN psychotropic medication also lacked information on monitoring for side effects and effectiveness, further contributing to the deficiency.
Failure to Administer Prescribed Medications
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. Specifically, the resident did not receive the prescribed medications metoprolol and atorvastatin for a period of 30 days. The resident's quarterly Minimum Data Set (MDS) indicated that the resident was cognitively intact and required minimal assistance with daily activities. The resident had multiple medical diagnoses, including hypertension and high cholesterol, which required the administration of metoprolol and atorvastatin, respectively. However, the facility's medical orders did not include these medications, and the Medication Administration Record lacked documentation of their administration between 2/13/24 and 3/13/24. Interviews with the nurse manager and the Director of Nursing (DON) confirmed that the orders for metoprolol and atorvastatin were not included in the facility's physician orders and that the resident had not received these medications during the specified period. The DON stated that it was expected for nurses to check medication orders received from a provider on the same day and reconcile them with the facility's physician orders. The facility's policy on medication management was requested but not provided, indicating a potential lapse in procedural adherence and documentation.
Failure to Act on Dental Needs for Resident
Penalty
Summary
The facility failed to ensure dental needs were appropriately acted upon for a resident (R47) who required dental care. R47's quarterly Minimum Data Set (MDS) indicated that the resident had intact cognition, no behaviors, and required setup assistance with oral hygiene. The resident was diagnosed with heart failure, diabetes, and depression. A dental progress note dated 1/4/24 recommended that R47 have five teeth extracted due to fractured teeth/root tips that were causing pain and were not restorable. However, by 2/27/24, a progress note indicated that R47 still had obvious cavities or broken natural teeth, and no follow-up appointment had been scheduled with an oral surgeon as recommended by the dentist. During an interview on 3/11/24, R47 expressed that no one had followed up regarding the dental appointment, and the resident continued to experience mouth pain and difficulty eating due to the dental issues. Interviews with the nurse manager (NM-E) and the medical records clerk (MRC) revealed that the responsibility for setting up out-of-facility appointments, including dental referrals, fell to the MRC. However, the MRC admitted that she had not seen the dental referral for R47 until the interview on 3/12/24, and therefore, no appointment had been scheduled. The director of nursing (DON) confirmed that the MRC was responsible for scheduling these appointments and emphasized the importance of doing so. A policy regarding dental needs was requested but not received, indicating a potential gap in the facility's procedures for managing dental care referrals and follow-ups.
Failure to Maintain Accurate Medical Records and Monitor Medication
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to discrepancies in medication lists and lack of proper monitoring and interventions. For one resident, the facility's medication orders did not match the clinic's current medication list, missing several medications and having incorrect dosages for others. The nurse manager confirmed these discrepancies and acknowledged that the medication orders were not reconciled as expected. The medical director and the director of nursing both expressed concerns about the mismatched lists and emphasized the importance of reconciling medication orders to prevent negative outcomes for the resident. For another resident, the facility's records lacked evidence of an order for an intrathecal baclofen pump, including details about the placement, dose, and rate of medication. The medication administration record and care plan did not include monitoring or assessment of the pump, and progress notes lacked coordination with the agency responsible for filling the pump. The resident confirmed that staff did not monitor the pump, and the nurse manager verified the absence of current orders and monitoring practices. The director of nursing acknowledged the importance of staff being aware of the pump and its dose, confirming that no monitoring was in place. The facility's failure to maintain accurate medical records and ensure proper monitoring and interventions for these residents highlights significant deficiencies in their medication management and record-keeping practices. The lack of accurate and up-to-date information in the residents' medical records poses risks to their health and safety, as evidenced by the discrepancies and omissions found during the survey.
Failure to Clearly Communicate Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that binding arbitration agreements were clearly communicated and understood by residents prior to signing. Two residents, one with multiple sclerosis and another with heart failure, diabetes, and depression, were reviewed for binding arbitration agreements. Both residents had intact cognition according to their Minimum Data Set (MDS) assessments. However, during interviews, neither resident could recall being informed that signing the arbitration agreement was not a condition of admission, nor could they recall the agreement being explained in a manner they understood. The signed agreements indicated that the residents were giving up their rights to bring lawsuits or have jury trials for disputes with the facility. The social worker responsible for reviewing the admission packet, which included the arbitration agreement, stated that the packet was provided by corporate and that she had no input or training regarding the arbitration agreement. She also mentioned that her process for determining competency was based on her judgment of the resident's demeanor and diagnosis. The administrator confirmed that the arbitration paperwork came from the corporate office and that his role was limited to ensuring it was included in the admission paperwork and discussed during admission. The facility's policy required obtaining the resident's acknowledgment that the arbitration agreement was explained in a manner they understood, which was not adhered to in these cases.
Failure to Post Timely Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted on the weekend and in a timely manner at the start of the shift. During an entrance to the nursing home, it was observed that the staffing information displayed was dated four days prior, and there was no visible nurse staffing information posted for the subsequent days. The administrative assistant verified the outdated posting and confirmed that no other nurse staff information postings were present. The staffing coordinator admitted to sometimes getting the dates mixed up and acknowledged that incorrect postings could misrepresent staffing levels or census data. The director of nursing emphasized the importance of having the correct staff posting to accurately depict staffing in the building. The administrator also highlighted that the staff posting provides an account of the number of residents and the staff responsible for them. Despite requests, a facility policy for staff posting was not provided. This deficiency had the potential to affect all 69 residents, staff, and visitors who might wish to review the nurse staffing information.
Failure to Account for Controlled Substances
Penalty
Summary
The facility failed to have a system in place to record accurate narcotic reconciliation, resulting in the inability to account for thirty morphine tablets ordered for a resident. The deficiency was identified when a pharmacy receipt for the morphine delivery was not found in the facility's receipt bin, and the narcotic logbook did not include the physician's order for the morphine. Interviews with staff revealed that the morphine was delivered by a third-party courier and signed for by a staff member whose signature was later disputed. The resident's hospice nurse discovered the missing medication when attempting to administer it, leading to an investigation that confirmed the medication was never properly logged or accounted for in the facility's records. The resident involved had cognitive impairment and required moderate assistance for daily activities. The resident was admitted to hospice care and prescribed morphine for severe pain and air hunger. Despite the medication being delivered, it was not available when needed, and staff interviews indicated a lack of awareness and proper procedures for ensuring the medication was received and logged. The facility's policy on controlled substances did not provide clear guidance on actions to take if medication was not received, contributing to the oversight and failure to identify the missing morphine in a timely manner.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,028 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inver Grove Heights
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society Inver Grove Heights | 1.2 mi | ★★★★★ | 10 | 0 |
| Southview Acres Healthcare Center | 1.4 mi | ★★★★★ | 12 | 0 |
| Walker Methodist Westwood Ridge Ii | 2.6 mi | ★★★★★ | 8 | 0 |
| Cerenity Care Center On Humboldt | 4.5 mi | ★★★★★ | 12 | 0 |
| Shirley Chapman Sholom Home East | 5.1 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.