Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Abundant Acres Care And Rehab during CMS and state inspections, most recent first.
Infection control and water management deficiencies were identified when the facility lacked a complete Legionella water management program, with no documented risk assessment or full testing and maintenance records for the water system. Staff also failed to perform hand hygiene between dirty and clean tasks while providing care to a dependent resident with severe cognitive impairment, incontinence, and extensive assistance needs; CNAs entered the room without hand hygiene, changed gloves without washing or sanitizing, and continued care tasks.
Failure to obtain and document informed consent for antipsychotic use: Two residents receiving psychotropic medications, including Zyprexa and cariprazine, had no record of being informed of the risks and benefits or of signed consent. One resident had intact cognition with diagnoses including Alzheimer’s disease and bipolar disorder; the other had moderate cognitive impairment with diagnoses including dementia, depression, and bipolar disorder. Staff and the DON stated consent should be obtained before starting the medication, but the DON also said there was no current process for obtaining informed consent.
Resident council grievances and recommendations were not promptly documented or reported back to the council in writing. Eight of eight council members said they did not receive meeting minutes and only received verbal feedback, while meeting notes showed repeated resident concerns over multiple months without documented facility responses or a comprehensive month-to-month report of grievance resolutions.
Failure to return resident funds and complete final accounting after discharge. Three residents had credit balances left in facility accounts after discharge, including one resident with unresolved vendor coverage, one resident awaiting a refund check, and one resident whose Medicare coverage determination was still pending. The BOM said one refund was being prepared and another account had not been resolved with DSS; the Administrator stated accounts should be closed out and refunds issued within 30-60 days.
Resident Grievance Rights Not Clearly Available: The facility failed to ensure residents knew how to file grievances in writing or anonymously, had access to the Grievance Official’s contact information, and could obtain a written decision within a reasonable time frame. In a resident council interview, 7 of 8 residents did not know who the Grievance Official was or how to file a complaint, and 8 of 8 did not know where complaint forms were located or how to submit an anonymous grievance. The Administrator identified the SSD as the Grievance Official and stated grievances could be verbalized, but there were no resident forms available.
Delayed Access to EMR Records: Surveyors were given access to the EMR system but could not view resident MDSs, care plans, Advance Directives, assessments, wound reports, or labs for over a day. The Administrator said the facility had contacted the EMR provider, but adding access for each survey team member would be costly, and access was not fully provided until the survey process had already been delayed.
A facility failed to provide written information to residents on how to file complaints with the State Survey Agency and where to find Ombudsman contact information. Two cognitively intact residents with multiple diagnoses and seven of eight Resident Council members said they did not know how to contact the state or Ombudsman, and the facility’s Residents’ Rights policy did not include a grievance process for the Missouri DHSS.
Resident toilet did not flush properly. A cognitively intact resident who was independent with toileting reported the toilet had been having flushing problems for about two months and said the issue had been reported to nursing staff, but it remained unresolved. Survey observation confirmed the toilet did not flush completely. Staff gave mixed reports about awareness of the problem, with housekeeping noting several toilets on the unit did not flush all the way and that maintenance had been notified.
A facility failed to have PASRR Level I and Level II documentation for a resident with major depressive disorder, schizophrenia, and an intellectual disability diagnosis. The resident’s care plan noted a potential for verbal aggression related to hallucinations and delusions. The SSD said she could not produce the PASRR paperwork, and the DON stated she expected the resident to have a PASRR in the record.
Incomplete and Non-Resident-Specific Care Plans: The facility failed to maintain comprehensive, person-centered care plans for two residents with current medical and nursing needs. One resident had diabetes, leg wounds, incontinence, and recent UTI treatment, but the care plan did not address diabetes management, anticoagulant use, antibiotic therapy, or wound interventions. Another resident had impaired cognition, total dependence for care, incontinence, wounds, and recent pneumonia, but the care plan did not include skin breakdown prevention, pressure-relief measures, wound care details, or infection-related interventions. Staff interviews confirmed the care plans were not reflecting current resident needs.
A resident who was dependent for toileting, perineal care, and all personal hygiene, and who was always incontinent of bowel and bladder, did not receive complete peri care. Two CNAs provided incontinent care and wiped the groin and skin folds, but did not separate and clean all areas of skin where urine had touched before dressing and transferring the resident. CNA B, an RN, CNA A, and the DON stated staff should separate the skin folds and clean all areas of skin where urine had touched.
Improper Transfer Without Gait Belt: A resident with severely impaired cognition, incontinence, and diagnoses including Alzheimer's disease, Parkinson's disease, COPD, CHF, and HTN was transferred from the bed to a wheelchair by two CNAs without a gait belt. Staff placed their arms under the resident's armpits and held the resident's pants during the transfer, and both CNAs later stated they should have used a gait belt but forgot. RN, DON, and the Administrator all confirmed the transfer technique was improper.
Medication administration errors exceeded the allowed rate after staff made two errors in 25 opportunities, resulting in an 8% error rate and affecting two residents. An CMT gave Flonase without shaking the bottle or closing a nostril during administration, and gave artificial tears when the bottle strength did not match the order while the dropper tip touched the resident’s eyelashes. The DON stated staff should have followed the manufacturer’s directions for the nasal spray and clarified the eye drop strength before giving it.
Medication Storage and Labeling Deficiencies: Surveyors found loose pills in a med cart, food stored in the med refrigerator, an expired bottle of Milk of Magnesia, and two opened bottles of Lorazepam that were not dated when opened. RN and DON acknowledged the storage and labeling problems, and the facility policy required meds to be monitored for expiration, contamination, and usability.
The facility did not have a policy or maintain records regarding staff CPR certification, resulting in several staff members lacking current certification and no clear way to identify who on shift was certified. Staff were not asked about CPR certification upon hire, and there was no list of CPR-certified personnel available, potentially affecting all residents who required CPR.
A facility failed to protect residents from physical abuse when two residents, both with severe cognitive impairments and behavioral issues, were involved in a physical altercation. One resident struck the other, resulting in minor injuries. The incident was witnessed by a CNA who intervened, and an RN provided first aid. The facility's policy on abuse prevention was not effectively implemented, leading to this deficiency.
A resident with a history of inappropriate sexual behavior was found in another resident's room, engaging in non-consensual contact. The resident had a history of sexual behaviors and cognitive impairment, contributing to the incident. The affected resident was asleep and had severe cognitive impairment, highlighting a failure in monitoring and protection.
The facility failed to install backflow preventers on all shower hoses, risking contamination of the potable water supply. Observations revealed missing preventers on hoses in two shower rooms and a resident's room. The Maintenance Supervisor was unaware of the requirement, affecting the safety of 47 residents.
The facility failed to provide the SNF Advance Beneficiary Notice (ABN) to three residents who continued to stay after their Medicare Part A benefits ended. The Business Office Manager and Administrator were unaware of the requirement to issue the SNF ABN, resulting in residents not being informed of their potential financial responsibility for services not covered by Medicare.
The facility failed to maintain a clean and safe environment, with observations of cobwebs, scuffed walls, broken blinds, and mold-like substances on vents. The SCU dining room had dusty blinds and flies landing on residents. The Administrator noted maintenance and housekeeping responsibilities, but no cleaning policy was provided.
The facility failed to conduct necessary background checks for new hires, neglecting to verify the CNA Registry and FCSR for six staff members, contrary to its policy. The Business Office Manager, new to the role, lacked complete employee records due to a recent county takeover and was unaware of the required agencies for background checks. The Administrator confirmed the need for documented checks, indicating a systemic hiring process failure.
Two residents with cognitive impairments and incontinence did not receive necessary perineal care and repositioning every two hours as required. Observations showed that one resident was left in a saturated brief for over three hours, while another was not repositioned or provided care for a similar duration. Interviews with CNAs confirmed the lack of timely care, despite expectations from the LPN, DON, and Administrator.
The facility failed to provide an ongoing program of activities tailored to meet the individual interests and well-being of three residents. A resident with significant cognitive loss was observed without engagement in preferred activities, despite a care plan emphasizing structured activities. Another resident expressed dissatisfaction with limited activities and was often found idle or walking the halls. A third resident, with severely impaired cognition, was observed lying in bed without staff interaction. The Activity Director, new to the role, struggled to provide adequate activities due to a lack of training and support.
The facility failed to ensure call lights were accessible to two residents, both with cognitive impairments and dependent on staff for ADLs. Observations showed call lights out of reach, either on the floor or behind curtains. Staff interviews confirmed the expectation for call lights to be within reach, but this was not consistently practiced.
The facility failed to address significant weight loss in three residents and did not provide adequate snacks and fluids to residents in the SCU. A resident lost 17.6 pounds over 180 days, another lost 11.07% of their body weight, and a third complained of hunger without receiving snacks. Observations showed residents without access to snacks or drinks, and empty water pitchers. The staff acknowledged the lack of snack and drink offerings, and there was no specific person responsible for entering weight data into the EMR.
The facility failed to provide proper respiratory care for three residents, with issues such as undated oxygen tubing, empty humidified bottles, and dusty concentrator filters. Despite physician orders and facility policies, staff did not maintain the equipment, leading to discomfort for residents. Interviews revealed a lack of awareness and adherence to maintenance protocols.
The facility failed to ensure monthly drug regimen reviews by a licensed pharmacist, affecting two residents with significant cognitive and mental health conditions. Both residents were on multiple medications, but their records showed no medication regimen reviews for 2024, highlighting a lapse in monitoring unnecessary medications and drug irregularities.
The facility failed to ensure the Dietary Manager had the necessary competencies and skills for food and nutrition services, as the DM lacked dietary certification and was not enrolled in training. The Administrator was aware of this deficiency, and the facility did not provide a policy on DM qualifications. The facility census was 47 residents.
The facility failed to provide pureed foods with the appropriate texture and consistency, as observed during a lunch meal where the tuna casserole and tortellini were not smooth and contained particles. The Dietary Manager did not follow recipes or measure ingredients, leading to inconsistencies. Interviews confirmed that pureed foods should be smooth, but the facility lacked a policy for their preparation.
The facility failed to maintain sanitary conditions in its kitchen and food storage areas, affecting all residents receiving food. Observations showed unsanitary conditions, including dirty equipment, incomplete logs, and improperly stored food. Staff interviews revealed inconsistencies in food safety practices and unclear responsibilities, leading to these deficiencies.
The facility failed to establish an effective antibiotic stewardship program, lacking protocols for optimizing infection treatment and monitoring antibiotic use. New staff, including the Infection Preventionist and DON, were unable to provide data on current antibiotic use or infection trends, highlighting a significant gap in infection control practices.
The facility failed to provide dementia and behavior training for staff, affecting residents with cognitive and behavioral issues. A resident with severe dementia was inappropriately teased by a CMT, while another resident at risk for wandering was not offered snacks or drinks. Staff lacked awareness of residents' conditions and had not received recent dementia education.
The facility failed to meet professional standards of care for three residents. A resident with severe shoulder pain did not receive a physician-ordered MRI, preventing further pain management. Another resident with cognitive loss and multiple diagnoses did not have a scheduled ENT consultation after an ear incident. Additionally, a resident with severe cognitive loss was prescribed Lorazepam without a stop date, contrary to medication management protocols.
The facility failed to manage its resources effectively, resulting in non-payment to staffing agencies and suspension of services. This, coupled with inadequate communication during a transition of ownership, caused significant stress and anxiety among residents and families. Many were unaware of who the current administrator was or who to contact with concerns, leading to feelings of anger and frustration. The lack of transparency and communication exacerbated these issues, particularly affecting residents with cognitive impairments.
The facility failed to communicate effectively with residents and their families during a transition to a new operator, leading to stress and anxiety. Residents and family members were left to rely on rumors for information, causing significant distress about future care and living arrangements. Despite expectations for leadership to address concerns, the administrator did not acknowledge the stress experienced by residents.
The facility failed to offer residents and their families a choice of pharmacy when the primary pharmacy was changed to Pharmacy B, affecting nine residents. Despite the facility's policy to support resident choice, several residents and their families were unaware of the change and were not given a choice. Interviews with staff revealed a lack of communication and responsibility regarding the change.
The facility failed to notify residents and families of Resident Council Meetings and did not honor requests for staff and family attendance, affecting several residents. A resident council president was informed of a meeting about ownership transition only 30 minutes prior, causing anxiety and insufficient preparation time. Other residents and family members were either not informed in time or unable to attend, leading to confusion and distress among residents with cognitive impairments.
The facility did not refund personal funds and provide a final accounting to six residents within 90 days of discharge. This issue was identified through interviews and record reviews, and the facility lacked a policy on refunding resident funds.
The facility was found to have a deficient call system in resident bathrooms and bathing areas. The system failed to allow residents to communicate with staff effectively, as it did not relay calls directly to staff or alert them in the corridor. This issue was identified through observation and interviews, with the facility census at 47 residents.
The facility did not refund personal funds to six residents within the required 90 days after discharge, with balances ranging from $399.00 to $3,321.10. The Director of Operations was aware of the 30-day refund requirement but was unsure why the corporate accounting department had not processed the refunds. The facility also lacked a policy on refunding resident funds.
The facility failed to provide drinks consistent with residents' needs and preferences, affecting four residents. A resident with moderate cognitive impairment reported infrequent water provision, and observations showed signs of dehydration. Another resident, severely cognitively impaired, had a warm water pitcher unchanged throughout the day. A third resident had dry, cracked lips, and a fourth resident reported not receiving water that day. Staff interviews revealed inconsistencies in water provision practices.
The facility's call system was found to be deficient, with call lights in several rooms failing to activate indicator lights above doors or on the call light board. Notifications appeared only at the central nurses' station for the open unit, while the secure unit relied on staff presence to relay alerts. Staff interviews confirmed the system's prolonged malfunction, and the Director of Operations was unaware of the issue.
A resident with severe cognitive impairment was found with multiple injuries, including bruising and a skin tear, which were not reported to the appropriate authorities in a timely manner. Despite documentation by an LPN and observations by other staff, the injuries were not reported to the DON or Administrator immediately, leading to a delay in notifying the state agency beyond the required two-hour window.
A resident with severe cognitive impairment was found with bruises and a skin tear, but the facility failed to conduct a thorough investigation. Key staff were not interviewed, and documentation was incomplete, leading to a deficiency in addressing the injuries.
Infection Control and Water Management Deficiencies
Penalty
Summary
The facility failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of its water systems to inhibit the growth of waterborne pathogens and reduce the risk of Legionella. Review of building maintenance inspection and testing records from 8/2024 through 8/2025 showed no documentation of a complete water management program to monitor the facility’s water systems for the growth of waterborne pathogens and prevent Legionnaire’s Disease. The facility’s undated Legionella policy instructed staff to complete a risk assessment and develop procedures to monitor for Legionella in accordance with CDC guidelines, but the maintenance director had not completed the risk assessment or the related procedures. During interview, the maintenance director stated he checked water temperatures and flushed toilets that were not used daily, but had no documentation of preventative measures other than water temperatures. The administrator stated the maintenance department was responsible for monthly water testing for the Legionella program, but had no documentation available. The report also states that the facility census was 44.1 and that the deficiency had the potential to affect all residents of the facility. The facility also failed to ensure staff washed or sanitized their hands between dirty and clean tasks during care of a resident who required extensive assistance. Resident #12’s care plan showed the resident needed assistance with toileting, perineal care, clothing management, and all personal hygiene tasks. The resident’s MDS showed severely impaired cognitive skills, dependence for toilet use, substantial to maximal assistance for dressing, supervision or touch assistance for transfers and oral care, and that the resident was always incontinent of bowel and bladder. During observation, two CNAs entered the room without washing hands, applied gloves, performed incontinent care, changed gloves without hand hygiene, transferred the resident, made the bed, and later re-entered the room without hand hygiene to comb hair and apply personal items.
Failure to Obtain and Document Informed Consent for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that two sampled residents were fully informed of the risks and benefits of physician-ordered antipsychotic medications and that informed consent was documented before or during use. Resident #5 had diagnoses including progressive neurological conditions, Alzheimer’s disease, anxiety, depression, and bipolar disorder, and the quarterly MDS showed intact cognitive skills, no behaviors, and regular antipsychotic use. The resident’s care plan directed staff to administer psychotropic medications as ordered and monitor for side effects and effectiveness, and the POS showed Zyprexa orders that changed from 10 mg daily for bipolar disorder to 7.5 mg at bedtime for behaviors. The medical record contained no consents or education documenting risks and benefits of psychotropic medication use from 7/1/25 through 8/19/25. Resident #7’s care plan identified psychotropic medication use for behavior management and mood problems related to bipolar disorder, anxiety, and major depressive disorder. The quarterly MDS showed moderate cognitive impairment, no potential indicators of psychosis, and diagnoses including heart failure, hypertension, kidney disease, diabetes, depression, dementia, and bipolar disorder, with antipsychotic use noted. The Behavioral Diagnostic Assessment and August physician order showed cariprazine 6 mg daily, but the clinical record contained no documentation of informed consent for psychotropic medication use. During interviews, an RN and an LPN stated consent should be obtained before the medication started, and the DON stated there was currently no process for obtaining informed consent for psychotropic medications and that the facility was developing a program and training.
Resident Council Grievances Not Documented or Reported Back
Penalty
Summary
The facility failed to act promptly on grievances and recommendations raised by the resident council and failed to document responses to the council regarding follow-up actions. The resident council stated that it preferred written feedback about concerns, but eight of eight council members had not received copies of the monthly meeting minutes and reported that feedback was given only verbally. They also stated they did not remember staff reviewing the prior month’s concerns at the start of each new meeting. The facility census was 44, and the issue affected all residents serving on the resident council and potentially other residents. Review of resident council meeting notes showed repeated resident concerns from January through July 2025 without documented lists of concerns or facility responses being provided back to the council for the prior month’s issues. Some concerns were addressed verbally during meetings, but the record did not show a comprehensive report of resolutions from month to month. The Social Services Designee stated that minutes were not routinely provided to the council unless requested, and the Activities Director stated that the facility did not formally go over each grievance and complaint from the prior meeting and did not make a comprehensive report to the council on the resolution of complaints and grievances from month to month.
Failure to Return Resident Funds and Provide Final Accounting After Discharge
Penalty
Summary
The facility failed to provide personal funds and a final accounting within 30 days after discharge for three residents. An accounts receivable aging report dated 8/20/25 showed credit balances remaining in the facility’s operating account for Resident #49, discharged on 2/13/25 with a $5,142.00 credit in the Private Pay account; Resident #48, discharged on 10/25/24 with a $4,932.00 credit in the Resident Liability account; and Resident #50, discharged on 8/17/24 with a $13,852.00 credit in the Private Pay account. This affected 3 of 12 residents sampled, and the facility census was 44. Email documentation between the Social Services Director and Missouri DSS showed Resident #48 was approved for vendor coverage from 9/30/24 through 10/25/24, while Resident #49 was not approved for vendor coverage and the facility was notified by phone on 9/24/24. Follow-up emails in April, May, and June 2025 did not resolve Resident #48’s account. During interview, the Business Office Manager said she was working on a refund check for Resident #49, that Resident #50’s stay still needed a Medicare determination, and that Resident #48’s account had not been resolved or followed up with DSS. The Administrator stated residents should have their accounts closed out and refunds issued within 30-60 days of discharge.
Resident Grievance Rights Not Clearly Available
Penalty
Summary
The facility failed to ensure residents had the right to file grievances in writing, the right to file grievances anonymously, access to the grievance official’s contact information, and the right to obtain a written decision regarding a grievance within a reasonable expected time frame. This deficiency affected 8 of 8 residents who attended the group meeting, and the facility census was 44. Review of the facility’s Residents’ Rights policy showed that grievances were to receive prompt attention through staff, administration, resident councils, or the ombudsman program, and that residents could file complaints verbally or in writing and all complainants would be investigated and responded to. During the resident council group interview, 7 of 8 residents did not know who the Grievance Official was or how to file a grievance or complaint, and 8 of 8 residents did not know where complaint forms were located or how to file an anonymous complaint with the facility. The same 8 of 8 residents did not know what their rights were concerning the grievance process. During interview, the Administrator identified the Social Services Director as the Grievance Official and stated grievances could be verbalized to the SSD, who would notify the resident’s caretaker and either handle the issue informally or write it up as a formal complaint. The Administrator also stated there were no forms for residents and that an anonymous grievance could be submitted by sliding a piece of paper under the Administrator’s door.
Delayed Access to EMR Records
Penalty
Summary
The facility failed to provide timely access to resident electronic medical records from 8/18/25 at 10:00 A.M. through 8/19/25 at 1:45 P.M., which prevented surveyors from timely reviewing records needed to conduct the survey and review care provided to residents. The facility census was 44. The facility's undated EMR policy stated that documentation would be done in real time, access would be controlled by job role, staff may view documentation as necessary to perform their role, and the facility would comply with HIPAA, CMS, and state regulations regarding access to medical records. On 8/18/25 at 10:45 A.M., surveyors were given access to the EMR system but had no digital/electronic access to resident information, including MDS information, care plans, Advance Directive documents, assessments, wound reports, and labs. The Administrator said the facility had contacted the EMR provider for assistance, but adding access options for each survey team member would be costly. Later that day, the Administrator still had no update and said they were working on the issue. On 8/19/25 at 11:00 A.M., surveyors still had no electronic access to resident records and requested paper records until access could be granted. The Administrator was told at 12:45 P.M. that the lack of access was impeding the survey process, and at 2:10 P.M. said access had been provided to all surveyors; by 2:15 P.M., the team had full access to review records.
Failure to Provide Written Complaint and Ombudsman Contact Information
Penalty
Summary
The facility failed to protect resident rights by not informing residents in writing how to file a complaint with the State Survey Agency and where to find the Ombudsman’s contact information. Review of the facility’s Residents’ Rights policy showed no information on a process for residents to contact and file a grievance with the Missouri Department of Health and Senior Services. The census was 44, and the deficiency involved two sampled residents and seven of eight resident council members. Resident #20’s MDS dated 6/30/25 showed the resident was cognitively intact with diagnoses of epilepsy, traumatic brain injury, anxiety disorder, and schizophrenia. The resident’s electronic medical record contained nothing in writing about how to contact the Missouri Department of Health and Senior Services, and during interview the resident said he/she did not know how to contact the state to make a complaint or where the number was located, and did not know how to contact the Ombudsman or where the phone number was located. Resident #26’s MDS showed the resident was cognitively intact with diagnoses of neurogenic bladder, diabetes, seizure disorder, depression, and bipolar disorder; the record also had nothing in writing about contacting the state agency, and the resident stated he/she did not know how to contact the state or the Ombudsman. In addition, during interview the Resident Council said seven of eight members did not know how to file a complaint with the state agency or where Ombudsman contact information was located, and they were not provided written information on how to contact either source.
Resident Toilet Did Not Flush Properly
Penalty
Summary
The facility failed to ensure that one resident had a toilet that flushed properly, despite the resident reporting that the toilet had been having problems for the last two months. Resident #25 was cognitively intact, independent with transfers and toilet use, and always continent of bowel and bladder. The resident stated the toilet did not flush completely, had reported the issue to nursing staff, and felt embarrassed because it seemed like the problem was the resident's fault. During observation, the surveyor flushed the toilet and saw that it did not flush completely. Facility staff gave mixed accounts of awareness and reporting of the problem. The Maintenance Director said he/she had been in the position for a month and was not aware of any residents with toilet issues until the DON informed him/her that morning. RN A and CNA A said they had not had complaints about toilets not flushing correctly and would report such issues to maintenance by walkie, verbally, or through the Tels log. The Housekeeping Supervisor said there were quite a few toilets that did not flush all the way and had to be flushed twice, and stated he/she was aware Resident #25's toilet sometimes had trouble flushing and maintenance had been notified. The Administrator said she was unaware of the toilet problem but expected resident toilets to flush properly.
Missing PASRR Documentation for Resident with Serious Mental Illness and IDD
Penalty
Summary
The facility failed to have documentation of a PASRR Level I preadmission screening and a PASRR Level II screen for a resident with diagnoses of major depressive disorder and schizophrenia, along with an intellectual disability diagnosis noted in the report. The resident’s care plan, dated 02/14/2022 and revised on 09/28/2022, identified a potential for verbal aggression related to hallucinations and delusions associated with the schizophrenia diagnosis. During interview, the Social Service Director stated she was unable to produce any PASRR for the resident, explaining that the resident had been in the facility for more than one year and that she was unable to obtain all paperwork. She also stated she emailed COMRU to try to obtain a copy, but they could not produce one. The DON stated she was new to the PASRR process and was unable to provide direction on what needed to be done, but expected the resident to have a PASRR in the record.
Incomplete and Non-Resident-Specific Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans with measurable objectives and timeframes for two residents whose assessments and orders showed multiple current care needs. Resident #8’s quarterly MDS showed intact cognition, bowel and bladder incontinence, need for nursing assistance with personal care and hygiene, and diagnoses including diabetes, wounds to the legs, cardiac disease, and hypertension. The resident’s August 2025 physician orders included Bactrim DS for a UTI, Januvia for diabetes, Eliquis for blood thinning, and wound care to the lower legs, but the care plan last dated 5/16/25 did not include interventions for diabetes management, anticoagulant use, the recent antibiotic treatment for UTI, or staff interventions for the lower-leg wounds. Resident #1’s MDS showed impaired cognition, dependence on staff for all cares, incontinence, wounds, and recent pneumonia. August 2025 physician orders included daily wound care to the right heel and left arm, but the care plan dated 7/20/25 did not address the resident’s risk for skin breakdown, bed mobility and pressure-reducing measures with positioning aids, the wound to the left wrist where the skin was missing, or the recent pneumonia and infection risk. During interview, RN A stated the care plan should reflect current care and treatment needs, including wound care and medical changes, and said the DON or MDS person updates the care plan. The MDS Coordinator said the care plans were lacking interventions and were not resident specific, and the DON stated the care plans should match the current needs and goals of the resident.
Incomplete Perineal Care for Dependent Resident
Penalty
Summary
The facility failed to ensure a dependent resident received complete perineal care when staff did not fully clean all areas of skin that had been exposed to urine. The resident’s care plan, revised 7/11/25, required assistance with toileting, perineal care, clothing management, and all personal hygiene tasks. The resident’s MDS dated 8/1/25 showed severely impaired cognitive skills, dependence on staff for toilet use, substantial to maximal assistance for dressing, and that the resident was always incontinent of bowel and bladder. Diagnoses included CHF, HTN, Alzheimer’s disease, Parkinson’s disease, and COPD. During observation on 8/20/25 at 7:00 A.M., two CNAs provided incontinent care. They unfastened the resident’s brief, wiped each side of the groin and once down the middle skin folds, turned the resident on his/her side, and wiped once from front to back before placing on a clean brief and dressing the resident. The CNAs did not separate and clean all areas of skin where urine had touched. In interviews, CNA B, RN A, CNA A, and the DON stated staff should separate the skin folds and clean all areas of skin where urine had touched during peri care.
Improper Transfer Without Gait Belt
Penalty
Summary
The facility failed to ensure staff used proper transfer techniques to reduce the possibility of accidents or injuries when two CNAs transferred a resident without using a gait belt. The resident's care plan, revised 7/11/25, showed the resident required assistance with toileting, perineal care, clothing management, and all personal hygiene tasks, but it did not address how to transfer the resident. The resident's significant change MDS dated 8/1/25 showed severely impaired cognitive skills, dependence on staff for toilet use, substantial to maximal assistance for dressing, supervision or touch assistance for transfers, and diagnoses including CHF, HTN, Alzheimer's disease, Parkinson's disease, and COPD. During observation on 8/20/25 at 7:00 A.M., CNA A and CNA B provided incontinent care, dressed the resident, sat the resident on the side of the bed, and then stood the resident by placing their arms under the resident's armpits before transferring the resident into a wheelchair without a gait belt. The CNAs also pulled up the resident's pants and held onto the pants during the transfer. In interviews, both CNAs stated they should not have placed their arms under the resident's armpits or grabbed the back of the resident's pants and said they should have used a gait belt but forgot. RN A, the Administrator, and the DON all stated staff should not have transferred the resident in that manner and should have used a gait belt.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent after surveyors identified two medication errors out of 25 opportunities for error, resulting in an 8% error rate and affecting two of 12 sampled residents, Resident #25 and Resident #28. The facility’s medication administration policy required staff to verify the medication, dose, route, and time against the MAR before administration. For Resident #28, CMT A administered Flonase nasal spray without shaking the bottle and without closing one nostril while administering the spray, which did not follow the facility’s nasal spray administration policy or the manufacturer’s directions. For Resident #25, CMT A administered Artificial Tears when the bottle and box showed 0.2% even though the physician’s order and MAR listed 1.4%, and the dropper tip touched the resident’s eyelashes during administration. CMT A stated the nasal spray should have been shaken and each nostril closed during use, and that the eye drop percentage should have matched the order and the dropper tip should not have touched the eyelashes. The DON stated staff should have followed the manufacturer’s guidelines for Flonase and clarified the eye drop percentage before administration.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled according to accepted professional principles. During observation of the medication carts, surveyors found one oblong white pill, one oblong orange pill, and one oblong blue pill loose in a medication cart drawer. A CMT stated there should not be any loose pills in the medication cart. The facility’s policy stated medications were to be monitored to ensure they were not expired, contaminated, or unusable, and that expired, contaminated, and unusable medications were to be promptly removed and disposed of. In the medication room, surveyors observed an opened container of Lay’s French Onion Dip in the medication refrigerator, an opened bottle of Milk of Magnesia that had expired, and opened bottles of Lorazepam 2 mg/ml for two residents that were not dated when opened. The box for the Lorazepam indicated it should be discarded 90 days after opening, and RN A stated the medication should be dated when opened. The DON stated there should not be food in the medication refrigerator, expired medications should be disposed of properly, and the Lorazepam should be dated when opened.
Failure to Ensure Availability of CPR-Certified Staff
Penalty
Summary
The facility failed to ensure the availability of staff who could provide cardiopulmonary resuscitation (CPR) prior to the arrival of emergency medical personnel, as required by physician orders and residents’ advance directives. There was no policy in place regarding staff CPR certification or maintaining a list of staff currently on shift who were CPR certified. Review of employee files revealed that several staff members, including RNs, CNAs, and CMTs, did not have evidence of current CPR certification in their files. Interviews with staff indicated that some had expired certifications, some were not certified at all, and none were asked about their CPR certification status upon hire. Staff also reported not knowing which coworkers on shift were CPR certified, often assuming the charge nurse was certified without confirmation. The Director of Nursing and the Administrator both confirmed that the facility lacked a policy on staff CPR certification and did not maintain a list or record of which staff had current CPR certification. The physician interviewed expected the facility to have such a policy and for at least all nursing staff to be CPR certified. The deficiency had the potential to affect all residents who were full code, as there was no assurance that staff present during an emergency would be able to provide CPR.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when an incident occurred involving two residents. One resident, who has severe cognitive impairment and a history of dementia, PTSD, and anxiety disorder, was observed striking another resident in the face. This resulted in a bruise and two facial skin tears for the second resident, who also has severe cognitive impairment and is on hospice care for senile dementia. The incident was witnessed by a Certified Nursing Assistant (CNA) who intervened to separate the residents. The facility's investigation revealed that the altercation began as a verbal dispute between the two residents, which escalated into physical violence. The CNA immediately intervened, and a Registered Nurse (RN) assessed both residents. The resident who was struck had minor injuries, including red areas and small skin tears on the cheek, which were treated with first aid. The resident who initiated the altercation admitted to hitting the other resident because of a verbal insult. The facility's undated Abuse and Neglect policy outlines the prevention and protection of residents from abuse, but the incident indicates a failure in monitoring and intervention. Both residents involved have a history of cognitive impairments and behavioral issues, which were documented in their care plans. Despite these documented risks, the altercation occurred, suggesting a lapse in the facility's ability to effectively monitor and manage residents with known aggressive behaviors.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse when a resident with a history of inappropriate sexual behavior was found in another resident's room. The incident occurred when a staff member observed the resident sitting on another resident's bed with their pants and underwear pulled down and their hand inside the other resident's brief. The resident being touched was asleep at the time of the incident. The resident who committed the inappropriate act had a history of sexual behaviors and was on medication to manage these behaviors. They also had a diagnosis of dementia with agitation, which contributed to their impaired cognitive skills. The resident had been known to wander into other residents' rooms and had been identified as an elopement risk. Despite these known behaviors, the resident was able to enter another resident's room and engage in inappropriate conduct. The resident who was touched had severe cognitive impairment and was also identified as a wandering risk. At the time of the incident, they were asleep and did not appear to be in distress when assessed afterward. The facility's failure to adequately monitor and prevent the resident with a history of inappropriate sexual behavior from accessing other residents' rooms led to this deficiency.
Lack of Backflow Preventers on Shower Hoses
Penalty
Summary
The facility staff failed to ensure that all shower hoses were equipped with a backflow preventer, a device that prevents toxins from contaminating the facility's potable water supply. This deficiency was observed during a survey on June 26, 2024, affecting all five shower hoses in the facility. Specifically, two shower hoses in the 400 hall shower room, two in the 500 hall shower room, and one in a resident's room were found without backflow preventers. The facility census at the time was 47 residents. During an interview on the same day, the Maintenance Supervisor admitted to not being aware that all shower hoses required backflow preventers, indicating a lack of knowledge or oversight regarding this safety measure. This oversight had the potential to affect all residents in the facility.
Failure to Provide SNF Advance Beneficiary Notice
Penalty
Summary
The facility failed to issue the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) to residents, which is necessary for informing them about potential financial responsibility for services not covered by Medicare. This deficiency affected three residents who continued to stay in the facility after their Medicare Part A benefits ended, without being provided the SNF ABN. The residents had received a Notice of Medicare Non-Coverage (NOMNC) indicating the end of their Medicare Part A benefits, but the SNF ABN was missing from their records. Interviews with the Business Office Manager and the Administrator revealed a lack of awareness regarding the requirement to provide the SNF ABN. The Business Office Manager, responsible for issuing beneficiary notices, was not aware of the need to provide the SNF ABN, and the Administrator was also unaware of this requirement. This oversight led to the failure to inform residents of their potential financial liability for continued services not covered by Medicare.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable homelike environment for its residents, as evidenced by multiple observations of unclean and damaged areas within the facility. Specific deficiencies included cobwebs and scuffs on walls, missing privacy curtain hooks, dusty and broken window curtain rods, and broken window blinds in several rooms. Additionally, some rooms lacked privacy curtains, and there were issues with light fixtures, such as missing globes and light bulbs. The utility hall window seal was rusted and dirty, and the air conditioning vent in the Special Care Unit (SCU) had a black mold-like substance. Further observations revealed that the SCU dining room blinds were coated with dust, and there were multiple flies in the dining area, which were landing on residents, tables, and furniture. During an interview, the Administrator stated that maintenance was responsible for cleaning the SCU vents, while housekeeping staff were responsible for monitoring privacy curtains and daily cleaning tasks, including dusting. The facility did not provide a policy on cleaning, and the provided cleaning checklists were undated.
Failure to Conduct Required Background Checks for New Hires
Penalty
Summary
The facility staff failed to conduct necessary background checks for new hires, specifically neglecting to verify the Certified Nurses' Assistant (CNA) Registry and the Family Care Safety Registry (FCSR) for six sampled staff members. This oversight is contrary to the facility's policy, which mandates that all new employees undergo a criminal background check and be screened through the CNA Registry and FCSR before starting employment. The deficiency affected all six sampled staff members, with the facility having a census of 47 residents. During interviews, the Business Office Manager, who had only been working at the facility for a few months, admitted to not having all employee records available due to a recent county takeover. She acknowledged the lack of knowledge regarding the necessary agencies for background checks and was in the process of adding the facility to the FCSR for future background checks. The Administrator confirmed that all new employees should have completed and documented background checks, highlighting a systemic failure in the facility's hiring process.
Failure to Provide Timely Incontinent Care and Repositioning
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene. Specifically, the staff did not provide perineal care and repositioning at least every two hours for two residents. Resident #25, who had moderate cognitive impairment and was always incontinent of bowel and bladder, was observed to have not received incontinent care or repositioning from 8:30 A.M. until 11:47 A.M., when CNAs A and B finally provided care. The resident's brief was found saturated with urine and feces, indicating a lack of timely care. Similarly, Resident #29, who had severe cognitive impairment and was also always incontinent, did not receive the required care. The resident was observed sitting in a Broda chair from 8:30 A.M. until being taken to the dining room at 11:53 A.M. without having been repositioned or provided with incontinent care. Interviews with CNAs A and B confirmed that they did not provide the necessary care every two hours as required by the facility's policy. Interviews with the LPN, DON, and Administrator revealed that they expected dependent residents to be repositioned and given perineal care at least every two hours. However, the observations and interviews with the CNAs indicated that this standard was not met, leading to the deficiency in care for the residents involved.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the individual interests and well-being of three residents. Resident #7, who has significant cognitive loss and is dependent on staff for activities of daily living, was observed sitting passively in various locations without engagement in activities that matched his/her preferences, such as cooking, sewing, or being outside. Despite having a care plan that emphasized the need for structured activities and one-on-one engagement, the resident was often left without appropriate stimulation or interaction. Resident #12, who also has significant cognitive loss and enjoys arts, crafts, and group activities, was similarly observed without meaningful engagement. The resident expressed a desire for more activities beyond bingo and was often found sitting idly or walking the halls out of boredom. The care plan indicated a need for encouragement and escort to activities, but observations showed a lack of fulfillment of these needs, leading to the resident's dissatisfaction and lack of engagement. Resident #43, with severely impaired cognition, was observed lying in bed with the television on but without sound, and no staff interaction was noted during the observation periods. The resident's care plan highlighted a preference for favorite activities and music, yet these preferences were not met. The Activity Director, new to the role and without prior long-term care experience, struggled to provide adequate activities, particularly for residents with dementia, due to a lack of training and support, contributing to the deficiency in meeting residents' activity needs.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to provide a safe environment by not ensuring that call lights were accessible to residents, affecting two of the twelve sampled residents. Resident #25, who has moderate cognitive impairment, Parkinson's Disease, depression, and asthma, was observed multiple times with the call light out of reach, either on the floor or hanging on the privacy curtain. The resident is dependent on staff for activities of daily living (ADLs) and transfers, and is always incontinent of bowel and bladder. The care plan for Resident #25 emphasized the need for assistance with repositioning and incontinence care, yet the call light was consistently inaccessible. Similarly, Resident #29, who has severe cognitive impairment, traumatic brain injury, dementia, and high blood pressure, was also found with the call light out of reach on several occasions. This resident is totally dependent on staff for ADLs, transfers, and toileting, and has a history of falls. Observations showed the call light either under a pile of clothes and blankets or hanging on the privacy curtain, out of reach. Interviews with staff, including CNAs and an LPN, revealed an expectation that call lights should be within reach at all times, yet this was not consistently practiced, leading to the deficiency.
Failure to Address Weight Loss and Provide Snacks in SCU
Penalty
Summary
The facility failed to recognize and address significant weight loss in three residents, as well as failed to provide adequate snacks and fluids to residents in the Special Care Unit (SCU). Resident #7 experienced a significant weight loss of 17.6 pounds over 180 days, with poor meal intake averaging less than 50%. Despite being on a mechanical texture diet with supplements like Ensure and Med Pass 2.0, the resident was observed multiple times without snacks or drinks, and their water pitcher was empty. The care plan indicated a potential for weight loss, but no new dietary recommendations were made despite the significant weight loss. Resident #44, who had severe cognitive deficits and was on hospice services, also experienced weight loss, losing 11.07% of their body weight over 180 days. The care plan included monitoring for weight loss and encouraging oral intake, but observations showed the resident walking around without access to snacks or drinks, and their water pitcher was empty. There were no dietary notes in the Electronic Medical Record from January to June 2024, indicating a lack of monitoring and intervention for the resident's nutritional needs. Resident #12, with significant cognitive loss, complained of hunger but was not provided with snacks or drinks by the staff. Observations showed the resident without access to snacks or drinks, and their water pitcher was empty. The staff, including CNA C, acknowledged the lack of snack and drink offerings and were unsure why the pitchers were empty. Additionally, Resident #10 experienced a weight loss of 11.7 pounds in less than 30 days, but the facility staff did not identify or report this weight loss to the physician. The Director of Nursing and the Administrator acknowledged the lack of a specific person responsible for entering weight data into the EMR, contributing to the oversight.
Deficiencies in Respiratory Care Management
Penalty
Summary
The facility failed to provide proper respiratory care for three residents, as observed through multiple deficiencies in the management of oxygen equipment. Resident #11, who had a terminal prognosis related to chronic respiratory failure, was found with undated oxygen tubing, an empty humidified water bottle dated over a month prior, and a concentrator filter caked in dust. Despite having a physician's order for oxygen management, these issues persisted over several days, with the resident expressing discomfort and a sore nose due to the inadequate oxygen setup. Resident #27, with moderate cognitive impairment and a diagnosis of COPD, also experienced similar deficiencies. The oxygen tubing was outdated, the humidified water bottle was empty and undated, and the concentrator filter was dusty. Observations over consecutive days showed no improvement, and the resident was found with the nasal cannula improperly placed on one occasion. The care plan did not address the use of oxygen, and the physician's orders lacked specific instructions for equipment maintenance. Resident #151, admitted with lung cancer and anxiety disorder, was observed with a dusty oxygen concentrator and undated tubing. Interviews with staff, including CNAs and an LPN, revealed a lack of awareness and adherence to the facility's oxygen policy, which required weekly maintenance of the equipment. The Director of Nursing and the Administrator acknowledged the expectations for staff to maintain the equipment but noted the absence of a checklist to ensure compliance.
Failure to Conduct Monthly Drug Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted a monthly drug regimen review for each resident, as required by their policies and procedures. This deficiency was identified through observation, interviews, and record reviews, affecting two residents out of a sample of twelve, with the potential to impact all residents in the facility. The facility did not provide a policy on Medication Regimen Review, which is crucial for monitoring unnecessary medications, psychoactive medication parameters, and drug irregularities. Resident #12, who has significant cognitive loss, dementia, PTSD, depression, and other conditions, had multiple medications prescribed, including Depakote, Lexapro, Rivastigmine Tartrate, and Trazadone. However, there was no record of a medication regimen review for 2024. Similarly, Resident #44, with severe cognitive deficits and diagnoses including anxiety and Alzheimer's Disease, was prescribed Ativan, Lorazepam Intensol, and Seroquel, but also lacked a medication regimen review for 2024. The facility's administrator acknowledged the issue and mentioned that a new consultant pharmacist had started in June, but no corrective actions were detailed in the report.
Dietary Manager Lacks Required Competencies
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to perform the functions of the food and nutrition services. This deficiency was identified through interviews and record reviews, revealing that the DM did not hold any dietary certification and was not enrolled in any relevant training or classes. The facility did not provide a policy outlining the qualifications required for the DM position. The Administrator acknowledged awareness of the DM's lack of certifications and expressed the expectation that the DM should have the necessary certifications and training. The facility census at the time was 47 residents.
Inadequate Preparation of Pureed Foods
Penalty
Summary
The facility failed to provide food in a form designed to meet individual needs, specifically in the preparation of pureed foods. During an observation of a lunch meal, it was noted that the pureed tuna casserole had a thick, sticky consistency with rice-sized particles, requiring chewing before swallowing. The mashed potatoes also had a thick, sticky consistency, although they were smooth without chunks. The facility did not have a policy regarding the preparation of pureed food, and the Dietary Manager did not measure ingredients when preparing pureed meals, leading to inconsistencies in texture. Further observations revealed that the pureed tortellini contained particles, indicating it was not smooth. Interviews with the Dietary Manager, Administrator, and Registered Dietician confirmed that pureed food should be smooth with no large particles, and recipes should be followed to ensure proper consistency. However, the Dietary Manager relied on visual and taste assessments rather than following specific recipes, contributing to the deficiency in providing appropriately textured pureed foods.
Facility Fails to Maintain Sanitary Food Storage and Kitchen Conditions
Penalty
Summary
The facility failed to maintain a sanitary environment in its kitchen and food storage areas, which had the potential to affect all residents receiving food from the facility's kitchen. Observations revealed multiple instances of unsanitary conditions, including a dirty microwave in the dining room, trash cans without lids in the dishwashing area, and incomplete chemical testing logs for the dishwasher and sanitizer levels. Additionally, refrigerator and freezer temperature logs were incomplete, and various food items were found unlabeled, undated, and improperly stored. In the dry storage area, a large container of soy sauce was dirty, a bin of white flour was unlabeled and undated, and a container of drink lids was dirty. The walk-in refrigerator contained unlabeled and undated food items, such as thickened juice, shredded lettuce, and pieces of cake. The freezer had ice build-up, and food items like pancakes and ice cream were not labeled or dated. Similar unsanitary conditions were observed in the utility room refrigerators, with dirty shelves and food particles present. Interviews with staff, including a Dietary Aide, the Dietary Manager, the Administrator, and a Registered Dietician, revealed inconsistencies in the documentation and monitoring of food safety practices. Staff were unclear about responsibilities for cleaning and labeling food, and there were discrepancies in the expected frequency of temperature checks and documentation. The facility's policies on food storage and sanitation were not being followed, leading to the observed deficiencies.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking a comprehensive antibiotic stewardship program. The program was supposed to include protocols for optimizing infection treatment, reducing adverse events from inappropriate antibiotic use, and implementing a system to monitor antibiotic use. However, the facility did not provide documentation of these protocols or procedures. Additionally, there was no evidence of designated staff accountable for overseeing antibiotic stewardship, nor was there access to pharmacists or other experts in antibiotic stewardship. The facility also lacked regular reporting on antibiotic use and resistance, and there was no education provided to staff and residents about antibiotic stewardship. During interviews, both the Infection Preventionist and the Director of Nursing, who were new to the facility, were unable to provide data on current antibiotic use or trends of infections within the building. The Infection Preventionist, on their third day, could not determine who was on antibiotics or identify recent infection trends. Similarly, the Director of Nursing was unsure about the current antibiotic use and the monitoring and tracking of antibiotic activity. This lack of knowledge and documentation indicates a significant gap in the facility's infection control practices.
Lack of Dementia Training Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure that staff participated in a dementia and behavior training program before providing direct care to residents in the special care unit. This deficiency affected three of the twelve sampled residents, who exhibited various cognitive and behavioral issues. The facility was unable to provide education records for current employees, indicating a lack of proper training in dementia care and abuse prevention. Resident #9, who had severe vascular dementia with behavioral disturbances, was observed in distress multiple times. The resident was seen yelling out for help and expressing discomfort, but the Certified Medication Technician (CMT) A responded inappropriately by teasing and joking with the resident, which was not acceptable. The resident's comprehensive care plan indicated a need for staff to anticipate needs and reduce distractions, but these measures were not effectively implemented. Resident #44, who had severe cognitive deficits and was at risk for wandering, was observed walking repetitively without access to snacks or drinks. The staff did not offer any refreshments, and the resident's water pitcher was found empty. Additionally, a Certified Nurse Aide (CNA) admitted to not being aware of the resident's PTSD diagnosis and had not received recent dementia education. The facility's administrator acknowledged the lack of staff education on dementia care and recognized the situation with Resident #9 as unacceptable.
Failure to Schedule Tests and Appointments, and Monitor Medications
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality care for three residents. Resident #10, who was diagnosed with Parkinson's Disease, orthostatic hypotension, shoulder pain, muscle wasting, and depression, did not receive a physician-ordered MRI for shoulder pain. Despite the resident experiencing severe pain, reaching a level 10 on a scale of one to ten, the MRI was not scheduled, and no results were found in the medical records. This oversight prevented the resident from being referred to pain management as planned. Resident #12, with moderate cognitive loss and diagnoses including dementia, PTSD, depression, rheumatoid arthritis, insomnia, and GERD, had an incident of blood in the ear. The primary care physician prescribed an antibiotic and ordered a consultation with an ENT specialist. However, the facility failed to schedule the ENT appointment, and there was no record of the consultation being completed. This lack of follow-through on the physician's order left the resident without the necessary specialist evaluation. Resident #44, who had severe cognitive loss and diagnoses of anxiety, dementia, Alzheimer's Disease, and cognitive communication deficit, was prescribed Lorazepam Intensol Oral Concentrate for restlessness and anxiety. The medication order did not include a stop date, which is required for as-needed medications to be reevaluated after 14 days. This omission in the medication order process resulted in the resident potentially receiving medication without proper reassessment.
Facility's Administrative Failures and Vendor Payment Issues Cause Resident Anxiety
Penalty
Summary
The facility failed to effectively utilize its resources to provide essential services for residents, as evidenced by the non-payment of essential service vendors, including staffing agencies. This resulted in the suspension of services from the staffing agency due to overdue invoices, which the facility's administrator was aware of but mistakenly believed had been resolved. The lack of payment and communication with the staffing agency led to a halt in staffing support, impacting the care provided to residents. Additionally, the facility did not ensure continuity of administration or active involvement of the administrator during an impending transition of ownership. This lack of leadership and communication caused significant stress and anxiety among residents and their families. Many residents and family members reported not knowing who the current administrator was or who to contact with concerns, leading to feelings of anger, anxiety, and frustration. The absence of clear communication regarding the transition of ownership further exacerbated these feelings, as residents and families were left to rely on rumors and hearsay about potential changes and the possibility of having to move to another facility. The report highlights the experiences of several residents and their families, who expressed concerns about the lack of information and transparency from the facility. Residents with cognitive impairments, such as dementia, were particularly vulnerable to the stress caused by the uncertainty of the situation. Family members expressed worry about the continuity of care and the potential negative impact on their loved ones' health and well-being. The administrator's limited presence and lack of communication with residents and families contributed to the overall deficiency in the facility's administration and management during this critical period.
Lack of Communication During Ownership Transition Causes Resident Anxiety
Penalty
Summary
The facility failed to ensure that residents and their families were treated with dignity and respect during a transition to a new operator, leading to stress and anxiety among the residents and their families. This deficiency affected nine out of eleven sampled residents. The facility did not communicate effectively with the residents or their families about the transition, leaving them to rely on rumors and hearsay for information. This lack of communication caused significant distress, as residents were uncertain about their future care and living arrangements. Several residents and their family members expressed their concerns and frustrations during interviews. For instance, one resident was upset because they had only heard rumors about the facility's management change and feared they might have to move if the new operator was not ready. Another resident's family member was angry about the lack of communication and worried about the potential impact on their family member's health and well-being. The absence of clear information from the facility led to feelings of disrespect and disregard for the residents' and families' rights and needs. The facility's administrator acknowledged the expectation that both current and new leadership should be available to address questions and concerns from residents and families. However, the administrator did not believe that the transition had caused any stress or anxiety, despite the numerous accounts from residents and their families indicating otherwise. This disconnect between the administration's perception and the residents' experiences highlights the deficiency in communication and respect for resident rights during the transition period.
Failure to Offer Pharmacy Choice to Residents
Penalty
Summary
The facility failed to ensure that residents and their families were offered a choice of pharmacy when the primary pharmacy for the facility changed. This deficiency affected nine out of eleven sampled residents. The facility's policy on promoting and maintaining resident self-determination emphasizes the importance of supporting resident choice, including the choice of healthcare providers. However, the facility did not adhere to this policy when it changed the primary pharmacy to Pharmacy B without notifying the residents or their families or offering them a choice. Several residents and their family members reported that they were unaware of the change in the primary pharmacy. For instance, Resident #1's family member believed that Pharmacy A was the chosen pharmacy at the time of admission and was upset to learn that Pharmacy B was providing medications without their knowledge. Similarly, Resident #2's family member was not offered a choice of pharmacy at admission or when the change occurred. This pattern was consistent across other residents, including those with cognitive impairments, who were not informed or given a choice regarding the change in pharmacy. Interviews with facility staff revealed a lack of communication and responsibility regarding the change in pharmacy. The Social Services Designee and the Administrator both stated that residents and families should be offered a choice of pharmacy at admission and during their stay. However, the Social Services Designee was unaware that all residents' primary pharmacy had been changed to Pharmacy B, and the former Assistant Director of Nursing, who facilitated the change, was no longer employed at the facility. This lack of communication and oversight contributed to the deficiency in honoring resident choice and self-determination.
Failure to Notify and Include Residents and Families in Council Meetings
Penalty
Summary
The facility failed to ensure that residents and families were reasonably notified of Resident Council Meetings and did not honor the residents' requests regarding staff and family attendance at these meetings. This deficiency affected five of the eleven sampled residents. The facility's policy stated that Resident Council Meetings should be noted on the Activities calendar and that reasonable steps should be taken to inform residents and family members of upcoming meetings. However, the facility did not adhere to this policy, as evidenced by the lack of timely notification and the exclusion of family members and staff from a critical meeting about the transition of facility ownership. Resident #4, who is the Resident Council President, was informed of a meeting regarding the transition of ownership only 30 minutes before it was scheduled to occur. This left the resident feeling rushed and anxious, with insufficient time to prepare or notify other residents. The President of the company conducting the meeting did not allow staff to attend, except for one resident representative, and did not permit family members to be contacted or attend due to time constraints. Additionally, a previously scheduled meeting to discuss the transition was canceled by the new operating entity's representative, further contributing to the lack of communication and preparation. Other residents and their family members expressed concerns about the lack of notification and the inability to attend the meeting. Resident #1 and their family member were not informed in time to attend, and Resident #2's family member, who visits daily, was unaware of the meeting. Resident #3, who has dementia, attended the meeting but did not understand the information, causing distress. Resident #11 was also unaware of the meeting until it was over. The facility administrator acknowledged the expectation for leadership to be available for questions and for residents to receive advance notice of meetings, but was unaware of the meeting on 5/2/24.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide personal funds and a final accounting to six residents within 90 days of their discharge. This deficiency was identified through interviews and record reviews. The facility did not have a policy in place regarding the refunding of resident funds, which contributed to the issue. The facility census at the time was 47 residents.
Deficient Call System in Resident Bathrooms
Penalty
Summary
The facility failed to maintain a functional call system in each resident's bathroom and bathing area. This deficiency was identified through observation and interview, revealing that the call system was not adequately equipped to allow residents to communicate with staff. The system did not relay calls directly to a staff member or a centralized staff work area, nor did it alert staff in the corridor. The facility had a census of 47 residents at the time of the survey.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide personal funds and final accounting to six residents within 90 days upon their discharge. The residents affected had varying balances in the facility's operating account, ranging from $399.00 to $3,321.10. During an interview, the Director of Operations acknowledged the requirement to refund personal funds within 30 days of discharge and stated that these refunds are processed through the corporate accounting department. However, the refunds had been requested but not processed, and the facility did not provide a policy regarding the refunding of resident funds.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to provide drinks, including ice and fresh water, consistent with the residents' needs and preferences, affecting four residents out of a sample of eight. Resident #2, who had moderate cognitive impairment and was dependent on staff for hydration, reported that staff did not bring water as often as desired, and the water glass on the table had been there since the previous day. Observations showed the resident had sunken eyes and cracked lips, indicating possible dehydration. Resident #4, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed with a water pitcher that was full but warm to the touch, with no ice. The resident did not respond to engagement, and the water pitcher remained unchanged throughout the day. Resident #6, also severely cognitively impaired, had dry, cracked lips with a sore, suggesting inadequate hydration. Resident #7, with moderate cognitive impairment, reported not receiving water that day, and the water on the table was lukewarm. Interviews with staff revealed inconsistencies in the provision of water. CNA A mentioned that ice water was usually passed around 9:00 A.M. to 10:00 A.M. but had not been done that day. The Administrator and Director of Nursing stated that water should be passed before, between, and after meals, and residents should be offered hydration frequently throughout the day. However, these practices were not consistently followed, leading to the deficiency in resident hydration.
Deficient Call System Functionality
Penalty
Summary
The facility failed to maintain a functioning call system that allowed residents to effectively communicate with staff. Observations revealed that call lights in multiple rooms on both the secure and open units were activated, but the indicator lights above the doors and on the call light board in the hall did not turn on. Although notifications appeared on the screen at the central nurses' station for the open unit, the secure unit lacked this functionality, leading to a reliance on staff presence at the nurses' station to manually inform others of activated call lights. Interviews with staff, including an LPN and a CNA, confirmed that the call light system had not been working properly for several months, with the lights above the doors previously functioning but now inoperative. The LPN mentioned that the system was incompatible with the building's electrical system, and the CNA noted that if no one was at the nurses' station, staff would be unaware of activated call lights. The Director of Operations was unaware of the malfunctioning indicator lights and expected the system to be fully operational.
Failure to Timely Report Injuries of Unknown Origin
Penalty
Summary
The facility staff failed to report injuries of unknown origin for a resident in a timely manner to the Department of Health and Senior Services (DHSS). On 3/23/24, a resident was found with multiple injuries, including bruising to the right eye, elbows, and right hand, as well as a skin tear on the right wrist. Despite the discovery of these injuries by various staff members, including a Licensed Practical Nurse (LPN), a Certified Nurse Aide (CNA), and a Certified Medication Technician (CMT), the injuries were not reported to the Director of Nursing (DON) or the Administrator immediately. The LPN documented the injuries in the medical record but failed to notify the appropriate authorities. The Director of Nursing became aware of the injuries on 3/25/24 through the nurse's notes, and the Administrator acknowledged that the report to the state agency was delayed beyond the required two-hour window. The resident involved had severe cognitive impairment, was dependent on a walker, and required assistance with daily living activities. The facility's policy mandates prompt reporting and investigation of such incidents, but this protocol was not followed, resulting in a deficiency in reporting suspected abuse, neglect, or injuries of unknown origin.
Incomplete Investigation of Resident's Injuries
Penalty
Summary
The facility failed to thoroughly investigate injuries of unknown origin for a resident who was found with bruising on the arms, right eye, and a skin tear on the right arm. The facility did not follow its policy, which required interviewing all staff who had contact with the resident and providing complete documentation of the investigation. The investigation lacked statements from key staff members who were present during the time of the incident, and there was no documentation of interviews with the resident's family or other potential witnesses. The resident involved had severe cognitive impairment, was dependent on a walker for mobility, and required assistance with daily living activities. The resident had a history of wandering and was at risk for falls due to impulsiveness and decreased safety awareness. On the morning of the incident, staff discovered the resident with bruises and a skin tear, but there was no record of a fall or any incident that could explain the injuries. The facility's investigation was incomplete, as it did not include statements from all relevant staff or a thorough review of the events leading up to the injuries. Interviews with staff revealed inconsistencies and gaps in the investigation process. The Director of Nursing (DON) and Administrator were involved in the investigation but did not use formal documentation forms, and some interviews were not recorded. The DON was unaware of the incident until two days later, and the investigation lacked a written summary. The facility's failure to conduct a comprehensive investigation and document findings properly resulted in a deficiency in addressing the resident's injuries of unknown origin.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 44 citations issued within 25 miles in the last 12 months — including the 2 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 Savannah
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laverna Manor Health & Rehabilitation | 3.4 mi | ★★★★★ | 20 | 2 |
| Carriage Square Rehab And Healthcare Center | 10.1 mi | ★★★★★ | 5 | 0 |
| Living Community Of St Joseph | 10.8 mi | ★★★★★ | 0 | 0 |
| Advanced Care Of St Joseph | 10.9 mi | ★★★★★ | 2 | 0 |
| St Joseph Manor Health & Rehabilitation | 11 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.