Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Adair Village during CMS and state inspections, most recent first.
A resident with dementia, diabetes, kidney disease, and neurologic neglect syndrome had severe unplanned weight loss, dropping more than 15% of body weight in about three months. Staff did not fully notify the MD, DM, or RD, did not implement the RD’s increased TwoCal recommendation in the POS/MAR, did not document meal intake, and did not consistently provide assistance or encouragement during meals. During observation, the resident struggled to eat regular-textured food, left the dining room early, and ate less than 10% of the meal.
The facility failed to provide a SNFABN or alternative denial letter when Medicare Part A skilled services were initiated, reduced, or terminated for two residents who remained in the facility after covered services ended. Although NOMNCs were given by phone to family representatives with verbal acknowledgement, staff did not give the resident or legal representative the required written notice of potential liability, and the SSD and administrator stated they were unaware of the requirement.
Missing Written Transfer and Bed-Hold Notices: The facility did not ensure written transfer notices and bed-hold information were provided for three residents sent to the hospital. Records showed each resident had acute medical issues such as COPD, respiratory failure, pneumonia, sepsis, or dementia, and staff documented emergency transfers or hospital admissions, but there was no documentation that written notices were given or mailed to the resident or representative. Interviews showed staff typically called family and sent clinical paperwork, but were not aware of written transfer notices being provided.
Insulin pen administration errors exceeded the allowed rate when an LPN failed to prime pens and did not hold the pen in place after injection for three residents with diabetes. Observations showed the LPN administered Humalog/insulin lispro to residents with orders for sliding-scale, scheduled premeal, and evening doses without priming the pen and without waiting after pushing the plunger, resulting in 3 errors out of 26 opportunities (11.54%). Interviews with nursing leadership confirmed pens should be primed every time and held in place after administration.
Insulin pens were not primed before administration and the pen was not held in place after injection for three residents receiving insulin lispro. An LPN administered insulin to residents with diabetes-related diagnoses without following the manufacturer’s instructions, and interviews with nursing leadership confirmed that pens should be primed every time and held in place after the dose is given.
A resident admitted with ESRD and dialysis dependence did not have a baseline care plan completed within the required 24 to 48 hours. The plan was dated 4 days after admission, and the 48-hour care plan was dated 5 days after admission. Records showed the resident was legally blind, used a walker, needed assistance with ADLs, and attended dialysis M/W/F. Staff including the RN, MDS coordinator, LPN, ADON, DON, and Administrator stated the baseline care plan should have been completed within 24 to 48 hours.
Missing Documentation for New Schizophrenia Diagnosis: The facility failed to provide sufficient medical documentation to support a new schizophrenia diagnosis for a resident receiving Seroquel. Physician progress notes and nursing notes did not document a psychiatric evaluation or symptoms supporting schizophrenia, and a pharmacy fax requested the physician select schizophrenia as the medication indication. Staff interviews showed the MDS coordinator believed the diagnosis was based on the pharmacy recommendation, while the DON stated a new mental health diagnosis should include rationale, physician notification, and behavior documentation.
A resident with ESRD and dependence on renal dialysis did not have physician orders documented for dialysis or for assessment of the dialysis site, and the chart lacked a specific dialysis policy. Although the care plan noted hemodialysis on M/W/F and staff discussed checking the shunt site, staff interviews showed they were unsure whether the required orders were in place. The resident reported leaving very early for dialysis and returning later for breakfast.
Failure to use EBP and perform hand hygiene during resident care. Two CNAs provided personal care to a resident with a urinary catheter without wearing gowns, handled the catheter bag during care, and one CNA was not observed removing gloves or washing hands when leaving the room. The resident was dependent on staff for all care and had an order and care plan for EBP due to the catheter. Staff interviews confirmed that gowns, gloves, and hand hygiene were expected during care.
A resident with multiple medical conditions and a care plan requiring two-person assistance for transfers and changing was left unattended by a single nurse assistant, despite clear documentation and staff awareness of the need for two staff. The resident fell from bed during care, resulting in a fractured humerus. Staff interviews confirmed that the requirement for two-person assistance was well known and communicated throughout the facility.
Two nurse aides worked beyond four months without completing state-approved CNA training, competency evaluation, or certification, and continued to provide direct care to residents. Both aides started classes late and were scheduled for testing after the required timeframe, contrary to facility policy and federal requirements.
Nursing staff failed to document the administration of scheduled medications for three residents with complex medical conditions, leaving blank spaces in the MAR without explanation or required codes. This included missed documentation for critical medications such as anticoagulants, antidepressants, antihypertensives, and pain medications. Interviews with staff confirmed that all medication administrations should be recorded, and blank MAR entries indicate either non-administration or lack of documentation, with no further information found in the medical records.
Staff did not consistently document the administration of a physician-ordered 2 Cal nutritional supplement for a resident with significant weight loss and multiple health conditions, despite care plans and orders requiring it three times daily. Medication Administration Records showed several missed or undocumented doses, and staff interviews confirmed that documentation was expected for both administration and refusals. This failure to document or administer the supplement as ordered resulted in a deficiency related to maintaining the resident's nutritional status.
Staff failed to consistently document and administer ordered oxygen therapy for a resident with multiple respiratory and cardiac conditions. Multiple shifts lacked documentation of oxygen administration, and staff did not record reasons for missed checks, despite facility policy and physician orders requiring this. Interviews confirmed that nurses are responsible for this documentation, and blank spaces on records indicated the task was not completed.
A resident with multiple health conditions experienced significant delays in receiving pain medication, despite visible discomfort and repeated requests. The resident waited over three hours for tramadol, which was eventually administered by the DON without proper documentation or pain assessment. Staff interviews revealed communication and documentation lapses, contributing to the deficiency in pain management.
A resident with multiple health conditions and at risk for pressure ulcers did not receive proper wound care in a LTC facility. Staff failed to document and treat wounds on the resident's knee, legs, and buttocks according to facility protocols. The DON acknowledged the lack of physician orders for these wounds, and the resident's physician was unaware of all the wounds. Observations showed inadequate treatment, and staff interviews revealed a lack of awareness and documentation.
A resident experienced an improper transfer resulting in bruising and swelling due to rough handling by a CNA. Despite reporting the incident, the facility failed to document or investigate the injury, violating protocols for skin assessments and communication. The resident's care plan highlighted a risk for bruising, yet staff did not adhere to procedures for reporting new skin issues.
Failure to Address Significant Weight Loss and Meal Assistance Needs
Penalty
Summary
The facility failed to provide enough food and fluids to maintain a resident’s health for a resident with multiple diagnoses including heart disease, kidney disease, dementia, diabetes, high blood pressure, and neurologic neglect syndrome. The resident had severe cognitive impairment, required assistance with most activities of daily living, and needed supervision and set-up assistance for eating. The resident was identified as being at risk for weight loss and had a documented unplanned weight loss, but the facility did not fully inform the physician, involve the Dietary Manager, or notify the consultant RD for assessment when the weight loss became significant. The resident’s weight declined from 137.5 pounds to 115.8 pounds over about three months, a loss of 21.7 pounds or 15.78%. The facility policy required verification of significant weight changes, notification of the dietician, and multidisciplinary evaluation of undesirable weight loss, including assessment of causes, intake, and individualized interventions. Although the care plan included supplements, weekly weights, diet modification, and monitoring for weight loss, the physician order sheet did not reflect the RD’s recommendation to increase TwoCal from 30 ml to 60 ml three times daily, and the medication administration record did not show that increase. Staff also did not document meal intake, and no Dietary Manager notes were found in the record. During observation, the resident was served regular textured food on a regular plate rather than in bowls, despite poor vision and prior discussion of using bowls. The resident struggled to eat with a fork, spilled food, appeared frustrated, left the dining room before finishing, and ate less than 10% of the meal. No staff approached or encouraged the resident during the meal, and the meal intake was not documented. Interviews with nursing, dietary, and administrative staff showed they were aware the resident had weight loss and that staff should have sat with and assisted the resident, documented intake, and implemented the RD’s recommendation, but these actions were not consistently carried out. The Medical Director stated he had not been notified of the resident’s weight loss or the RD’s recommendations.
Failure to Provide SNFABN or Denial Letter for Medicare Part A Termination
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN, CMS-10055) or an alternative denial letter when Medicare Part A skilled nursing services were initiated, reduced, or terminated for two residents who remained in the facility after Medicare-covered services ended. Record review showed that for one resident, Medicare A skilled services began on 12/22/25 and the last covered date was 01/20/26; for the other resident, Medicare A skilled services began on 10/31/25 and the last covered date was 12/11/25. In both cases, the facility/provider initiated discharge from Medicare Part A services before the benefit days were exhausted. For both residents, a Notice of Medicare Non-Coverage (NOMNC, CMS-10123) was provided by phone to a family representative with verbal acknowledgement, but staff did not provide the resident or legal representative with the SNFABN or an alternative denial letter. The social service designee stated she did not know an ABN was needed, and the administrator stated that she and the SSD did not know the requirement to provide the SNFABN or alternative denial letter for residents remaining in the facility.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility failed to ensure that residents or their representatives received written notice of transfer and bed-hold information when residents were sent to the hospital. The report states that the facility did not have a process in place to routinely provide transfer letters and notice of bed hold for three sampled residents who were transferred to acute care settings. Facility policies dated March 2025 and October 2022 required written transfer or discharge notices, written bed-hold information, and documentation of attempts to notify representatives when emergency transfers occurred. For Resident #57, the record showed diagnoses including COPD with acute exacerbation and encephalopathy. Nursing notes documented that on 11/15/25 the resident became weak, slumped over on the toilet, was later shaking and very drowsy, and was evaluated by the charge nurse and physician. The resident refused hospital transfer at that time, but was admitted to the hospital on 11/16/25. The medical record did not contain documentation that a written transfer notice was given or mailed to the resident or representative for this hospital transfer. For Resident #25, the record showed diagnoses including acute and chronic respiratory failure with hypoxia, COPD, and hypokalemia. Nursing notes documented oxygen desaturation into the low 80s while on oxygen, confusion, diminished lungs with crackles, and physician notification; EMS transported the resident to the emergency room on 11/8/25. The resident returned from hospitalization on 11/11/25 with pneumonia and acute on chronic respiratory failure with hypoxia and hypercapnia. The medical record did not contain documentation of a written transfer notice given or mailed to the resident or representative for the 11/8/25 hospital transfer. For Resident #7, the record showed diagnoses including COPD, pneumonia, severe sepsis with septic shock, and dementia. Nursing notes documented that on 12/31/25 the resident complained of not feeling well, was shaking and light-headed, had elevated blood pressure and pulse, and had oxygen saturation of 87% on 3 liters of oxygen; the physician suggested sending the resident to the emergency room and the family was notified. The resident returned to the facility on 01/07/26 with a PICC line and IV antibiotics. The medical record did not contain documentation of a written transfer notice given or mailed to the resident or representative for the 12/31/25 hospital transfer. Interviews with the Social Service Director, nursing staff, MDS Coordinator, ADON, DON, and Administrator confirmed that staff were aware of phone notification and sending clinical paperwork, but were not aware of written transfer notices being sent to residents or families.
Insulin Pen Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure medication error rates remained below 5% when staff did not prime insulin pens and did not follow the manufacturer’s administration instructions for three residents. Surveyors identified 3 medication errors out of 26 opportunities, resulting in an error rate of 11.54%. Facility policies stated that medications are to be administered safely and in accordance with prescriber orders, and the insulin administration policy required staff to have access to manufacturer instructions for insulin delivery systems before use. Resident #8 had diagnoses including type 2 diabetes mellitus and metabolic encephalopathy and had an order for Humalog Kwikpen before meals based on sliding scale blood glucose results. During observation, an LPN prepared the resident’s insulin, obtained a blood glucose of 216, administered the insulin into the left lower abdomen, did not prime the pen, and did not hold the needle in the skin for at least five seconds after pushing the plunger. Resident #44 had diagnoses including cerebrovascular disease and type 2 diabetes mellitus and had an order for insulin lispro 10 units before meals. During observation, the LPN turned the pen dial to 10 units, administered the insulin into the left upper arm, did not prime the pen, and did not hold the needle in the skin for at least five seconds. Resident #4 had diagnoses including stroke, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3 and had an order for insulin lispro 8 units in the evening. During observation, the LPN obtained the insulin pen, dialed it to 8 units, administered the insulin into the left lower abdomen, did not prime the pen, and did not hold the pen in the skin for any length of time. Interviews with nursing staff, the ADON, DON, and Administrator confirmed that insulin pens should be primed every time and held in place after administration to ensure the full dose is delivered.
Insulin Pens Not Primed Before Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when insulin pens were not primed before administration and the manufacturer’s instructions for use were not followed. The report identified this issue during observations, interviews, and record review for three residents who received insulin lispro by pen. Facility policy defined medication errors as administration not in accordance with physician orders, manufacturer specifications, or accepted professional standards, and the insulin pen instructions required priming before each injection and holding the pen in the skin after injection. Resident #8 had diagnoses including type 2 diabetes mellitus and metabolic encephalopathy and had an order for Humalog Kwikpen before meals based on sliding scale blood glucose results. During one observation, an LPN prepared supplies, obtained a blood glucose of 216, wiped the resident’s abdomen, and administered insulin without priming the pen and without holding the needle in the skin for any length of time after pushing the plunger. During a second observation, another LPN entered the room with an insulin pen, turned the dial to two units, and administered the insulin without priming the pen. Resident #44 had diagnoses including cerebrovascular disease and type 2 diabetes mellitus and had an order for insulin lispro 10 units before meals. During observation, an LPN turned the pen dial to 10 units, wiped the resident’s upper arm, and administered the insulin without priming the pen and without holding the needle in the skin for any length of time after pushing the plunger. During a second observation, the same resident received insulin from another LPN who turned the dial to 10 units and administered the insulin without priming the pen. Resident #4 had diagnoses including stroke, type 2 diabetes mellitus with hyperglycemia, and chronic kidney disease stage 3 and had an order for insulin lispro 8 units in the evening. During observation, an LPN obtained the insulin lispro pen from the medication cart, turned the dial to 8 units, and administered the insulin to the resident’s abdomen without priming the pen and without holding the pen in the skin for any length of time. Interviews with nursing staff, the ADON, DON, and Administrator confirmed that insulin pens should be primed every time and that the pen should be held in place after administration to ensure the full dose is delivered.
Baseline care plan not completed within required timeframe
Penalty
Summary
The facility failed to complete a baseline care plan within 48 hours of admission for one resident. Facility policy titled Baseline Care Plans, dated March 2022, required a baseline plan of care to be developed within 48 hours of admission to address the resident’s immediate health and safety needs and to include initial goals, physician orders, dietary orders, therapy services, and social services. The policy also stated the baseline care plan would be used until the comprehensive care plan was developed. Resident #60 was admitted on 01/15/26 with diagnoses including end stage renal disease and dependence on renal dialysis. The resident’s admission MDS showed the resident was admitted to the facility on 01/15/26. The resident’s baseline care plan was dated 01/19/26, which was 4 days after admission. That baseline care plan documented that the resident was on dialysis Monday, Wednesday, and Friday; could communicate easily with staff; required supervision or touching assistance with toileting hygiene, dressing, personal hygiene, and transfers; required partial to moderate assistance with showering; used a walker; and was cognitively intact. The resident’s 48-hour care plan, used with the initial care plan, was dated 01/20/26, 5 days after admission. It listed an admitting diagnosis of renal disease and participation in treatment for long term care placement. The comprehensive care plan, also dated 01/20/26, addressed hemodialysis, monitoring for complications, avoiding blood pressure and blood draws in the graft arm, encouraging dialysis attendance, monitoring labs, and watching for signs and symptoms of renal insufficiency. Nursing progress notes on 01/15/26 documented the resident arrived by private car, ambulated to the room on own, had a shuffled gait, was legally blind, attended dialysis Monday, Wednesday, and Friday at 5:15 A.M., was on a regular diet, and voiced a desire to follow a renal diet even though the facility did not offer special diets. During interviews, the Social Service Director, RN, MDS Coordinator, LPN, ADON, DON, and Administrator all stated the baseline care plan should have been completed within 24 to 48 hours of admission and should not have been started 4 days after admission.
Missing Documentation for New Schizophrenia Diagnosis
Penalty
Summary
The facility failed to provide sufficient medical documentation to support a new mental health diagnosis of schizophrenia for one resident. The resident had an admission diagnosis of cerebral infarction and existing diagnoses of bipolar disorder and schizophrenia was later added to the face sheet. The resident’s quarterly MDS showed cognitive impairment, wheelchair use, and bowel and bladder incontinence, and the care plan noted use of psychotropic, antianxiety, and antidepressant medications along with periods of verbally aggressive behavior. Review of the resident’s physician progress notes on 9/7/25, 10/5/25, and 11/2/25 showed no psychiatric evaluation or documentation supporting the new schizophrenia diagnosis. Nursing notes from 9/21/25 to 10/21/25 and from 10/21/25 to 11/21/25 also showed no documentation of symptoms supporting schizophrenia and no documentation of the added diagnosis. A pharmacy recommendation fax on 10/30/25 asked the physician to choose schizophrenia, Huntington’s disease, or Turret’s syndrome as the indication for Seroquel, and the physician response section indicated schizophrenia, but the response was not signed. During interviews, nursing staff stated they document behaviors and symptoms each shift and report changes to the DON or ADON, while the MDS coordinator said he/she handles PASRR issues and believed the schizophrenia diagnosis was based on the pharmacy recommendation. The physician said he/she had treated the resident for over two years, that Seroquel was necessary for mood and behavior management, and that he/she did not recall the added schizophrenia diagnosis but would not argue with it because the resident had many schizophrenia-like symptoms. The DON stated documentation of a new mental health diagnosis should include a rationale, physician notification, and documentation of behaviors and symptoms, and the Administrator said staff were expected to document on residents with a new mental health diagnosis.
Missing Dialysis Orders and Site Monitoring
Penalty
Summary
The facility failed to provide dialysis services per professional standards of practice for a resident with end stage renal disease and dependence on renal dialysis. The resident was admitted with diagnoses including ESRD and renal dialysis dependence, and the record showed the resident attended dialysis on Monday, Wednesday, and Friday at 5:15 A.M. The facility’s dialysis communication forms were present in the chart, and the care plan identified that the resident needed hemodialysis every Monday, Wednesday, and Friday, but the physician order sheet did not document an order for dialysis or an order for assessment of the dialysis site. The care plan also did not include information about the time of dialysis or which arm was affected. The record review and interviews showed the facility lacked a specific dialysis policy. Staff members, including the RN, LPN, ADON, DON, and Administrator, stated that residents on dialysis should have physician orders and that the shunt site should be checked, but they did not know whether the resident had the needed orders. The resident stated he/she left the facility at about 5:00 A.M. for dialysis and did not receive breakfast until after returning. The facility’s admission summary noted the resident was legally blind, ambulatory with a shuffle gait, and pleasant during assessment, and the comprehensive care plan included monitoring for signs and symptoms of renal insufficiency and avoiding blood pressure or blood draws in the graft arm.
Failure to Use EBP and Perform Hand Hygiene During Resident Care
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not use Enhanced Barrier Precautions (EBP) during personal care for a resident with an indwelling urinary catheter and did not complete proper hand hygiene during resident care. The resident had diagnoses including chronic kidney disease, Alzheimer's disease, and atherosclerotic heart disease, was severely cognitively impaired, rarely able to make self understood, and dependent on staff for all care. The resident's care plan identified infection risk related to the catheter and directed staff to use EBP, and the physician order also required EBP due to the catheter. During observation of care, two CNAs entered the resident's room wearing gloves but not gowns. They removed the resident's pants and incontinence brief, assisted the resident to roll, placed a new brief and Hoyer lift pad, fastened the brief and pants, and handled the catheter bag by placing it in the resident's lap and later into the dignity bag attached to the wheelchair. One CNA then brushed the resident's hair while the other gathered trash and made the bed. One CNA was not observed removing gloves or washing hands when leaving the room, and the other CNA removed gloves and washed hands. The resident's catheter bag was handled during care, and staff did not don gowns as required for EBP. Staff interviews confirmed knowledge of EBP and hand hygiene expectations, including wearing gowns and gloves for residents with catheters and washing hands before and after resident contact and when moving from dirty to clean tasks. The CNA involved stated a gown was forgotten during care, and the other CNA stated the same. RN, LPN, ADON, DON, and the Administrator all stated that residents with catheters should be on EBP and that staff should wear gowns and gloves and perform hand hygiene during resident care.
Failure to Provide Required Two-Person Assistance Results in Resident Fall and Fracture
Penalty
Summary
Staff failed to provide care as required by the resident's care plan and facility policy, resulting in a fall and injury. The resident involved had multiple diagnoses, including cerebral infarction, congestive heart failure, metabolic encephalopathy, and was on anticoagulant medication. The care plan specified that the resident was at risk for falls, was totally dependent on staff for repositioning and transfers, and required a mechanical lift with the assistance of two staff members for all transfers and changing. Despite these documented requirements, a nurse assistant provided care to the resident alone after the resident requested to be changed immediately. The nurse assistant acknowledged being aware that two staff were required for such care, as indicated on the care plan and signage in the resident's room, but proceeded to change the resident without waiting for assistance. During the process, the resident rolled in the opposite direction as instructed and fell from the bed, resulting in a fracture to the left humerus. Multiple staff interviews confirmed that the resident was known to require two staff for all transfers and changing, and that this information was communicated through care plans, door signage, and staff reports. The incident was further corroborated by interviews with other nurse assistants, a certified medication technician, a physical therapist, the resident's physician, and facility leadership, all of whom stated that two staff were required for the resident's care due to the resident's size, lack of mobility, and cognitive status. The failure to follow the established care plan and facility policy directly led to the resident's fall and injury.
Failure to Ensure Timely CNA Training and Certification for Nurse Aides
Penalty
Summary
The facility failed to ensure that nurse aides who had been employed for more than four months completed a state-approved certified nursing assistant (CNA) training program, competency evaluation, and certification within the required timeframe. Two nurse aides, both hired in August, began their CNA classes in late October and completed them at the end of January of the following year. However, both were scheduled to take the CNA test in early March, which is beyond the four-month period allowed for completion of training and certification. Review of the state agency CNA registry confirmed that neither aide was listed as a CNA at the time of the survey. Interviews with the nurse aides revealed that they had been providing direct care to residents since their hire dates, with one aide stating they were paired with a CNA for about five days before working independently. Observations confirmed that these aides were actively providing care. The facility's policy and statements from the CNA instructor and administrator indicated an understanding of the four-month requirement, but the aides continued to work beyond this period without certification or completion of the competency evaluation.
Failure to Document Medication Administration as Ordered
Penalty
Summary
Facility nursing staff failed to ensure that all residents received care and treatment in accordance with professional standards of practice by not documenting the administration of medications as ordered by physicians for three residents. The facility's policy requires medications to be administered and documented in the Medication Administration Record (MAR) according to prescriber orders, with any deviations or omissions to be clearly noted and explained. However, multiple instances were identified where staff left blank spaces in the MAR, indicating either a failure to administer the medication or a failure to document its administration, without any accompanying explanation or code. For one resident with complex medical needs including diabetes, stroke, heart failure, and other chronic conditions, staff did not document the administration of several critical medications such as anticoagulants, antidepressants, antihypertensives, and others on multiple occasions. The MARs for this resident showed repeated blank entries for both morning and evening doses across several days, and there was no documentation in the nurses' notes to explain these omissions. Similar patterns were observed for two other residents with significant medical histories, including chronic pain, depression, anxiety, neuropathy, respiratory failure, and cardiovascular disease. For these residents, staff also failed to document the administration of various scheduled medications, including pain medications, antidepressants, diuretics, and antibiotics, with no corresponding notes or explanations in the medical records. Interviews with facility staff, including a Certified Medication Technician, an LPN, the Director of Nursing, and the Administrator, confirmed that the expectation is for all medication administrations to be documented in the MAR, with reasons provided for any missed doses. Staff acknowledged that blank spaces in the MAR indicate either non-administration or lack of documentation, and that such blanks would not automatically trigger a concern during management review. The lack of documentation for administered or missed medications was consistent across all three residents reviewed, and no additional information was found in the nurses' notes to account for the missing entries.
Failure to Document Administration of Dietary Supplement for Resident with Weight Loss
Penalty
Summary
Staff failed to consistently document the administration of a physician-ordered dietary supplement for a resident with significant weight loss and multiple medical conditions, including dementia, severe cervical fracture, hypertension, and dysphagia. The resident experienced notable weight loss over several months, with records showing a 12.6-pound decrease in one month and a body mass index in the underweight range. The care plan and physician orders required the administration of a 2 Cal nutritional supplement three times daily with meals, as well as additional interventions to address the resident's nutritional needs. Review of the Medication Administration Records (MAR) for January and February revealed multiple instances where staff did not document the administration of the 2 Cal supplement at various meal times. Specifically, there were several dates where the supplement was not recorded as given during breakfast, lunch, or dinner. Interviews with dietary and nursing staff confirmed that the supplement was to be provided at each medication pass, and refusals or administrations should have been documented in the MAR. However, blank spaces in the MAR indicated either a lack of documentation or a failure to administer the supplement as ordered. The facility's policy required regular monitoring and documentation of interventions for residents with weight loss, including the use of supplements. Despite these requirements, the lack of consistent documentation for the prescribed supplement represented a failure to ensure the resident received all recommended interventions to maintain acceptable nutritional status. This deficiency was confirmed through record review and staff interviews, which highlighted the importance of accurate documentation for residents at risk of further weight loss.
Failure to Document and Administer Ordered Oxygen Therapy
Penalty
Summary
Facility staff failed to provide respiratory care in accordance with standards of practice by not ensuring documentation of oxygen administration and checks every shift as ordered by the physician for one resident. The resident, who had diagnoses including cerebral infarction, obstructive sleep apnea, congestive heart failure, and acute respiratory failure with hypoxia, had a physician's order for oxygen at two to three liters per nasal cannula every shift for shortness of breath. Review of the Treatment Administration Records (TAR) for January and February showed multiple instances where staff did not document the administration of oxygen on both A.M. and P.M. shifts. Additionally, nurses' notes did not provide explanations for the missed documentation or checks. Interviews with staff, including CNAs, CMTs, LPNs, the DON, and the Administrator, confirmed that nurses are responsible for completing and documenting oxygen administration on the TAR, and that blank spaces indicate the task was not completed. The resident reported that staff had forgotten to replace the oxygen nasal cannula after a mechanical transfer. Facility policy required documentation and assessment for oxygen administration, but these procedures were not consistently followed or recorded for the resident in question.
Failure in Timely Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, leading to a deficiency in care. The resident, who was cognitively intact and required substantial assistance for daily activities, had a history of kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism. Despite having orders for pain management, including lidocaine gel and tramadol, the resident experienced significant delays in receiving pain medication. The resident reported waiting two to three hours for pain relief after requesting medication, which was corroborated by observations of the resident in visible discomfort and interviews with staff. On the day of the incident, the resident requested pain medication in the morning and was observed grimacing and in discomfort throughout the day. Despite multiple requests and visible signs of pain, the resident did not receive tramadol until over three hours later. During this time, the resident was transferred using a mechanical lift, which caused additional pain due to a visibly red, swollen, and bruised arm. The Director of Nursing (DON) eventually administered the medication but failed to document the administration or assess the resident's pain level before or after giving the medication. Interviews with staff, including the DON, revealed a lack of communication and documentation regarding the resident's pain management. The DON was unaware of the resident's need for pain medication until late in the afternoon and did not document the administration of tramadol or the resident's pain level. The facility's failure to administer pain medication timely, assess pain levels, and document the process led to a deficiency in providing appropriate pain management for the resident.
Failure to Document and Treat Resident Wounds
Penalty
Summary
The facility failed to provide care per standards of practice for a resident with multiple wounds. The resident, who was admitted with diagnoses including kidney failure, type two diabetes, high blood pressure, and chronic pulmonary embolism, was at risk for pressure ulcers. Despite this, staff did not document skin evaluations for several weeks, and when they did, they failed to consistently note the presence of wounds. The resident's care plan was updated to include an open area on the left knee, but staff did not document or care plan for additional sores on the backs of the resident's legs and buttocks. Interviews with staff revealed a lack of awareness and documentation regarding the resident's wounds. The Director of Nursing (DON) acknowledged the presence of wounds on the resident's left knee, bottom, and thighs but noted that there were no physician orders for these areas. The facility's protocol book for wounds was not signed off by a physician, and staff were reportedly following this protocol without specific orders. Observations showed that the resident's wounds were not being treated according to the facility's protocols, with some areas left open and others covered with dry dressings. The resident's physician was not aware of all the wounds and had only referred the resident to a wound care clinic for the knee wound. The physician expected nursing staff to assess, measure, notify, and document new wounds, which was not consistently done. The facility's computer system was supposed to notify staff of due skin assessments, but this process was not effectively followed. Interviews with various staff members, including the Social Services Director and Corporate Nurse, highlighted the expectation for wounds to be documented, monitored, and treated according to protocol, which was not adhered to in this case.
Improper Transfer and Lack of Documentation Leads to Resident Injury
Penalty
Summary
The facility failed to ensure that a resident was free from accident hazards and provided with adequate supervision during transfers. A resident, who was cognitively intact and required substantial assistance for mobility, experienced an improper transfer that resulted in pain and visible bruising on the arm. The resident was supposed to be transferred using a mechanical sit-to-stand lift but was instead roughly handled by a CNA, leading to significant bruising and swelling. Despite the resident reporting the incident to an LPN and the therapy department, there was a lack of documentation and follow-up on the reported injury. The facility's policy required staff to observe and document any skin issues, but the resident's bruising was not recorded in the skin assessments or progress notes. Interviews with various staff members, including CNAs, LPNs, and the DON, revealed a lack of awareness and communication regarding the resident's condition, with some staff assuming the bruise was pre-existing and not documenting it. The facility's failure to document and investigate the bruising, as well as the improper transfer, highlights a breakdown in communication and adherence to protocols. The resident's care plan indicated a potential for bruising due to anticoagulant therapy, yet the staff did not follow the required procedures for reporting and assessing new skin issues. This deficiency in care and supervision was not addressed or reported to the necessary parties, including the resident's physician and family.
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 26 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Clinton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clinton Healthcare And Rehabilitation Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Windsor Healthcare & Rehab Center | 16.7 mi | ★★★★★ | 0 | 0 |
| Truman Lake Manor Inc | 17.7 mi | ★★★★★ | 7 | 0 |
| Appleton City Manor | 19.2 mi | ★★★★★ | 2 | 1 |
| Aspire Senior Living Warsaw | 23.6 mi | ★★★★★ | 9 | 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.