Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Aegis Health And Rehabilitation during CMS and state inspections, most recent first.
Staff failed to complete required post-fall observation reports for 72 hours, did not obtain or document current vital signs for two residents, and did not complete post-fall observations for another. The facility also did not notify the physician and emergency contact after a fall, and care plans were not updated in a timely manner for multiple residents. Additionally, a fall was not documented in the nurse progress notes, and neuro checks were not performed after an unwitnessed fall.
The facility failed to ensure comprehensive, person-centered care plans for four residents, leading to incomplete documentation of respiratory issues, incontinence, behavioral interventions, and incorrect catheter status.
The facility failed to follow physician orders for a PICC line dressing change for a resident and did not document another resident's skin assessment since February 2024, despite the presence of a wound. Observations and interviews revealed that the PICC line dressing was not changed for over two weeks, and the skin assessments were not completed as required by the facility's policy.
The facility failed to ensure that each CNA received the required twelve hours of in-service education per year based on their individual performance review and hire date. A review of employee files for four CNAs showed no in-service tracking to confirm the required training. The DON acknowledged being behind on training, and a binder of in-service training lacked documentation of hours and individualized tracking records.
The facility failed to establish a system for accurately reconciling controlled drugs, with multiple instances of incomplete shift change counts and single nurse counts. Interviews revealed confusion and non-compliance with the narcotic count process.
The facility failed to maintain a medication error rate below 5%, resulting in a 28.94% error rate. Errors included improper insulin administration, failure to administer medications as ordered, and incorrect preparation of medications. Policies on medical provider orders and medication administration were not followed.
The facility failed to ensure proper medication storage and labeling. The medication room refrigerator temperature was out of range, and staff were not logging temperatures as required. Medications were not labeled with resident names, and medication carts were left unlocked and unsupervised, with Schedule II narcotics not stored behind double locks.
The facility failed to provide adequate and varied food options for residents, leading to dissatisfaction and unmet nutritional needs. Two residents were directly affected, with one being denied a requested alternative meal and another struggling with inappropriate food options. Residents expressed concerns about carb-heavy meals, small portions, and limited access to snacks.
The facility dietary staff failed to follow proper hand hygiene protocols and maintain cold fruit at safe temperatures. A dietary cook handled food and kitchen utensils with contaminated gloves, and cold fruit was served at unsafe temperatures on two separate days.
The facility failed to follow infection control standards, including not cleaning a PICC line lumen before administering medication, allowing urinary drainage bags to lie on the floor, and not performing hand hygiene between glove changes during personal care and wound dressing changes. These deficiencies were observed in multiple residents with severe cognitive impairments, indwelling urinary catheters, and chronic wounds.
The facility failed to follow their antibiotic stewardship policy by not collecting data on residents' antibiotic treatments and not using the approved antibiotic surveillance tracking form. The DON admitted that an antibiotic stewardship program had not been set up, and the infection log did not cover antibiotic tracking. The Regional Nurse confirmed that the facility was expected to have such a program in place.
The facility failed to ensure that residents allowed to self-administer medications had been assessed by the interdisciplinary team. Two residents were observed with medications left at their bedside without proper assessments or physician orders. The residents were using the medications without knowing the correct dosages and frequencies, and the facility's policy for self-administration was not followed.
The facility failed to ensure accurate coding of a resident's discharge status. The resident was sent to the hospital, but the discharge MDS incorrectly coded the discharge status as an Inpatient Rehabilitation Facility. The MDS Coordinator acknowledged the error during an interview.
A resident was left soiled and in pain after staff failed to provide timely and appropriate incontinence care. The resident experienced multiple episodes of incontinence and was not cleaned properly, leading to skin irritation and improper hygiene practices by staff.
A resident with a femur fracture and cervical spinal cord compression did not receive pain medication for over two hours after requesting it, despite repeated complaints to CNAs. The facility's Pain Management policy was not followed, and the resident's care plan did not address pain management, leading to a significant delay in administering pain relief.
The facility failed to provide necessary behavioral health care services for a resident with a suspected eating disorder, leading to the resident feeling self-conscious and distressed. Despite reports of binge eating and vomiting, no formal behavioral management plan or follow-up actions were documented.
The facility failed to ensure residents were free from significant medication errors when a resident was administered the wrong dose of insulin and another had a medication patch applied for longer than recommended. The errors involved improper insulin dosing and failure to follow guidelines for Lidocaine patch application.
The facility failed to obtain timely diagnostic tests for two residents, one needing an MRI for a humerus lesion and another requiring a swallow test due to coughing during meals. Administrative issues and lack of communication led to significant delays in both cases.
The facility failed to provide appealing and nutritionally comparable meal options to residents who did not want or could not eat the food initially served. Multiple residents, including one who requested scrambled eggs instead of quiche, were not provided with alternate meals. The Dietary Manager cited budget constraints, and the Administrator acknowledged the issue but was uncertain about the food ordering process.
Failure to Complete Post-Fall Assessments, Notifications, and Care Plan Updates
Penalty
Summary
The facility failed to follow its own policy and accepted standards of practice regarding post-fall care and documentation for three residents. Staff did not accurately complete post-fall observation reports for 72 hours, as required, by failing to obtain and document current vital signs for two residents and not completing post-fall observations for the full 72 hours for another resident. Additionally, there was a failure to document a fall in the nurse progress notes for one resident, and neuro checks were not completed for an unwitnessed fall as required by protocol. The facility also did not ensure timely notification of the physician and emergency contact when a resident experienced a fall. In one instance, after a resident was assisted to the floor by a CNA during a transfer, there was no documentation of physician or emergency contact notification. Furthermore, the care plans for two residents were not updated in a timely manner following their falls, and for another resident, the care plan was not updated at all after the incident. In several cases, interventions related to falls were not implemented or documented promptly. The residents involved had various medical conditions, including diabetes, malnutrition, syncope, muscle weakness, and cognitive communication deficits. At the time of the deficiencies, residents experienced falls that were either unwitnessed or involved injury, such as bruising, lacerations, and pain. Despite these incidents, required assessments, monitoring, and documentation were either incomplete or not performed according to facility policy, as evidenced by missing or outdated vital signs, lack of neuro checks, and incomplete progress notes.
Deficiencies in Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were comprehensive, person-centered, and developed based on the Minimum Data Set (MDS) care area assessment summary (CAAS) for four of 14 sampled residents. For Resident #33, the care plan did not include the resident's respiratory issues, need for a simple face mask for oxygen, shortness of breath, history of facial burns, incontinence of bowel and bladder, and need for assistance with ADL care. The triggered CAAS for ADL care, urinary incontinence, vision, and pain were also not included in the care plan. Resident #23's care plan inaccurately included a problem related to a urinary catheter, which the resident did not have at the time of the survey. The resident's care plan was not updated to reflect the discontinuation of the catheter, leading to incorrect documentation and potential mismanagement of care. Resident #188's care plan did not address the resident's behaviors or interventions for care when the resident exhibited behaviors such as verbal aggression and frustration. The care plan also failed to include the psychosocial well-being and mood state as triggered in the CAAS. Similarly, Resident #187's care plan was not developed within 7 days after the completion of the comprehensive assessment and did not address the resident's alcohol abuse or behaviors as mentioned in the baseline care plan upon admission.
Failure to Follow Physician Orders and Document Skin Assessments
Penalty
Summary
The facility failed to follow acceptable standards of practice for quality of care for two residents. Resident #337's peripherally inserted central catheter (PICC) line dressing had not been changed in accordance with the facility policy and physician orders. The physician's orders specified that the PICC line dressing should be changed every seven days or as needed if it became loose, not occlusive, or showed signs of moisture accumulation, drainage, redness, or irritation. However, observations on 4/4/24 and 4/8/24 showed that the resident's PICC line dressing was dated 3/22/24, indicating that it had not been changed for over two weeks. The Director of Nursing (DON) confirmed that the PICC line dressing change should be followed per physician orders, but it was not documented as performed by the Licensed Practical Nurse (LPN) on duty on 4/2/24 as required by the Treatment Administration Record (TAR) report. The facility also failed to document Resident #20's skin assessment since February 2024, despite the resident having a wound on the left heel. The facility's Skin Assessment Policy requires a full body skin assessment to be conducted weekly by a licensed or registered nurse. However, the resident's electronic medical record (EMR) showed no skin assessments were done between 2/7/24 and 4/3/24. The resident's care plan, initiated on 4/5/24, indicated that the resident had an unstageable pressure ulcer on the left heel, which was related to decreased mobility. The wound care progress note dated 4/4/24 described the wound as having 90% eschar and 10% slough, with moderate purulent drainage. The Director of Nursing (DON) acknowledged that skin assessments were not completed as required and expected nursing staff to fill out skin assessments weekly. Interviews with the nursing staff revealed confusion and lack of adherence to the facility's policies. LPN O admitted to not knowing what to do with the wound and did not put in a daily order for dressing changes, assuming the wound care company would handle it. The DON confirmed that staff were supposed to complete an assessment in the EMR, but this was not done. The failure to follow physician orders for PICC line dressing changes and the lack of timely skin assessments for Resident #20 led to deficiencies in the quality of care provided to the residents.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received no less than twelve hours of in-service education per year based on their individual performance review and calculated by their employment date. This deficiency was identified for four CNAs who had been employed for more than a year. The facility's assessment tool indicated that staff training and education were conducted through in-services and 1-on-1 training education packets with post-tests. However, a review of the employee files for CNAs R, F, S, and T showed no in-service tracking based on their hire dates to confirm the required twelve hours of training had been provided. During interviews, the Director of Nursing (DON) acknowledged being behind on training for March and had not started April's training. The DON and Regional Nurse M confirmed that nursing and Human Resources were responsible for the training. A binder containing sign-in sheets for monthly in-service training was reviewed, but it lacked documentation of the number of hours for each in-service and individualized tracking records for the CNAs. Regional Nurse M stated that she would expect the CNA 12-hour training to be documented and reflect at least twelve hours of in-service training per year, with a system in place to provide evidence of the training.
Failure to Accurately Reconcile Controlled Substances
Penalty
Summary
The facility failed to establish a system of records for the receipt and disposition of controlled drugs, leading to inaccuracies in the reconciliation of narcotics. Specifically, the facility's narcotic count books showed multiple instances where required shift change counts were not completed, and counts were often conducted by only one nurse instead of the required two. For Narcotics Book #1, there were four instances where the day/night count was not completed and three instances where the night/day count was not completed. Additionally, eight instances had only one nurse signature. For Narcotics Book #2, there were eight instances each where the day/night and night/day counts were not completed, and 16 instances had only one nurse signature. There was also an instance where the off-going nurse pre-signed the narcotic count sheet without listing a date. Interviews with the Assistant Director of Nursing (ADON) and a Licensed Practical Nurse (LPN) revealed confusion and non-compliance with the narcotic count process. The ADON mentioned that she sometimes had to count narcotics by herself due to the day shift nurse leaving before the count was completed. The LPN confirmed that nurses are expected to count narcotics at the beginning and end of their shifts and should not pre-sign the narcotic book. The Director of Nursing (DON) stated that she expected the nurses to follow the policy and procedures for counting narcotics and not pre-sign before the oncoming shift, emphasizing that there should always be someone available to count with.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in an observed error rate of 28.94%. This was based on 11 errors out of 38 opportunities observed, involving three residents. The errors included improper administration of insulin, failure to administer medications as ordered, and incorrect preparation of medications. The facility's policies on medical provider orders and medication administration were not followed, leading to these deficiencies. Resident #27, who had diagnoses including diabetes and peripheral vascular disease, had orders for various types of insulin. On multiple occasions, the resident refused the ordered dose of insulin, and the Assistant Director of Nursing (ADON) administered a different amount as per the resident's request without notifying the physician or documenting the refusal properly. This was against the facility's policy, which requires physician notification and proper documentation in case of medication refusal. Resident #6 had multiple medication orders, including aspirin, fluticasone propionate, and clonazepam. During an observation, the Certified Medication Technician (CMT) administered the wrong form of aspirin, failed to administer several other medications, and applied a lidocaine patch incorrectly. Additionally, Resident #28 received Losartan Potassium without a prior blood pressure check, and polyethylene glycol powder was mixed with an incorrect amount of water. These actions were contrary to the facility's policies and proper medication administration practices.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored in accordance with currently accepted professional principles. The medication room refrigerator temperature was consistently out of range, measuring 50 degrees Fahrenheit on one occasion and 48 degrees Fahrenheit on another, while the policy required temperatures to be maintained between 36-46 degrees Fahrenheit. Staff were not checking or logging the refrigerator temperatures as required by the facility's policy. The Assistant Director of Nursing (ADON) was unsure who was responsible for this task, and the temperature log book showed inconsistent and insufficient entries. Medications were not properly labeled with resident names. A vial of Lantus insulin was found without a resident's name, and the ADON admitted that the insulin was shared among residents, which is against the facility's policy. Additionally, a tube of diclofenac sodium 1% was found without a label, and the ADON could not locate the bag that should have contained the resident's name. This lack of proper labeling could lead to medication errors and cross-contamination. Medication carts were frequently left unlocked and unsupervised, posing a significant risk to resident safety. On multiple occasions, medication carts containing prescription medications, over-the-counter medications, and narcotics were observed unlocked and unattended. Schedule II narcotic medications were not stored behind double locks as required. The Director of Nursing (DON) confirmed that it is unacceptable for insulin to be used on more than one resident and that medication carts should be locked when not in use. However, the facility failed to adhere to these protocols, leading to potential safety hazards for the residents.
Failure to Provide Adequate and Varied Food Options
Penalty
Summary
The facility failed to provide each resident with a variety of food in appropriate quantities to meet their needs. Specifically, two residents were affected by this deficiency. One resident, who had moderately impaired cognition and diagnoses including dementia and depression, requested a grilled cheese sandwich but was initially denied by the kitchen staff in a loud and angry tone. The resident was eventually given the sandwich after the staff person at the door intervened. Another resident, who was cognitively intact and had multiple diagnoses including coronary artery disease, high blood pressure, and diabetes, was served quiche for breakfast, which they did not like. The resident requested an alternative and was eventually given cold cereal, which they had difficulty eating and swallowing, resulting in coughing and spilling food on themselves. The resident expressed that they were supposed to receive fried eggs instead of the cereal they were given. During a group interview, all 11 residents expressed dissatisfaction with the meals, stating that they were very carb-heavy and that portions were too small. They mentioned that they often felt hungry after meals and that there was a lack of variety in the food provided. The residents also complained about the availability of snacks, which were kept behind the nurse's station and often not accessible until late at night. Additionally, the residents mentioned that they used to receive menus with breakfast, allowing them to indicate their preferences, but this practice had been discontinued. The facility's weekly menu and kitchen inventory were reviewed, showing limited variety and quantity of food items. The Dietary Manager and Administrator acknowledged the issues but cited budget constraints and the need to stick to the menu as reasons for not providing more variety or larger portions. The Administrator mentioned that residents should receive seconds if requested, but was unsure if there was enough food to accommodate this. The facility's policy on menu alternates was not being effectively implemented, leading to residents not receiving appropriate alternatives when they did not like the food served.
Failure to Follow Hand Hygiene and Food Temperature Protocols
Penalty
Summary
The facility dietary staff failed to follow proper hand hygiene protocols while preparing food for the steam table. Specifically, a dietary cook did not remove his/her gloves after touching/rubbing/adjusting his/her clothing, touching their face mask, and the inside of the kitchen door frame using both gloved hands, and wiping off countertops with a stained wet dish rag. The cook continued to handle food and kitchen utensils with the same contaminated gloves, despite being cued by the Registered Dietitian to wash his/her hands and change gloves. This failure to maintain hand hygiene was observed multiple times, including when the cook touched the trash can lid, face mask, and water pitcher, and then proceeded to chop cauliflower and place it on the steam table without changing gloves or washing hands. Additionally, the facility dietary staff failed to maintain cold fruit at a temperature of 41 degrees Fahrenheit or less on two separate days of observation. On one occasion, mandarin oranges were left out of the refrigerator and served to residents at a temperature of 66.9 degrees Fahrenheit. On another occasion, the temperature of tropical fruit was measured at 51 degrees Fahrenheit despite being in the refrigerator all morning. These lapses in maintaining proper food temperatures could potentially lead to foodborne illnesses among residents.
Infection Control Deficiencies in Multiple Residents
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control in several instances. Staff did not clean the cap of a PICC line lumen before administering medication to a resident with sepsis, and urinary drainage bags were observed lying directly on the floor, full of urine, and with urine backing up into the tubing. Additionally, staff did not change gloves or sanitize their hands in accordance with the facility's policy during personal care and wound dressing changes. These deficiencies were observed in multiple residents, including those with severe cognitive impairments, indwelling urinary catheters, and chronic wounds. One resident with a PICC line for IV antibiotics and an indwelling urinary catheter had their urinary drainage bag on the floor, full of urine, and with urine backing up into the tubing. The LPN did not clean the PICC line lumen with alcohol before administering the IV antibiotic. Another resident with severe cognitive impairment and an indwelling catheter had their catheter tubing looped and kinked, preventing urine from draining into the bag, which was also observed lying on the floor. The DON confirmed that urinary drainage bags should not be on the floor and should be emptied every eight hours or as needed. During personal care observations, staff did not perform hand hygiene between glove changes, leading to potential cross-contamination. For instance, a CNA did not sanitize their hands after removing soiled gloves and before donning new ones while providing perineal care. Similarly, during wound dressing changes, staff did not follow proper hand hygiene protocols, such as changing gloves and sanitizing hands between different stages of the procedure. These lapses in infection control practices were observed in residents with various medical conditions, including end-stage renal disease, diabetes, and chronic wounds.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to follow their antibiotic stewardship policy by not collecting data regarding residents' antibiotic treatments and not reviewing and documenting that data on the facility-approved antibiotic surveillance tracking form. This deficiency had the potential to affect all residents receiving antibiotics. The Director of Nursing (DON), who also serves as the Infection Preventionist, was unable to provide the facility's Antibiotic Stewardship policy when requested. The facility's Infection Prevention and Control Program policy, revised on 9/1/23, outlined the requirements for an antibiotic stewardship program, including the implementation of antibiotic use protocols and a system to monitor antibiotic use. However, the DON admitted that an antibiotic stewardship program had not been set up, and the infection log being used did not cover antibiotic tracking. During an interview, the DON acknowledged that the facility had not implemented an antibiotic stewardship program and that the infection log provided did not include antibiotic tracking. The Regional Nurse also confirmed that the facility was expected to have an antibiotic stewardship program in place. The failure to implement and maintain an antibiotic stewardship program as part of the infection prevention and control program was a significant oversight, as it is essential for preventing the development and transmission of communicable diseases and infections within the facility.
Failure to Assess Residents for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that residents allowed to self-administer medications had been assessed by the interdisciplinary team to ensure their knowledge and safety in self-administration. Specifically, two residents were observed with medications left at their bedside without proper assessments or physician orders for self-administration. The facility's policy requires an interdisciplinary team assessment and a prescriber's order for residents to self-administer medications, which was not followed in these cases. Resident #4 had multiple inhalers and nebulizer medications at the bedside without an order or assessment for self-administration. The resident was observed using the medications and reported self-administering them since admission. The resident was unable to read the medication labels and was unsure of the correct dosages and frequencies. The Director of Nursing (DON) confirmed that there were no orders or assessments for the resident's self-administration of medications. Resident #7 was observed with a medication cup containing pills at the bedside, which the resident took without knowing what the pills were. The DON confirmed that medications should not be left at the bedside and that the resident had not been assessed for self-administration. The Certified Medication Technician (CMT) identified the pills as the resident's prescribed medications, but there was no assessment or order for self-administration in the resident's medical record.
Inaccurate Resident Assessment Coding
Penalty
Summary
The facility failed to ensure the resident assessment was accurately coded for one resident. The medical record review showed that the resident was discharged and a nursing note indicated that non-emergent transport was called to arrange transportation to the hospital. However, the discharge MDS inaccurately coded the discharge status as an Inpatient Rehabilitation Facility. During an interview, the MDS Coordinator acknowledged the incorrect coding, stating she was aware the resident was sent to the hospital and anticipated a return, but selected the wrong discharge status.
Inadequate Incontinence Care and Hygiene Practices
Penalty
Summary
The facility failed to ensure a resident who is incontinent of bowel and bladder received appropriate treatment and services after an incontinent episode. The resident was left saturated with urine by a staff member who did not return to complete the personal care. Later that morning, the same resident had another incontinent episode and requested personal care, but was told to wait until after lunch service, resulting in the resident waiting over 30 minutes while soiled. The resident had stool stuck to their skin and a reddened area on their buttocks, and staff did not apply cream to the area after providing personal care. The resident's admission Minimum Data Set (MDS) indicated they were cognitively intact, had an indwelling urinary catheter, and were always incontinent of bowel. Diagnoses included end stage renal disease (ESRD), atrial fibrillation (a-fib), pneumonia, asthma, hip fracture, and urinary tract infection (UTI). The resident had a voiding trial order after the catheter was discontinued. Observations showed the resident was left dirty for about 30 minutes, and when staff finally attended to the resident, they did not follow proper hygiene protocols, such as changing gloves and performing hand hygiene. Further observations revealed that the resident was not cleaned up after a smoke break and was told to wait until after lunch for care. When staff eventually provided care, they did not follow proper hygiene protocols, leading to contamination. The resident's buttocks were red, and they had both loose and hardened stool stuck to their skin. Staff failed to use barrier cream and did not change gloves or perform hand hygiene during the care process, further compromising the resident's condition.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to ensure proper pain management for a resident who required such services. The resident, admitted with a femur fracture and cervical spinal cord compression, did not receive pain medication for over two hours after requesting it. Despite the resident's repeated complaints of pain to Certified Nurse's Aides (CNAs), the pain was not promptly addressed, and the resident had to wait until a Licensed Practical Nurse (LPN) was available to administer the medication. This delay in pain management was observed during a survey, where the resident expressed pain multiple times before receiving the prescribed pain medication. The facility's Pain Management policy, which mandates a systematic approach for recognizing, assessing, treating, and monitoring pain, was not followed. The policy requires staff to recognize when a resident is experiencing pain, evaluate the resident for pain upon admission, and manage or prevent pain consistent with the comprehensive assessment and care plan. However, the resident's care plan did not address pain management, and the staff failed to follow through with the necessary steps to ensure timely pain relief. The resident's medical records indicated a history of pain and the need for pain management, including a prescription for Hydrocodone-Acetaminophen to be administered as needed. Despite this, the resident's pain was not adequately monitored or managed, leading to a significant delay in administering pain relief. The facility's failure to adhere to its pain management policy and promptly address the resident's pain resulted in a deficiency in the quality of care provided to the resident.
Failure to Address Suspected Eating Disorder
Penalty
Summary
The facility failed to provide necessary behavioral health care services for a resident's psychosocial well-being when staff did not address a suspected eating disorder after it was reported that the resident was binge eating and vomiting. Despite the resident's denial of the behavior, staff comments about the suspected eating disorder left the resident self-conscious about eating in front of others. The facility's Behavior Management policy requires a behavior management care plan for residents with identified behaviors, but no such plan was developed for the resident in question. The resident had a complex medical history, including Crohn's disease, diabetes, malnutrition, and PTSD. The resident's care plan included various interventions for these conditions but did not address the suspected eating disorder. Staff reported the resident's binge eating and vomiting to the Director of Nursing (DON), but there was no documentation of follow-up actions, referrals, or consultations with the physician, dietician, or social services. The resident expressed distress over the DON's comments and felt that other residents were making similar comments, exacerbating the resident's emotional well-being. Interviews with the DON and other staff revealed that the suspected eating disorder was based on verbal reports from previous staff and observations of the resident's behavior. However, there was no formal diagnosis or documentation to support these claims. The DON admitted to having conversations with the resident about their eating habits but did not document these interactions or implement any specific interventions. The lack of a comprehensive behavioral management plan and appropriate follow-up actions led to the deficiency in providing necessary behavioral health care services for the resident.
Medication Errors in Insulin and Lidocaine Patch Administration
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors when one resident was administered the wrong dose of insulin and another resident had a medication patch applied for longer than recommended. Resident #27, who had diagnoses including diabetes and peripheral vascular disease, was supposed to receive specific doses of Insulin Glargine and Insulin Lispro as per physician orders. However, the Assistant Director of Nursing (ADON) administered a different dose as requested by the resident, without notifying the physician or documenting the refusal and physician notification in the medical record. This action was against the facility's policy and professional standards of practice, as confirmed by interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON). The resident's blood sugar level was 327 at the time of the incident, and the ADON administered 18 units of Glargine and 5 units of Lispro instead of the ordered doses, which was not documented properly in the progress notes for several days following the incident. The DON confirmed that nurses should follow the policy and not allow residents to dictate the amount of insulin administered without physician notification and proper documentation. Resident #6, who had a diagnosis of unspecified pain, had an order for a Lidocaine patch to be applied to the right shoulder once a day and removed per schedule. However, during an observation, a Certified Medication Technician (CMT) applied a new Lidocaine patch to the resident's lower back without removing the previous patch from the shoulder, which was only removed just prior to the medication administration observation. The DON acknowledged that staff should follow the order for Lidocaine patches and was unaware of the specific recommendations per acceptable standards of practice but expected the physician order to follow these standards. The National Library of Medicine- Medline Plus website specifies that Lidocaine patches should not be worn for more than 12 hours per day to avoid overdose symptoms, which include lightheadedness, confusion, and slow heartbeat among others.
Failure to Obtain Timely Diagnostic Tests
Penalty
Summary
The facility failed to obtain a timely MRI and notify the physician when the MRI was delayed for a resident who showed a lesion on their right humerus. The resident, who had severe cognitive impairment and multiple diagnoses including heart failure, pneumonia, and quadriplegia, fell and was taken to the hospital where a lesion was found on their right humerus. Despite the physician's order for an MRI, the facility did not schedule the MRI in a timely manner and failed to obtain the necessary pre-certification, resulting in a delay of the diagnostic test. The Medical Records Supervisor and the Director of Nursing were aware of the need for the MRI but did not follow through with the necessary steps to ensure it was completed promptly. The resident's family was also involved in trying to expedite the process, but the MRI remained unscheduled due to administrative issues and lack of communication between the facility and the physician's office. The facility's failure to act promptly and efficiently led to a significant delay in the resident receiving the necessary diagnostic test. Additionally, the facility failed to obtain a timely appointment for a swallow test for another resident who had been coughing during meals. The resident, who was cognitively intact and had multiple diagnoses including coronary artery disease, high blood pressure, and diabetes, had an order for a speech evaluation and a Modified Barium Swallow test due to choking with meals. Despite the order, the facility did not schedule the test in a timely manner, and there was no documentation of the resident's coughing or difficulty swallowing in the progress notes. The Medical Records Supervisor and the Director of Nursing were aware of the need for the test but did not ensure it was scheduled promptly. The resident continued to experience coughing during meals, and the facility did not implement any interventions to address the issue while waiting for the test to be scheduled. The facility's inaction and lack of timely follow-up led to a delay in the resident receiving the necessary evaluation and potential dietary adjustments.
Failure to Provide Appealing and Nutritionally Comparable Meal Options
Penalty
Summary
The facility failed to provide appealing and nutritionally comparable meal options to residents who did not want or could not eat the food initially served. This deficiency was observed in multiple instances, including Resident #187, who complained about the breakfast served and was not provided with an alternate meal option despite requesting scrambled eggs. The Dietary Manager and LPN H both indicated that the facility had to stick to the menu due to budget constraints, and alternate meals were not provided even when requested by residents. Resident #8 also expressed dissatisfaction with the food, stating it was sometimes cold, tasteless, and that alternate options were not always available. Similarly, Resident #29 reported that the menu was repetitive and lacked variety. The Resident Council corroborated these complaints, noting that popular meals often ran out, and the alternates provided were limited to options like grilled cheese and hot dogs, which were not always appealing or nutritionally balanced. The Administrator acknowledged that residents should receive alternate meals upon request and that there should be enough food for seconds if requested. However, there was uncertainty about the food ordering process and the budget constraints mentioned by the Dietary Manager. The Administrator also mentioned plans to implement a resident choice system where the Resident Council would vote on meal options, but this had not yet been put into practice. The lack of appealing and nutritionally comparable meal options had the potential to affect all residents who could not eat or did not want the food being served.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Wildwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ellisville Rehabilitation And Nursing | 2.1 mi | ★★★★★ | 22 | 3 |
| Lutheran Senior Services At Meramec Bluffs | 3.6 mi | ★★★★★ | 2 | 0 |
| St Andrew's At Francis Place | 4.1 mi | ★★★★★ | 2 | 0 |
| Marymount Manor | 4.2 mi | ★★★★★ | 1 | 0 |
| Manchester Rehab And Healthcare Center | 4.2 mi | ★★★★★ | 0 | 0 |
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