Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Arbor Hills Care & Rehab Center during CMS and state inspections, most recent first.
Unsafe food storage, sanitation, and tray handling practices were observed in the dietary area. Food items in the freezer and dry storage were left uncovered or undated, dented cans remained in storage, and kitchen equipment and floors were dirty with caked-on grease and debris. During meal service, dietary staff handled sausage with gloved hands, cut food on the steam table, mashed mechanical soft items by hand, and transported hall trays on open carts with desserts and other items left uncovered.
Staff failed to follow infection control practices when an LPN repeatedly used non-medical-grade, lemon-scented wipes to clean a shared glucometer between blood glucose checks on three residents with diabetes, despite leadership later stating that only germicidal wipes should be used on multi-use medical equipment. In addition, a resident receiving nebulized medications for COPD exacerbation was observed with a nebulizer mask on the lap while the machine was running, and later with soiled clothing placed over nebulizer tubing, mask, and machine balled up on a chair, contrary to the DON’s expectation that such equipment be stored on a clean surface in a dated plastic bag. The corporate nurse confirmed there was no facility policy specifying best practices for cleaning and storing glucometers or nebulizer masks.
A CNA spoke to a resident in a demeaning manner, telling the resident to do tasks independently and saying the resident was “killing my back,” which the resident said felt humiliating. Two residents were served meals without knives and had to tear food apart with their hands, despite needing supervision with eating and stating they preferred a knife. In another instance, an ADON stood over a resident while feeding, and staff identified this as a dignity issue.
Failure to Reconcile RTF and Issue Quarterly Statements: The facility failed to complete monthly RTF reconciliations and did not document trial balances, bank statements, or reconciliations for most months reviewed, preventing accurate accounting of resident funds. The facility also failed to provide quarterly statements to residents or their representatives for multiple quarters, despite policy requiring monthly reconciliation and quarterly reporting.
A facility failed to provide the bed-hold policy to two residents or their representatives at the time of hospital transfer or as soon as practicable, and failed to send discharge notices to the State LTC Ombudsman. Records for both residents showed no documentation that the bed-hold notice was given before discharge, and the Ombudsman reported not receiving discharge notices for months.
Expired and unlabeled medications were found in multiple medication rooms and treatment carts, including topical creams, wound care products, inhalation solutions, insulin-related items, and eye drops. Surveyors also found a bottle of latanoprost with no resident name, insulin pens with no name, and a faded, unreadable vial in a damaged box in the refrigerator. RN and CMT staff said they were unsure who was responsible for checking expiration dates, while the DON stated CMTs should check carts, medication rooms, and refrigerators daily.
A resident with dementia, moderate cognitive impairment, psoriasis, and a moderate fall risk was placed into a filled whirlpool using a bathtub Hoyer lift by a CNA who had not gathered all needed supplies in advance. The CNA left the room to obtain special soap, asking a non-nursing manager to "watch" the resident, during which time the resident slid down in the water, reported water entering the mouth, and later expressed fear and refusal to use the whirlpool again. The lift chair in use lacked the manufacturer-indicated lap belt, and the resident’s ongoing fear and related interventions were not fully documented in the care plan. Separately, during supervised smoke breaks, multiple residents with lung disease, neurologic and psychiatric conditions, and care plans requiring supervised, safe smoking and use of smoking aprons were observed discarding lit or smoldering cigarettes into a plastic flowerpot/planter and onto the ground, while staff passed and lit cigarettes but did not redirect residents to use the fireproof ash receptacles or educate them on proper disposal, and the smoking area remained littered with cigarette butts and trash.
A resident with schizophrenia and bipolar disorder had a Level Two PASARR that identified needed supports and services, including a behavioral support plan, structured environment, crisis intervention services, medication therapy, ADL support, and a personal support network. The care plan did not reflect the Level Two PASARR or the recommended services, and CNA, LPN, SSD, and MDS staff were unable to describe the resident’s behavioral plan or crisis intervention services.
Failure to Provide ADL Hygiene Care: A dependent resident with severe cognitive impairment, aphasia, dementia, paraplegia, and MS was observed with gray stubble under the chin and long nails with chipped polish and debris under the nails. Staff said the resident did not resist care and preferred bed baths, but shaving was not consistently offered during baths/showers and the resident’s hygiene preferences were not addressed in the care plan or documented as refused.
Wound orders were not timely transcribed and ordered wound care was not followed for a resident with severe cognitive impairment, paraplegia, MS, and three stage 3 pressure ulcers. The wound physician changed both wound treatments to calcium alginate with silver, but progress notes did not show the change and the ADON used plain calcium alginate during wound care. The resident was also observed in bed on a blue mattress without a pump, while the care plan called for a pressure reducing mattress.
The facility failed to prevent significant medication errors involving two residents. One resident with COPD had a scheduled nebulizer treatment documented by the CMT, but later was observed in bed with the nebulizer machine running and the mask lying across the lap while the resident had noisy, rattling respirations. Another resident with dementia and muscle weakness had a Lidoderm 5% patch order for morning pain relief, but was observed with multiple patches in place, including patches dated from prior days, and the CMT removed the old patches and applied a new one.
A resident with severe cognitive impairment, paraplegia, MS, and multiple pressure ulcers had a wound culture ordered for a non-healing ankle wound, but staff delayed obtaining the swabs and did not document when the culture was collected, when the lab was notified, or the results. Later, the wound physician ordered WBC, ESR, CRP, and an ankle x-ray for possible osteomyelitis, but the lab requisition was written incorrectly and the wrong tests were drawn, while the x-ray order was not initially recognized by the ADON. The DON and Administrator stated orders should be followed and labs completed timely.
Insufficient dietary staffing resulted in delayed breakfast service and failure to follow the menu. With only one cook and one dietary aide working, meal service began late, trays were passed out slowly, and residents received juice, a biscuit with gravy, and a sausage patty, but no eggs, cereal, or milk. The DON, Corporate Nurse, and RD confirmed scheduled mealtimes and stated the menu should have been followed despite the staffing shortage.
Staff failed to consistently complete and document wound care treatments and weekly skin assessments for several residents at risk for or with pressure ulcers. For one resident with advanced wounds and complex medical needs, daily wound care was not documented as completed on multiple occasions. Additionally, weekly skin assessments were missed for four residents, with facility leadership unaware of these lapses until the survey. The DON attributed missed assessments to the absence of the wound nurse during the period in question.
Two residents experienced deficiencies in medication management, including missed doses of anti-anxiety and pain medications due to failure to reorder and unauthorized discontinuation. One resident's change in condition after missing multiple doses was not properly documented or communicated, and pain assessments were missed for another resident. Staff interviews confirmed that medication reordering and communication protocols were not followed.
A resident with heart failure and other complex conditions did not receive several ordered medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, due to delays in ordering, lack of follow-up with pharmacy or hospice, and failure to use available E-Kit medications. Documentation was incomplete, and there was no evidence of timely communication with providers. Additionally, side rails were used after a fall without required assessment or documentation, contrary to facility policy.
Surveyors found that lorazepam (Ativan) liquid, a controlled medication requiring refrigeration, was stored in narcotic lockboxes on three medication carts instead of in a secured refrigerator as labeled. Staff interviews revealed the medication room refrigerator was not locked due to a lost key fob, leading to unauthorized access and improper storage. The DON and pharmacist confirmed the medication should have been refrigerated, and the facility's policy requires such medications to be stored securely and separately from food.
Two residents experienced abuse when CNAs yelled at, physically handled, and spoke disrespectfully to them, causing emotional distress. One resident with cognitive impairment was pulled by the arm and made to cry in the dining room, while another resident with quadriplegia was scolded and insulted after calling for help without a call light. Staff present did not intervene or promptly report the incidents, and the affected residents felt afraid and disrespected.
Two residents with severe cognitive impairment and high risk for skin breakdown experienced failures in pressure ulcer care, including lack of timely physician notification, missing or incomplete treatment orders, and inconsistent wound documentation. Wounds were often not staged or specified, treatments were not administered as ordered, and communication between nursing and hospice staff was unclear, resulting in undated and unsigned bandages and missed documentation in the TAR.
A resident with severe malnutrition, renal disease, and cognitive impairment did not receive increased fluids as ordered by the PCP and RD. Orders to push fluids were not timely entered into the POS or MAR, and when eventually implemented, were not consistently followed, as shown by incomplete documentation. The resident was later hospitalized with renal failure, hypernatremia, and altered mental status.
Staff failed to treat residents with dignity and respect when an activity aide spoke loudly and rudely to a resident with severe cognitive impairment, and when direct care staff argued and cursed at the nurses' station in front of several residents with cognitive impairments. The incidents were witnessed by other staff who did not intervene or report the events, and residents present were exposed to loud, confrontational behavior that was inconsistent with facility policy and resident rights.
The facility did not complete a thorough investigation into an alleged abuse incident involving a non-verbal, cognitively impaired resident receiving hospice care. The allegation was made by a roommate with a history of behavioral issues, but the Administrator and Social Worker failed to obtain required written statements from staff or residents, and the DON did not participate in the process, resulting in noncompliance with the facility's abuse prevention policy.
A resident with severe cognitive impairment and multiple diagnoses experienced an eight-day delay in urine specimen collection after a physician order, leading to delayed lab processing and antibiotic treatment. Staff were unclear about responsibilities for obtaining and documenting the specimen, and there was confusion and inconsistency in the administration and documentation of the prescribed antibiotic due to concerns about drug allergy and pharmacy communication.
A resident with severe cognitive impairment and total dependence on staff for ADLs did not receive required feeding assistance during a meal. Multiple CNAs failed to deliver the meal tray or provide feeding, each assuming the other was responsible, and did not communicate with the nurse. The resident's meal remained on the cart, and documentation inaccurately reflected meal consumption, despite no food or fluids being provided.
A resident with a Foley catheter and recent UTI was observed with improper catheter care, including a catheter tube not secured to the leg, compression of the tube by a limb, visible dried matter on the tube, and the catheter bag placed on the bed and near the floor. Staff did not follow infection control protocols or facility policy, and the resident reported pain and lack of catheter cleaning.
The facility did not act on a report that the Business Office Manager was placed on the Employee Disqualification List, resulting in the individual continuing to work while ineligible. Both the HR Director and Administrator were unaware of the disqualification, and required EDL checks were not performed as scheduled.
A resident with diabetes and Parkinson's disease continued to receive Metformin after hospital discharge orders directed it to be stopped. Facility staff administered the medication for several weeks, during which the resident experienced multiple hypoglycemic episodes requiring interventions. The DON later confirmed the medication was not discontinued as ordered.
The facility failed to maintain its resident transport van in a safe and sanitary condition, with exposed wires, debris, and unsanitary items present during use. Additionally, after falls involving two residents with cognitive and mobility impairments, the facility did not complete thorough investigations or documentation, omitting required witness statements and neuro checks, and failed to update care plans with new interventions as needed. Staff interviews confirmed gaps in post-fall procedures and lack of adherence to policy.
The facility did not remove a Business Office Manager who had been placed on the Employee Disqualification List (EDL), allowing the individual to continue working for over two weeks after notification from the Department of Health and Senior Services. Both the HR Director and Administrator were unaware of the EDL placement due to missed notifications and a lack of regular EDL checks.
A resident with diabetes and other chronic conditions continued to receive Metformin after hospital discharge orders directed its discontinuation. Facility staff administered the medication for several weeks, leading to repeated episodes of hypoglycemia that required emergency interventions. The DON was unaware of the ongoing administration, and there was no documentation of the medication's discontinuation in the resident's records.
A resident with documented dietary preferences and physician orders did not consistently receive meals in accordance with their stated dislikes and required portion sizes. Despite clear instructions to avoid certain foods and receive double portions, staff served meals with non-preferred items and incorrect portions, and the resident's concerns were communicated to facility leadership without resolution.
The facility failed to protect two residents from verbal and physical abuse, resulting in multiple altercations. One resident with paranoid schizophrenia exhibited disruptive behavior, leading to physical fights with another resident who has vascular dementia. Despite interventions, the incidents caused significant psychosocial harm to the second resident, who reported ongoing fear and anxiety.
A resident with severe cognitive decline and a recent hip surgery developed unstageable pressure ulcers due to the facility's failure to implement timely interventions and follow physician's treatment orders. The care plan was updated late, and multiple treatment orders were not documented as completed. The resident was also observed without the prescribed low-air-loss mattress.
The facility failed to ensure RN coverage for at least eight consecutive hours a day, seven days a week for 22 of 92 days reviewed. The DON confirmed the lack of RN coverage and stated that licensed nurses were aware she was on-call if needed. CMTs also knew how to notify the DON, especially on weekends.
The facility failed to develop, initiate, or revise a facility assessment to determine necessary resources for resident care. The DON could not provide the assessment during the entrance conference, and the Administrator was unfamiliar with it. A document was later provided but was undated and unapproved by the Quality Assurance committee. The DON admitted it was only initiated in January 2024 and revised on the day of the surveyor's request.
The facility failed to develop a QAPI program, affecting all 78 residents. Despite having a Quality Assurance Improvement Plan, the facility did not have a QAPI plan, did not keep minutes for QAPI meetings, and had not developed any PIPs or benchmarks for measuring improvement. The DON relied on daily meetings and EMR reviews to identify concerns.
The QA committee failed to identify quality deficiencies, develop or implement corrective actions, track and measure effectiveness, or develop new interventions based on discussions. The DON admitted that the facility did not have a QAPI plan and that no specific quality deficiencies or performance improvement programs (PIPs) had been identified or conducted.
The QA committee at the facility failed to meet at least quarterly with the required members, missing opportunities to identify and measure quality deficiencies. Only two meetings were documented since January 2022, and key members like the DON, IP, and Medical Director were absent. The Medical Director refused to attend until compensated, affecting the facility's ability to monitor and improve care for all 78 residents.
The facility failed to ensure resident funds were placed in a separate account from the facility operating account, did not obtain written authorization for withdrawals, and failed to provide timely Social Security/Medicaid allowances. Additionally, the facility used resident funds for checking account fees and did not allow residents ongoing access to their funds, affecting all residents whose funds were managed by the facility.
The facility failed to maintain an accurate accounting of resident trust fund accounts by not performing monthly reconciliations. The Business Office Manager admitted to not starting reconciliations until a specific month and could not provide documentation to support that reconciliations were performed.
The facility failed to provide a final accounting of resident fund balances within thirty days for one discharged and four expired residents. Funds were either delayed in being refunded, mismanaged, or not properly reported to the Department of Social Services, Third Party Liability Unit.
The facility failed to maintain an adequate surety bond for the resident trust fund account, which should have been $39,000.00 based on the average monthly balance. The current bond was only $4,000.00. The Business Office Manager and Administrator were unaware of the correct bond amount and lacked a policy for reviewing the surety bond.
The facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors. The Survey Results binder was kept behind the front desk, and a review revealed incomplete documentation. The Administrator and DON confirmed the binder's location and stated that complete survey results and POC were kept in the Administrator's office.
The facility failed to issue accurate Notices of Medicare Non-Coverage (NOMNC) for three residents, using the incorrect CMS-10095 form instead of the required CMS-10123. This resulted in missing information about the type of services ending and necessary QIO contact details, potentially affecting the residents' ability to request an expedited appeal.
The facility failed to protect three residents from misappropriation of their property when the Business Office Manager used resident funds for personal use. The manager manipulated documents, issued checks and cash withdrawals without proper documentation, and instructed family members to return portions of the money in cash.
The facility failed to screen new hires for Federal Indicators, CNA registry, and nursing licenses, affecting three staff members and four nurses. The HR Manager was unaware of the correct procedures, and the Administrator was not informed of the oversight.
The facility failed to post daily nurse staffing information in a timely and accessible manner as required by policy. Observations on multiple days and times revealed no postings, and the ADON admitted that the postings were not completed due to the survey process.
The facility failed to maintain complete and accurate PASRR documentation for three residents with mental illness or intellectual disabilities, increasing the risk of not receiving necessary specialized services. This was confirmed through record reviews and staff interviews.
A resident with paranoid schizophrenia and a history of traumatic brain injury made a verbal threat to shoot residents and staff after a physical altercation. Despite the severity of the threat, the DON did not report it to the State Survey Agency, as required by the facility's policy. The resident had a documented history of violent outbursts and was often allowed to smoke to prevent further escalation.
The facility failed to thoroughly investigate a resident's threat to shoot staff and other residents, and did not properly investigate an allegation of misappropriation involving the Business Office Manager. The DON did not consider the threat credible and did not search for weapons, while the Administrator allowed the BOM to return to work before completing the investigation and speaking with all witnesses.
Unsafe Food Storage, Sanitation, and Tray Handling
Penalty
Summary
Food storage and kitchen sanitation practices were not maintained in accordance with professional standards. During multiple kitchen observations, several food items in the walk-in freezer were left uncovered and exposed to air, including cookie dough, puffed pastry sheets, homestyle biscuits, and dinner rolls. Other frozen items were present without dates, and the dry storage room contained opened or partially opened items without dates, including parsley, cinnamon, Cheerios, and honey. Five dented cans were also observed sitting on the floor in the dry storage room, and the facility’s policies stated that leftovers and opened packages were to be labeled, dated, sealed, and that dented cans were to be removed from stock. Kitchen equipment and storage conditions were also observed to be unclean. The deep fryer contained old grease, old batter caked along the inside, and baked-on grease on the strainers and fryer interior. The stove and oven had heavy caked-on stains, and the kitchen floor was noticeably dirty with crumbs, dirt, debris, and stains. A sheet of ice was observed at the threshold of the walk-in freezer during two observations. The Registered Dietitian stated that all food items should be properly labeled, dated, and stored, that the kitchen should be cleaned daily, and that ice should not have accumulated on the freezer floor. Unsafe food handling and tray transport practices were also observed during meal service. During breakfast meal preparation, dietary staff handled sausage from the steam table with gloved hands, placed it directly on the tray line, cut it there, and used their hands to scoop and mash food for mechanical soft trays. The RD stated that tongs should be used to pick up food from the steam table, a food processor could be used for mechanical soft diets, and food should not be mashed with hands or cut on the steam table. During hall tray delivery observations, trays were transported on open wire carts and not all food items were covered; dessert bowls were left uncovered or lids were not flush, leaving food exposed to air while carts passed residents and staff in the hallways.
Improper Disinfection of Glucometer and Storage of Nebulizer Equipment
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to improper disinfection of a shared glucometer and improper storage of nebulizer equipment. The facility’s Communicable Disease Management Policy stated that infection prevention and control guidelines would be established to prevent transmission of infections and that employees would utilize barriers and implement isolation barriers beyond standard precautions per CDC guidelines. However, the facility lacked specific policies detailing best practices for cleaning and storing glucometers and nebulizer masks, as confirmed by the corporate nurse. For three residents with diabetes, staff used non-medical-grade, lemon-scented disinfecting wipes to clean a multi-use glucometer between blood glucose checks. One resident with moderately impaired cognition and diabetes had a physician’s order for Novolog insulin via sliding scale, and an LPN was observed cleaning the glucometer with a lemon-scented wipe and placing it on a barrier on the medication cart before and after performing the blood sugar test. The same glucometer was then used on two cognitively intact residents with diabetes, one with an order for insulin lispro via sliding scale and another with orders for blood glucose monitoring and physician notification for out-of-range values. In each instance, the LPN cleaned the glucometer only with the lemon-scented disinfecting wipe and placed it back on the barrier on the medication cart. The DON, administrator, and corporate nurse later stated that staff should not use lemon-scented wipes on multi-use medical equipment and that the facility did not purchase such wipes for that purpose, indicating that purple-top Sani Wipes with germicidal content were the expected product for cleaning medical equipment. For a resident with dysphagia following stroke, chronic systolic heart failure, muscle weakness, moderate depression, and COPD exacerbation, the facility failed to ensure proper storage of nebulizer equipment. The resident had orders for budesonide and arformoterol nebulizer treatments for COPD exacerbation. During observation, the resident was in bed with the head of bed elevated and a nebulizer mask lying across the lap while the nebulizer machine was turned on. On a subsequent observation period, soiled clothing was seen on top of the nebulizer tubing, machine, and mask, which were balled up on a chair. An LPN described that the CMT or nurse should remove the nebulizer mask from a protective pad, place medication in the cup, apply the mask, turn on the machine, and remain nearby to observe for nosebleeds or excessive coughing, with no formal monitoring required. The DON stated she expected the nebulizer to be stored on a clean surface with the mask and tubing in a dated plastic bag changed weekly, but this practice was not followed for the observed resident.
Dignity and Respect Deficiencies During Care and Meals
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect when a CNA spoke to a resident in an undignified manner. Resident #81 had severe cognitive impairment, diabetes with diabetic chronic kidney disease, and required total care with toileting, bathing, and transfers. During observation, the resident’s door was open with full view of the room, and CNA H was overheard telling the resident, “Come on, you need to do this yourself. You are killing my back.” The resident later said the comment made him/her feel like a child and humiliated, and stated that if he/she could do those things independently, he/she would. The facility also failed to provide adequate utensils at meals for two residents who required supervision with eating. Resident #24 had moderate cognitive impairment, Alzheimer’s disease, multiple sclerosis, and anxiety, and was observed at lunch eating baked chicken without a knife; the resident used his/her hands to tear pieces of chicken apart and said a knife was needed and preferred for cutting chicken. Resident #79 had no cognitive impairment, required supervision with eating, and had heart failure, hypertension, and diabetes. At breakfast, the resident was served oatmeal, sausage patties, biscuits and gravy, and orange slices without a knife, and used his/her hands to tear apart a sausage patty and place it into oatmeal. The resident stated a knife would have been preferred and that knives were never given. The facility further failed to maintain dignity during feeding assistance for Resident #9. This resident had moderate cognitive impairment, required supervision with eating, and had diagnoses including coronary artery disease, hypertension, high cholesterol, stroke, epilepsy, and COPD. During observation, ADON A stood next to the resident while feeding the resident. Staff interviews stated that when feeding residents, staff should sit next to them, maintain eye contact, and avoid standing over them because it can make residents uncomfortable, feel forced, and is a dignity issue. ADON A and the DON both stated staff are supposed to be sitting when feeding residents.
Failure to Reconcile Resident Trust Funds and Provide Quarterly Statements
Penalty
Summary
The facility failed to properly hold, secure, and manage resident personal money deposited with the nursing home by not completing monthly resident trust fund (RTF) reconciliations. Review of the facility’s RTF reconciliation documentation from February 2025 through January 2026 showed no documentation of trial balances, bank statements, and reconciliations completed for 9 of 12 months, which prevented accurate accounting of money held in the RTF account. The facility’s policy stated that the RTF is to be reconciled monthly and balanced to the bank statement. The facility also failed to provide quarterly statements to residents or their representatives. Review of the RTF records showed no documentation of quarterly statements for January through March 2025, April through June 2025, July through September 2025, and October through December 2025. During interview, the RBOM stated that prior ownership failed to provide RTF reconciliation reports and quarterly statements for multiple quarters, and that the prior BOM failed to upload signed quarterly statements for October through December 2025. The Administrator stated she expected the facility to reconcile resident trust accounts monthly and provide quarterly statements to residents or their responsible parties each quarter.
Failure to Provide Bed-Hold Notices and Ombudsman Discharge Notifications
Penalty
Summary
The facility failed to provide residents and/or their representatives with the bed-hold policy at the time of transfer or as soon as practicable after transfer to the hospital for two residents, Resident #83 and Resident #8. The facility’s Resident Bed Hold policy, revised 9/16/25, states that residents and/or their representatives are to be notified in writing of the bed-hold policy in advance of transfer to the hospital or when taking therapeutic leave, and within 24 hours in an emergency transfer. For Resident #83, the record showed discharge to the hospital with no documentation that the bed-hold notice was provided to the resident or representative before discharge. For Resident #8, the record also showed discharge to the hospital on 1/27/26 with no documentation that the bed-hold notice was provided to the resident or representative before discharge. The facility also failed to send copies of discharge notices to the representative of the Office of State LTC Ombudsman for either resident. During interview, the Ombudsman Representative stated discharge notices had not been received and the last one received was in January 2025. The Administrator stated she did not have the bed holds or a copy of the discharge notices and expected the nurse to provide the bed-hold policy at transfer or as soon as practicable, with the Social Worker following up; she also stated the Ombudsman should receive a copy of discharge notices monthly.
Expired and Unlabeled Medications Found in Medication Rooms and Carts
Penalty
Summary
Drugs and biologicals were not stored in accordance with accepted standards of practice in multiple medication storage areas. The facility had three medication rooms and seven medication/treatment carts, and surveyors sampled two medication rooms and four carts. In the 500 hall treatment cart, surveyors found opened topical medications and wound care products with expired dates, including jock itch cream, hydrocortisone 1% cream, triamcinolone 0.1% cream, Thera honey, and Dakin's solution. In the 200 hall medication room, surveyors found a bottle of latanoprost eye drops with no name on it, a faded and unreadable vial in a damaged box in the refrigerator that RN Q identified as something insulin related, two boxes of DuoNeb with one opened and expired and another open box expiring in 2/25, an opened bottle of Geri Lanta, an opened Breo Ellipta, and an opened bottle of docusate 100 mg. Additional storage problems were found on other carts and in another medication room. The 200 hall treatment cart contained an opened tube of ice cold pain relieving gel with an expired date, and the 200 hall medication room also contained a box of Trulicity with an opened expiration date and a plastic bag with two insulin pens with no resident name on them; LPN R said he/she did not know who the insulin belonged to and thought it may have been pulled from the stat kit. The 100 hall treatment cart contained an opened box of Hydrofera Blue and an opened tube of moisture barrier with expired dates. During interviews, RN Q said he/she did not know who was responsible for checking expiration dates and expected the pharmacy to have checked them after the facility switched pharmacies, while CMT D said it had been a while since he/she checked expiration dates. The DON stated CMTs should check medications on carts, in medication rooms, and refrigerators daily, and that medications should be stored and labeled properly.
Resident Left Unattended in Whirlpool and Unsafe Smoking Supervision
Penalty
Summary
The deficiency involves the facility’s failure to keep a resident free from accident hazards and to provide adequate supervision during whirlpool bathing. A resident with moderate cognitive impairment, dementia, diabetes, hypertension, psoriasis, and a moderate fall risk was ordered to receive whirlpool baths three times weekly for chronic psoriasis. The resident’s care plan noted a history of resistance to bathing and the need for substantial assistance with showering and supervision for tub/shower transfers. During a scheduled whirlpool bath, the CNA responsible for the bath did not have all required supplies, including the resident’s special soap, before placing the resident into the filled whirlpool using a bathtub Hoyer lift. After lowering the resident into the water, the CNA left the spa room to obtain the special soap and asked the Environmental Services Director (ESD), who was not nursing staff, to watch the resident. The resident remained in the filled whirlpool while the CNA exited. As the CNA left and the ESD entered, the resident began to slide down in the water. The ESD reported seeing the resident slipping under the water and pulled the resident up by the arms; the resident stated that water went into his/her mouth and that he/she was scared and felt like he/she was going under. The resident reported to staff afterward that a CNA had tried to kill him/her and refused further whirlpool use, stating he/she was too scared to go back into the whirlpool. The resident also reported not being belted into the chair, while the CNA stated the strap was under the resident’s armpits and acknowledged that residents without good trunk control could slide down in the chair. The facility’s bathing policy required staff to stay with residents throughout the bath, not leave them unattended, use the call signal for assistance, and place supplies within reach, but the CNA left the resident alone in the filled whirlpool and did not use the call light to obtain help from nursing staff. The bathtub Hoyer lift in the spa had only an upper torso belt and lacked a lower lap belt, despite manufacturer instructions indicating the chair should have both a torso and lap belt. The DON was not aware that the chair should have had a lap belt and the lift chair was not assessed for safety concerns after the incident. Documentation showed brief monitoring for fearfulness after the slip, but there was no further documentation of the resident’s ongoing fear of the whirlpool or care plan interventions addressing that fear. A separate deficiency involved the facility’s failure to ensure safe smoking practices and proper disposal of cigarettes in the designated smoking area. Observations showed the smoking area littered with numerous cigarette butts on the ground, in the grass, and on walkways, as well as cigarette butts and trash in a plastic flowerpot/planter and in trash cans. Fireproof metal containers and smokeless ashtrays were present, but residents repeatedly placed lit or smoldering cigarettes into the flowerpot/planter and onto the ground. During supervised smoke breaks, staff passed out cigarettes and assisted with lighting but did not intervene or educate residents when cigarettes were placed in the planter or dropped on the ground, including when a cigarette bounced under a resident’s Broda chair and when cigarettes in the planter continued to smoke. Multiple residents with diagnoses such as lung disease, hemiplegia, schizoaffective disorder, and cognitive communication deficits were care planned as smokers who required supervision, smoking aprons, and instruction on facility smoking policies, including location, times, and safety concerns. Despite these care plan directives and the facility’s smoking protocol requiring use of fireproof ashtrays and prohibiting disposal of smoking materials in inappropriate areas, staff supervising smoke breaks did not redirect residents to use the proper self-closing ash receptacles and did not address the accumulation of cigarette butts and trash in non-approved containers and on the ground. The Administrator stated that staff monitoring smoke breaks were responsible for supervising residents, passing cigarettes, ensuring safety, and educating residents on proper disposal, and acknowledged that cigarettes should not be disposed of in the flowerpot/planter, trash cans, or on the ground.
PASARR Services Not Documented on Care Plan
Penalty
Summary
The facility failed to ensure that one resident with a Level Two PASARR had the recommended services and supports identified and documented on the care plan. Resident #8’s quarterly MDS dated 12/1/25 showed diagnoses of schizophrenia and bipolar disorder, and the resident’s PASARR Level Two summary of findings dated 12/19/24 identified a serious mental illness and listed required supports and services, including a behavioral support plan, structured environment, crisis intervention services, medication therapy, ADL support, and a personal support network. The care plan in use at the time of survey did not show that the resident had a Level Two PASARR or list the recommended supports and services. During interviews, CNA T said the resident sometimes called staff names and had tried to hit staff, and that behaviors were ignored and reported to the nurse, but the CNA did not know the resident’s support plan or crisis intervention services. LPN M said the resident often did not want to get up and was inconsistent with allowing care, but did not know the behavioral support plan or crisis intervention services. The SSD said she had just started and did not know the resident, and the MDS Coordinator said Level Two PASARR supports and services should be on the care plan but did not know the resident’s behavioral plan or crisis intervention service. The DON and Administrator both stated that the recommended PASARR supports and services should be included on the care plan.
Failure to Provide ADL Hygiene Care
Penalty
Summary
The facility failed to ensure Activities of Daily Living care needs were met for a dependent resident with severe cognitive impairment, aphasia, dementia, paraplegia, multiple sclerosis, and depression. The resident’s MDS showed dependence on staff for bathing and personal hygiene, functional impairment in both upper extremities, and no rejection of care. The care plan directed staff to assist with ADLs as required and encourage the resident to do as much as possible, but it did not address the resident’s preferences for personal hygiene such as shaving or nail care. The resident’s progress notes did not document any refusal of shaving or nail care. Observations showed the resident had significant gray stubble on and under the chin on multiple occasions, and the resident’s nails were long with chipped red nail polish and a substantial amount of brown matter under the fingernails. A CNA stated the resident was his/her assigned aide, that the resident did not resist care, preferred bed baths, and needed to be shaved; the CNA also said the resident liked long, painted nails and that he/she would shave the resident and provide nail care during a bath. Later observation showed the chin was shaved but whiskers remained under the chin, and the nails were still long with chipped polish and visible dark matter under them. Another CNA stated he/she did not offer residents a shave during baths or showers and was not sure why, although he/she did provide nail care during showers and baths. The Administrator stated staff should offer to shave residents and clean their nails per resident preferences, and refusals should be documented.
Wound Orders Not Timely Transcribed and Pressure Relief Care Not Followed
Penalty
Summary
The facility failed to transcribe a wound treatment order into the medical record in a timely manner and failed to follow the physician’s ordered treatment for a resident with wounds. The facility’s Physician Orders policy required licensed nurses to record physician orders in the medical record and transcribe them to the appropriate MAR/TAR, and the Wound Management policy stated wound treatment would be provided in accordance with physician’s order. Resident #3 had severe cognitive impairment, functional limitations in both upper and lower extremities, dependence on staff for ADLs, rolling, and transfers, and diagnoses including non-Alzheimer’s dementia, aphasia, paraplegia, and multiple sclerosis. The quarterly MDS documented three stage 3 pressure ulcers. The care plan identified bilateral lower extremity pressure ulcers and included interventions to perform treatment per current order, assess for infection with each dressing change, and use a pressure reducing mattress while in bed. The physician order summary showed orders for the left foot and left lateral ankle dated 02/07/26, and the wound physician note dated 02/17/26 changed the treatment plan to calcium alginate with silver once daily and as needed for both wounds. Progress notes from 02/17/26 through 02/19/26 did not document that the treatment was changed. During observation on 02/19/26, the resident was lying in bed on his/her back on a blue mattress without a pump at the end of the bed. ADON A and LPN M performed wound care and used plain calcium alginate rather than calcium alginate with silver for both wounds. During interview, ADON A stated calcium alginate and calcium alginate with silver were not interchangeable and acknowledged she should have used calcium alginate with silver based on the wound note. The DON stated the wound physician’s notes were left with ADON A to enter into the medical record and that ADON A should verify the orders matched the medical record; the DON also stated staff should follow physician orders and that a resident with a wound would be expected to have an air loss mattress. The Administrator stated staff should follow physician orders.
Medication Administration Errors with Nebulizer Treatment and Lidoderm Patch Use
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors for two residents. Resident #52, who had COPD with acute exacerbation, had an order for arformoterol tartrate inhalation nebulization solution twice daily. The resident's MAR showed the CMT documented the nebulizer treatment, but observation later showed the resident lying in bed with the nebulizer machine running while the mask lay across the resident's lap. The resident had noisy respiration with a rattling quality. The facility's Corporate Nurse stated the facility did not have a policy to address nebulized medication administration, and the DON said the CMT should remain with the resident during the treatment and report changes to the nurse. Resident #71, who had diagnoses of dementia and muscle weakness, had an order for a Lidoderm 5% patch to be applied to the painful area in the morning for pain. The order did not include direction to remove the patch after 12 hours. During observation, the resident had three Lidoderm patches in place, including one dated the prior day and another dated two days earlier. The CMT removed the old patches and applied a new patch, and stated the second older patch was still present and was not sure why it remained there. The Administrator, DON, and Corporate Nurse stated Lidoderm should be given per manufacturer recommendations and that if one patch is ordered, a second patch should not be applied.
Delayed wound culture, labs, and x-ray orders
Penalty
Summary
The facility failed to follow physician orders for timely laboratory testing and an x-ray for a resident with severe cognitive impairment, aphasia, paraplegia, multiple sclerosis, functional dependence for ADLs, and multiple pressure ulcers, including stage 2, stage 3, and unstageable deep tissue injuries. The resident’s care plan addressed unavoidable pressure ulcers of the bilateral lower extremities and directed staff to perform wound treatments and monitor for signs and symptoms of infection. Progress notes showed a wound care provider ordered a wound culture for a non-healing right ankle wound, but staff documented that the facility did not have the wound swabs needed to complete the culture at that time. The record showed repeated delays and incomplete documentation related to obtaining the wound culture. Nursing notes documented attempts to contact the lab for swabs, but staff did not document when the swabs were received, when the culture was collected, when the lab was notified for pickup, or the results. During interview, the ADON stated the lab visited only on Mondays and Thursdays, that wound cultures should be obtained the same day they are ordered if supplies are available, and that the culture was eventually obtained several days later, with the lab not picking it up until several days after that. The physician later started doxycycline because infection was suspected. The wound physician later documented that the ankle wound was exacerbated due to infection and ordered additional testing, including WBC, ESR, CRP, and a left ankle x-ray to evaluate for osteomyelitis. The record showed an osteo panel was ordered, but the lab technician drew thyroid, parathyroid hormone, and vitamin D tests instead because the order was written incorrectly on the requisition. The ADON stated she was not aware of the x-ray order because she did not scroll through the wound note, and staff did not document when the deep wound culture or x-ray were completed. The DON and Administrator both stated they expected physician orders to be followed and labs to be completed timely, with documentation when delays occurred.
Insufficient dietary staffing led to delayed meal service and incomplete menu items
Penalty
Summary
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service was not met when the facility failed to provide enough dietary staff to carry out meal service as scheduled. The census was 89. During an interview, the Assistant Administrator, DON, and Corporate Nurse stated that mealtimes were scheduled for 8:00 A.M., 12:30 P.M., and 6:00 P.M., and the facility’s schedule of mealtimes confirmed breakfast, lunch, and supper times in the dining room. The breakfast menu for 2/18/26 included juice of choice, cereal of choice, egg, biscuit, sausage gravy, skim milk, and coffee or hot tea. During observation of breakfast meal service, staff passed drinks in the main dining room and meal service did not begin until 9:20 A.M. when the first food tray was served. In the kitchen, one staff member plated trays while another dietary staff member passed trays to residents one or two at a time. Residents were served juice, a biscuit with gravy, and a sausage patty, but no eggs were cooked or served, no cereal was served, and no milk was served. One cook and one dietary aide were working in the kitchen. A dietary staff member stated the kitchen was short staffed and could not serve everything on the menu, and the Registered Dietician stated she was overseeing the dietary manager position until someone was hired and expected menus to be followed, adding that not having enough staff was not a sufficient reason to not follow the menu.
Failure to Provide and Document Pressure Ulcer Care and Skin Assessments
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for multiple residents. For one resident with significant medical conditions, including peripheral vascular disease, hemiplegia, and cognitive communication deficit, staff did not complete daily wound care as ordered. Documentation in the Treatment Administration Record (TAR) showed that wound care treatments for both sacral and left lower extremity pressure ulcers were not consistently documented as completed on numerous days across July and August. The Wound Care Physician and facility leadership confirmed that if treatments were not marked as completed on the TAR, it indicated they were not performed, although they believed the care may have been provided but not documented. The resident was on hospice care, and the focus was on comfort, but the expectation remained that wound care orders would be followed and documented. Additionally, the facility failed to ensure that four residents identified as at risk for pressure ulcers received weekly skin assessments as ordered. Review of medical records and electronic Physician Order Sheets revealed that weekly skin assessments were missed on multiple occasions for these residents. The Director of Nursing (DON) stated that weekly skin assessments should be completed for all residents, regardless of hospice status, and that these assessments are typically performed by a nurse or wound nurse. The DON was unaware that these assessments had not been completed during the specified months and attributed the missed assessments to the departure of the wound nurse during that period. Interviews with facility leadership, including the Administrator and DON, confirmed that they expected nursing staff to follow physician orders and document completion of treatments and assessments. They were not aware of the missing documentation until it was brought to their attention during the survey. The lack of documentation for wound care and skin assessments was acknowledged as a failure to follow established protocols and physician orders, with the potential to negatively impact resident care and wound healing.
Failure to Document and Treat Change in Condition and Follow Physician Orders for Medication
Penalty
Summary
The facility failed to ensure that a resident's change in condition was appropriately documented and treated after the resident missed multiple doses of a prescribed medication. One resident with moderately impaired cognition and diagnoses including dementia and anxiety had an order for Lorazepam (Ativan) to be administered every 12 hours for anxiety. The resident missed several consecutive doses of Ativan due to the medication not being reordered in a timely manner, despite facility policy requiring medications to be reordered before running out. After receiving Ativan following a 48-hour lapse, the resident became unresponsive to questions, with low blood pressure and pulse, prompting a call to emergency services. The nurse involved did not communicate the change in condition to the oncoming shift or the DON, and no follow-up assessments were completed, contrary to facility policy requiring prompt notification and documentation of changes in condition. Additionally, the facility failed to follow physician orders regarding pain medication for another resident with multiple diagnoses, including peripheral vascular disease, hemiplegia, and pressure ulcers. This resident had orders for both scheduled and as-needed Hydrocodone-Acetaminophen (Norco) for pain management, as well as regular pain assessments. The resident did not receive the prescribed Norco doses for an extended period after coming off hospice care, and the medication was discontinued by a nurse without a physician order. Pain assessments were also missed on several shifts, and the DON was not aware of the discontinuation or the missed doses until after the fact. Facility policy requires medications to be administered as prescribed and prohibits discontinuation without a physician's order. Interviews with staff and the residents' physician confirmed expectations that medications should be reordered in advance and that changes in condition or medication status should be communicated promptly to ensure continuity of care. The failures identified included lack of timely medication reordering, inadequate communication between staff, failure to document and assess changes in condition, and unauthorized discontinuation of prescribed medications.
Failure to Administer Medications and Assess Side Rail Use per Orders and Policy
Penalty
Summary
The facility failed to provide treatment and care in accordance with physician orders, resident preferences, and accepted clinical standards for a resident with multiple complex medical diagnoses, including congestive heart failure, atrial fibrillation, and kidney failure. The resident had orders for several critical medications, including torsemide, amiodarone, lidocaine patch, and metoprolol, but these medications were not administered as ordered for an extended period. Documentation in the medication administration record (MAR) and progress notes repeatedly indicated that medications were on hold, waiting on prescription, or not available, with no evidence of timely follow-up with the pharmacy, physician, or hospice to resolve the issue. Additionally, there was no documentation of pharmacy contact, physician contact, or hospice notification regarding the missed or refused medications. The resident's care plan included interventions to administer medications as ordered and monitor for side effects and effectiveness, but these interventions were not consistently implemented. The MAR showed multiple days where medications were not given, and staff notes often lacked specific details about which medications were affected. The facility's own policies required timely ordering and administration of medications, as well as clear documentation and communication with the pharmacy and prescribers, but these procedures were not followed. The facility also failed to utilize available emergency medication kits (E-Kits) to obtain necessary medications, despite having relevant drugs in stock. In addition to medication administration failures, the facility did not assess or document the use of side rails for the resident, despite their use following a fall. The facility's policy required a side rail assessment, documentation of rationale, and consideration of less restrictive alternatives, but there was no evidence of such assessment or documentation in the resident's record. The resident was found on the floor after a fall and later found in another resident's room, having climbed over side rails, yet there was no order or care plan documentation regarding side rail use. Interviews with staff revealed inconsistent recollections about the resident's cognitive status and the events surrounding the use of side rails.
Improper Storage of Refrigerated Controlled Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals, specifically lorazepam (Ativan) liquid, were labeled and stored according to accepted professional standards. Observations revealed that lorazepam, which is labeled to be stored in a refrigerator, was instead kept in the narcotic lockboxes of three nurse medication carts. The medication was not stored in the refrigerator as required, and staff interviews confirmed that this was due to concerns about the security of the medication room refrigerator, which did not have a functioning lock. The facility's policy requires medications needing refrigeration to be stored in a secured refrigerator, separate from food, and accessible only to authorized personnel. Interviews with staff, including LPNs, RNs, and the DON, indicated that the medication room behind the charting break room did not lock because the key fob had been lost for approximately six months. This allowed unauthorized access by CNAs, who would enter the room to retrieve nutritional supplements from the refrigerator. As a result, lorazepam was kept in the medication cart's narcotic lockbox to maintain double-lock security, despite the medication's requirement for refrigeration. The pharmacist confirmed that lorazepam liquid should always be refrigerated to maintain its effectiveness and stability. Further observations and interviews with the DON confirmed that multiple boxes of lorazepam labeled for refrigeration were found in the narcotic lockboxes of medication carts across different halls. The DON acknowledged that these medications should have been refrigerated and that the current storage practice did not comply with labeling instructions or facility policy. The issue was identified on all three medication carts checked, affecting the facility's compliance with safe medication storage standards.
Failure to Protect Residents from Abuse and Ensure Timely Reporting
Penalty
Summary
The facility failed to protect two residents from abuse, as evidenced by direct staff actions and inactions observed and reported. In one incident, a resident with moderately impaired cognitive skills, traumatic brain dysfunction, depression, and psychotic disorder experienced an episode where a CNA yelled at them in the dining room, pulled on their arm, and insisted they leave to eat in their room due to wet shoes. This interaction caused the resident to cry and feel afraid. Witnesses, including another resident and a visitor, confirmed that the staff member physically handled the resident and that the event was distressing to both the affected resident and others present. The staff member continued to work with residents after the incident until being suspended later. In another case, a resident with muscle weakness, functional quadriplegia, and end-stage kidney disease, who had intact cognitive response, was left without a call light within reach and had to yell for assistance with incontinence care. The CNA who responded scolded the resident for yelling, told them it would be the last time they would provide care in bed, and later made a derogatory comment while passing the resident in the hallway. The resident reported feeling hurt, disrespected, and reluctant to report the incident due to fear that staff would not help them. The CNA involved denied any complaints and claimed to have a good relationship with the resident. The facility's abuse prevention policy outlines clear expectations for staff conduct, including prohibiting mistreatment, requiring prompt reporting and investigation of abuse, and providing training on abuse prevention. Despite these policies, staff failed to intervene or report the incidents in a timely manner, and other staff present during the events did not take action to protect the residents. The incidents were only reported after delays, and the affected residents experienced emotional distress as a result of the staff's actions and the lack of immediate support.
Failure to Notify Physician, Obtain Orders, and Administer Pressure Ulcer Care as Ordered
Penalty
Summary
The facility failed to notify the Primary Care Physician (PCP) and obtain orders for pressure ulcers when they were first identified for two residents, and also failed to administer treatments as ordered and maintain consistent documentation of wounds. For one resident with severe cognitive impairment, total dependence for activities of daily living, and multiple comorbidities, there were multiple instances where wounds were present but not properly documented, staged, or reported to the PCP or responsible party. The facility's weekly wound reports repeatedly listed wounds as 'not specified' in terms of stage, and there was inconsistent documentation between the wound reports, skin assessments, and progress notes. Orders for wound care were not always obtained or followed, and documentation in the Treatment Administration Record (TAR) showed that treatments were not completed as ordered on numerous occasions. Additionally, there was no documentation of a Braden score to assess the resident's risk for pressure ulcers. For another resident with severe cognitive impairment and high risk for skin breakdown, the facility's documentation was inconsistent regarding the presence and treatment of pressure ulcers and calluses. Weekly wound reports and skin assessments often failed to specify the stage of wounds or omitted documentation of certain wounds altogether. There were discrepancies between shower sheets, wound reports, and skin assessments, with some documents noting open areas or treatments in place while others did not mention any skin issues. Treatment orders were not always present or followed, and there was a lack of consistent communication and documentation regarding changes in the resident's skin integrity. Interviews with facility staff, including the Wound Nurse, Registered Nurse, and Director of Nursing, revealed confusion and lack of clarity regarding responsibilities for wound care, documentation, and communication with hospice staff. The Wound Nurse was responsible for wound reports, assessments, and treatments, but there was a lack of coordination and documentation when hospice nurses were involved. Bandages were found undated and unsigned, and staff were unsure who had changed them. There was also a lack of timely notification to the PCP and responsible party when new wounds were identified, and the facility did not have a policy to ensure physician orders were followed.
Failure to Implement and Follow Fluid Orders for Resident with Renal Disease and Malnutrition
Penalty
Summary
A deficiency occurred when the facility failed to implement and follow physician and registered dietitian (RD) orders to increase fluid intake for a resident with severe malnutrition, renal disease, and abnormal laboratory values. Despite a primary care physician's handwritten order on 9/10/24 to "push fluids" and a subsequent RD recommendation on 11/22/24 specifying fluid amounts at meals and between meals, these orders were not entered into the resident's physician order sheet (POS) or medication administration record (MAR) in a timely manner. The facility's own policy required individualized assessment and implementation of nutritional and hydration interventions, but the necessary orders were either delayed or not documented, and when eventually entered, were not consistently followed as evidenced by gaps in MAR documentation. The resident's medical records showed persistently abnormal lab values, including elevated creatinine and BUN, indicating ongoing kidney dysfunction and possible dehydration. The care plan was updated to include the RD's fluid recommendations, but the MAR showed that the facility only documented compliance with the fluid order 15 out of 65 opportunities, with multiple missed opportunities on specific dates. There was also a lack of documentation for discontinuation of medications and for follow-up lab orders as recommended by the RD and PCP. The resident, who had severe cognitive impairment and required moderate assistance with eating, was ultimately hospitalized with diagnoses of renal failure, hypernatremia, and altered mental status. Interviews with the DON confirmed expectations for timely entry and implementation of orders, as well as the risks to resident health if orders were not followed. The hospital charge nurse confirmed the resident was admitted with significant renal failure and hypernatremia, consistent with the facility's failure to provide adequate hydration as ordered.
Failure to Ensure Resident Dignity and Respect Due to Staff Conduct
Penalty
Summary
The facility failed to ensure that residents were treated with kindness, dignity, and respect, as required by their own policies and federal regulations. One incident involved an activity aide speaking loudly and rudely to a resident with severe cognitive impairment after the resident dropped a plastic wrapper on the floor. The aide stated, in a loud voice, that they did not like giving the resident anything because the resident was always dropping things. This interaction was witnessed by two staff members at the nurses' station, neither of whom intervened at the time. The resident in question had severe cognitive impairment, dementia, malnutrition, end-stage renal disease, and a history of stroke, and was care planned for psychosocial wellbeing concerns. Another deficiency occurred when direct care staff openly argued and cursed at the nurses' station in front of several residents. The argument began when a CNA refused to give a shower to a resident at the request of an LPN, leading to a loud and confrontational exchange between multiple CNAs. The argument included shouting, cursing, and physical gestures such as hitting the nurses' station tabletop. Several residents with moderate to severe cognitive impairment and various diagnoses, including dementia and depression, were present in the living room area within earshot and eyesight of the incident. Staff interviews confirmed that the argument was loud and could have been intimidating or distressing to the residents who witnessed it. Staff interviews revealed a lack of immediate intervention or reporting of the incidents by those present. Some staff expressed that the behavior was inappropriate and could have made residents feel unsafe or fearful, but did not take action to remove residents from the area or report the events to management at the time. The facility's policy required staff to treat residents with dignity and respect, to report violations of resident rights, and to ensure residents' psychosocial wellbeing, but these expectations were not met during the incidents described.
Failure to Conduct Thorough Abuse Investigation
Penalty
Summary
The facility failed to conduct a thorough investigation into an alleged incident of abuse involving a resident with severe cognitive impairment, who was non-verbal, required total staff assistance for daily care, and was receiving hospice services. The allegation originated from the resident's roommate, who reported to an outpatient counselor that inappropriate sexual behavior may have occurred. The roommate had a documented history of attention-seeking behavior, previous issues with roommates, and was unable to provide specific details about the alleged incident or identify any individuals involved. Upon notification of the allegation, the facility Administrator initiated an investigation but did not obtain written statements from staff, residents, or the reporting party, as required by facility policy. The Social Worker attempted to interview the non-verbal resident and conducted a skin assessment, which revealed no abnormal findings. The Social Worker also interviewed several residents but did not collect or have any written or signed statements from staff or residents. The Director of Nursing did not participate in the investigation process. Facility policy required that investigations into alleged abuse be thorough and include witness statements from staff, residents, and family members who may have relevant information. The investigation should also include interviews with those involved and a review of all circumstances surrounding the incident. In this case, the investigation lacked the required documentation and statements, resulting in a failure to meet the facility's own abuse prevention policy standards.
Failure to Follow Physician Orders and Delayed Antibiotic Administration
Penalty
Summary
Facility staff failed to follow physician orders as written for one resident, resulting in a significant delay in both the collection of a urine specimen and the initiation of antibiotic treatment. The physician ordered a complete blood count, basic metabolic panel, and urinalysis with culture and sensitivity. While blood samples were collected and processed promptly, the urine specimen was not collected until eight days after the order was given. This delay was not documented in a way that would alert subsequent staff, and there was confusion among nursing staff regarding responsibility for obtaining and documenting the urine sample. The resident involved was severely cognitively impaired, required moderate assistance with personal care, and had multiple diagnoses including dementia, seizure disorder, and myasthenia gravis. The delay in collecting the urine specimen led to a subsequent delay in laboratory processing and in notifying the primary care physician of the results. Once the results were available, there were further delays and confusion regarding the administration of the prescribed antibiotic, Levaquin, due to concerns about a possible drug allergy and issues with pharmacy communication and delivery. Documentation in the Medication Administration Record (MAR) was inconsistent, with conflicting notes about whether the antibiotic was administered as ordered. Nursing staff and the Director of Nursing both acknowledged that orders should be entered and acted upon promptly, and that delays in lab work and medication administration could negatively impact resident care. However, the facility failed to ensure timely collection of the urine specimen, prompt notification of the physician, and accurate documentation of medication administration, resulting in services that did not meet professional standards of quality.
Failure to Provide Feeding Assistance to Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was totally dependent on staff for all activities of daily living, including eating and drinking, did not receive necessary feeding assistance during a scheduled mealtime. The resident had severe cognitive impairment, contractures of both hands, and was on hospice care with multiple diagnoses including heart failure, diabetes, dementia, chronic kidney disease, and dysphagia. The resident's care plan and dietary orders specified a pureed diet, nutritional supplements, and total staff assistance for feeding. On the day of the incident, observations showed the resident remained in bed, unable to access fluids placed out of reach, and did not receive a meal tray during lunch. Multiple CNAs assigned to the hall failed to deliver the meal tray or provide feeding assistance, each assuming the other had completed the task. Neither CNA communicated with each other or with the nurse to confirm the resident had been fed, and the meal tray remained on the dining cart. Documentation later reflected that the resident ate 0 to 25% of the meal, despite not having received any food or fluids. Interviews with staff revealed a lack of clear communication and accountability regarding which CNA was responsible for feeding the resident. The assigned nurse was unaware the resident had not been fed and did not verify with CNAs whether all dependent residents received their meals. Facility policy required staff to provide individualized meal assistance and accurate documentation, but these procedures were not followed, resulting in the resident missing a meal and necessary hydration.
Failure to Maintain Infection Control and Proper Catheter Care
Penalty
Summary
Staff failed to maintain infection control and proper catheter care for a resident with an indwelling Foley catheter and a recent history of urinary tract infection. The resident was observed with the catheter tube compressed under a limb, not secured to the leg, and with visible dried dark matter on the tube. The catheter bag was repeatedly placed on the bed, allowed to dangle near the floor, and was kicked by staff during transfers, contrary to facility policy requiring the bag to be kept below the bladder and off the floor. The catheter tube was also observed to be cloudy with visible urinary sediment, and the resident's perineal area had dark brown, foul-smelling matter, identified as stool, in contact with the catheter. The resident reported pain in the genitalia, lower abdomen, and groin, and stated that nursing staff were not cleaning the catheter or addressing the pain. During care, staff did not secure the catheter tubing to the resident's leg, resulting in visible pulling at the insertion site. The catheter tube was repeatedly compressed by the resident's limb, and urine was seen backing up in the tube. Staff cleaned the catheter and perineal area but did not follow proper infection control practices, as the catheter bag was placed on the bed and handled in a manner that risked contamination. Facility policy required staff to keep the catheter and tubing free of kinks, secure the tubing to the resident's leg, keep the drainage bag below the bladder, and ensure the catheter and perineal area were clean. The Director of Nursing confirmed expectations for staff to follow these protocols, including cleaning the catheter and perineal area regularly, securing the tubing, and maintaining the drainage bag in the correct position. However, observations and interviews confirmed that these procedures were not followed for this resident, leading to the identified deficiency.
Failure to Remove Disqualified Employee from Duty
Penalty
Summary
The facility failed to respond appropriately to a report that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL), which made the individual ineligible to work in a certified long-term care facility. The Department of Health and Senior Services (DHSS) notified the facility that the BOM was permanently placed on the EDL, but the BOM continued to work at the facility for over two weeks after the placement. The EDL Active Report confirmed the BOM's name and Social Security Number were added to the list with a permanent order. Interviews revealed that both the Human Resources (HR) Director and the Administrator were unaware of the BOM's placement on the EDL until surveyors began their investigation. The HR Director, who had only been in the position since August, had not performed quarterly EDL checks and stated that no one notified him of the BOM's status. The Administrator also confirmed he was not informed and only became aware shortly before the surveyors' arrival. The BOM had worked at the facility as recently as the day before the investigation began, despite being ineligible for employment.
Failure to Discontinue Blood Sugar Medication as Ordered
Penalty
Summary
Staff failed to discontinue a blood sugar-lowering medication, Metformin, as ordered for a resident with a history of diabetes, hypertension, and Parkinson's disease. The resident had been hospitalized for hypoglycemia, and upon discharge, hospital orders specified to stop Metformin. However, upon the resident's return to the facility, there was no documentation regarding the discontinuation of Metformin, and the medication continued to be administered as per the previous schedule. The resident's Medication Administration Record (MAR) showed that Metformin was administered twice daily for several weeks following the hospital discharge, despite the stop order. During this period, the resident experienced multiple episodes of low blood sugar, including documented blood glucose readings as low as 40 and 51, requiring interventions such as administration of orange juice, glucose tablets, fudge brownies, and Glucagon. Progress notes and direct observations indicated the resident was slow to respond, held food in their mouth, and required staff assistance for blood sugar management. The facility's policies required medications to be administered according to prescriber orders and for all medication changes to be documented and followed. Despite these policies, the failure to discontinue Metformin as ordered resulted in ongoing administration of the medication, contributing to repeated hypoglycemic events for the resident. The Director of Nursing confirmed that the medication was not discontinued as ordered and was unaware of the error until after the fact.
Failure to Maintain Safe Transportation and Incomplete Fall Investigations
Penalty
Summary
The facility failed to ensure that the vehicle used for resident transportation was maintained in a safe and sanitary condition. Observations revealed the van had exposed wires, missing panels, debris, soiled linen, a used urinal with urine, water leaking from the roof, and a black substance on the wall. The van was used to transport residents, including those in wheelchairs, and there was no formal tracking for preventative maintenance or services performed on the vehicle. The Administrator was unaware of the van's condition, and the issues persisted over multiple days without being addressed. Additionally, the facility did not conduct thorough investigations or maintain complete documentation following resident falls. For two residents with significant cognitive and physical impairments, fall incident reports lacked witness statements and neuro checks, despite requests from surveyors. Progress notes and care plans showed repeated falls, but interventions were not consistently updated after each incident. In some cases, new interventions discussed in interdisciplinary team meetings were not added to the care plan, and there was no evidence of follow-up assessments or documentation as required by facility policy. Interviews with staff revealed a lack of understanding and adherence to post-fall investigation protocols. CNAs reported never being asked to provide statements after witnessing falls, and LPNs considered their progress notes sufficient as statements. The DON acknowledged that a complete investigation should include incident reports, statements, assessments, and neuro checks, but these elements were missing. The DON also did not have access to facility policies and was unaware of their specific requirements.
Failure to Remove Disqualified Employee from Facility Staff
Penalty
Summary
The facility failed to respond appropriately after being notified that the Business Office Manager (BOM) had been placed on the Employee Disqualification List (EDL), which disqualifies individuals from working in certified nursing homes. The Department of Health and Senior Services (DHSS) notified the facility that the BOM was permanently placed on the EDL, but the BOM continued to work at the facility for over two weeks after the placement. Both the Human Resources (HR) Director and the Administrator were unaware of the BOM's EDL status until surveyors began their investigation. The HR Director stated that no one had notified him of the placement and that he had not yet performed quarterly EDL checks since starting in the position a few months prior. The Administrator also confirmed he had not received any notification and was unsure how often EDL checks were being conducted. The EDL Active Report confirmed the BOM's name and Social Security Number had been added to the list with a permanent order. Interviews revealed that the BOM had worked at the facility as recently as the day before the surveyors' arrival and was only absent due to a personal emergency. The lack of timely EDL checks and communication breakdowns within the facility allowed the BOM to remain employed despite being ineligible, as required screenings and ongoing monitoring were not performed as mandated.
Failure to Discontinue Diabetes Medication as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not discontinuing a blood sugar-lowering medication, Metformin, as ordered by the hospital upon the resident's discharge. The resident, who had diagnoses of diabetes, hypertension, and Parkinson's disease, was dependent on staff for all activities of daily living and had a history of both insulin and oral diabetes medication administration. Despite hospital discharge instructions to stop Metformin following an episode of hypoglycemia, the medication continued to be administered by facility staff for several weeks after the resident's return. The resident experienced multiple episodes of low blood sugar (hypoglycemia) after readmission, with documented blood glucose levels as low as 40 and 51, requiring interventions such as administration of glucagon, orange juice, and glucose tablets. Progress notes and medication administration records showed that Metformin was given twice daily from the date of readmission until it was finally discontinued, despite the hospital's explicit order to stop the medication. There was no documentation in the resident's chart regarding the discontinuation of Metformin upon return from the hospital, and the care plan continued to list diabetes medications as ordered by the physician. Staff interviews revealed that the DON was unaware that Metformin had not been discontinued as ordered, and the nurse responsible for the error was no longer employed at the facility. The ongoing administration of Metformin, contrary to the hospital's discharge orders, directly contributed to repeated hypoglycemic events in the resident, as evidenced by clinical documentation and staff observations.
Failure to Honor Resident Food Preferences and Dietary Orders
Penalty
Summary
The facility failed to provide a resident with meals that met their documented food preferences and dietary needs. The resident, who was cognitively intact and able to communicate their preferences, had clear instructions in their care plan and physician's orders to avoid pork, cooked tomatoes, and carrots, and to receive double portions at each meal. Despite these documented requirements, the resident reported that staff continued to serve meals with gravy, foods they disliked, and did not provide the required double portions. The resident had communicated these concerns to both the DON and the Administrator. Observations confirmed that the resident received single portions and was served foods specifically listed as dislikes, such as cooked carrots and stewed tomatoes. Meal trays were not consistently prepared according to the resident's preferences, as evidenced by the presence of non-preferred items and incorrect portion sizes. The Dietary Director acknowledged that resident preferences are documented in the electronic medical record and should be followed when preparing meal trays, but this was not consistently done for this resident.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents from verbal and physical abuse, resulting in multiple altercations between them. Resident 54, diagnosed with paranoid schizophrenia and a history of traumatic brain injury, exhibited disruptive and verbally abusive behavior towards staff and other residents. Despite being placed on 15-minute checks, Resident 54 was observed yelling and shouting vulgarities, primarily focused on his desire to go outside to smoke. On two occasions, Resident 54 engaged in physical altercations with Resident 45, who has vascular dementia and osteoarthritis, leading to kicking and hitting each other. These incidents were not effectively prevented or managed by the facility staff. The first incident occurred when Resident 54 entered Resident 45's room and made a vulgar comment, leading to a physical fight where both residents kicked and hit each other until separated by staff. Despite being transferred to the hospital for a psychiatric evaluation, Resident 54 returned with no new orders to manage his behaviors. The second incident happened when Resident 54 was found hitting Resident 45 near her room, and she retaliated by hitting him with her reacher/grabber tool. Both residents were assessed and found to have no physical injuries, but the incidents caused significant psychosocial harm to Resident 45. Resident 45 reported feeling fearful and unable to sleep well due to concerns about Resident 54 entering her room. Despite being moved to a different part of the building, she continued to express anxiety about her safety. The facility's Director of Nursing acknowledged the challenges in managing Resident 54's behaviors and the impact on other residents. The Medical Director provided situational orders to manage Resident 54's behaviors but did not have specific information about the incidents. The facility's failure to effectively prevent and manage these altercations resulted in a deficiency in protecting residents from abuse.
Failure to Implement Pressure Ulcer Interventions and Follow Treatment Orders
Penalty
Summary
The facility failed to implement pressure ulcer interventions and follow physician's treatment orders for a resident who had undergone left hip surgery. The resident, who was readmitted to the facility with a diagnosis of surgical repair of the left hip, had a severe cognitive decline and was at risk for pressure ulcers as indicated by the Braden Scale scores. Despite this, no pressure ulcer prevention measures were initiated post-surgery until the resident developed unstageable pressure ulcers on the left foot. The care plan was only updated after the ulcers had developed, and interventions such as bilateral heel protectors and monitoring were implemented late. The resident's medical records revealed multiple instances where physician orders for pressure ulcer treatment were not followed. Orders to apply skin prep, Medi-honey, and foam dressing, as well as to cleanse the area with normal saline and apply collagen, were frequently not documented as completed. Additionally, the resident was observed without the prescribed low-air-loss mattress, which the Director of Nursing admitted was not ordered due to cost concerns. Interviews with the Director of Nursing confirmed that the care plan should have been updated post-surgery and that physician orders should always be followed. The failure to implement timely interventions and adhere to treatment orders resulted in the resident's pressure ulcers deteriorating to an unstageable and later a Stage 4 condition, causing actual harm to the resident.
Failure to Ensure RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 22 of the 92 days reviewed. This deficiency was identified through interviews, review of the Payroll Based Journal (PBJ) staffing report, and nursing schedules from October 1, 2023, to December 31, 2023. Specifically, there was no RN coverage on multiple days in October, November, and December 2023. The Director of Nursing (DON) confirmed the lack of RN coverage on these dates and acknowledged the requirement for an RN to be scheduled for at least eight hours in a 24-hour period, seven days a week. The facility did not have any RN coverage waivers, and the DON was unable to find a policy stating the RN requirement. During interviews, the DON stated that licensed nurses on shift were aware that she was on-call and would notify her if an RN was needed, at which point she would come to the facility. Certified Medication Technicians (CMTs) also confirmed their awareness of how to notify the DON if needed, especially on weekends. Despite this, the facility's failure to have an RN on duty for the required hours has the potential to affect the care provided to residents and the supervision of the unit.
Failure to Develop and Maintain Facility Assessment
Penalty
Summary
The facility failed to develop, initiate, or revise a facility assessment to determine the necessary resources to care for its residents competently during day-to-day operations. During the entrance conference, the Director of Nursing (DON) was unable to provide the Facility Assessment. The Administrator was unfamiliar with the concept of a Facility Assessment and confirmed that one had not been created since the facility's initial certification in January 2022. A document titled Facility Assessment Tool was later provided but was undated and had not been reviewed or approved by the facility's Quality Assurance committee. The DON admitted that the document was only initiated in January 2024 and revised on the day of the surveyor's request.
Failure to Develop QAPI Program
Penalty
Summary
The facility failed to develop a Quality Assurance and Performance Improvement (QAPI) program, which had the potential to affect all 78 residents. The facility's Quality Assurance Improvement Plan, dated February 2020, outlined a process for identifying and correcting quality deficiencies, including tracking and measuring performance, establishing goals, identifying and prioritizing deficiencies, analyzing causes, implementing corrective actions, and monitoring effectiveness. However, during an interview, the Director of Nursing (DON) stated that the facility did not have a QAPI plan in place. Further interviews revealed that the facility had conducted two QAPI meetings but did not keep minutes for these meetings. The DON mentioned that information was gathered from daily morning meetings, nursing 24-hour reports, and incident/accident reports to identify concerns, which were then reviewed during meetings and communicated to floor staff. However, the facility had not developed any Performance Improvement Plans (PIPs) or benchmarks for measuring improvement. The DON confirmed that there were no benchmarks or regular meetings to identify potential problem areas, relying instead on discussions at morning meetings and reviews of residents' electronic medical records (EMR).
QA Committee Fails to Identify and Address Quality Deficiencies
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to identify quality deficiencies, develop or implement corrective actions, track and measure effectiveness, or develop new interventions based on QA committee discussions. This failure had the potential to affect all 78 residents residing at the facility. The facility's policy titled Quality Assurance and Performance Improvement (QAPI) Program, dated February 2020, mandates the development, implementation, and maintenance of an ongoing, facility-wide, data-driven QAPI program focused on care outcomes and quality of life for residents. However, during interviews, the Director of Nursing (DON) admitted that the facility did not have a QAPI plan and that the QA committee had not identified any specific quality deficiencies or conducted any performance improvement programs (PIPs).
QA Committee Fails to Meet Quarterly with Required Members
Penalty
Summary
The Quality Assurance (QA) committee at the facility failed to meet at least quarterly with the required members, resulting in potential missed opportunities for identifying, tracking, and measuring quality deficiencies. The facility's policy stated that the QA committee should meet monthly, but only two meetings were documented since January 2022. The meetings on 11/18/22 and 09/28/23 were missing key members such as the Director of Nursing (DON), Infection Preventionist (IP), Medical Director, and Administrator. The DON confirmed that no QA meetings had been held in 2024, nor were any planned. During interviews, the DON and Administrator acknowledged the lack of regular QA meetings and the absence of key members. The Medical Director stated he would not attend any QA meetings until he was compensated by the facility. This failure to hold regular QA meetings with the required members had the potential to affect all 78 residents at the facility, as it hindered the facility's ability to effectively monitor and improve quality of care.
Failure to Properly Manage Resident Funds
Penalty
Summary
The facility failed to ensure resident funds were placed in an account separate from the facility operating account, resulting in delayed refunds for six residents. Additionally, the facility staff did not obtain written authorization for money withdrawals for 19 residents, and failed to provide the Social Security and/or Medicaid monthly allowance in a timely manner for seven residents. This lack of proper financial management did not allow residents or their financial guardians the right to manage their financial affairs effectively. The facility also failed to withdraw the correct monthly surplus for room and board for one resident, and used resident funds for checking account fees deducted from the resident trust account. Furthermore, the facility did not provide a statement explaining the facility's policies and resident's rights regarding resident funds, and did not allow residents access to their funds on an ongoing basis. Resident petty cash funds were not kept separate from facility funds, affecting all residents whose funds were managed by the facility. Interviews with residents, their guardians, and family members revealed that many were unaware of the withdrawals or did not sign any paperwork authorizing them. The Business Office Manager admitted to not obtaining written authorization for withdrawals if the resident could talk, and was unsure about the reasons for certain credits and debits in the accounts. The facility census was 80, indicating that these deficiencies had the potential to affect a significant number of residents.
Failure to Reconcile Resident Trust Fund Accounts Monthly
Penalty
Summary
The facility failed to maintain a system to ensure the resident trust fund account was managed in accordance with proper accounting principles. Specifically, the facility did not maintain an accurate accounting of all monies held in the resident trust fund account by failing to reconcile each month. The facility managed funds for 21 residents, with a census of 80. Record review of the facility-maintained bank statements for account ending in #5015 for several months showed no documentation of reconciliations. Additionally, attempted reconciliation forms for two specific months did not reconcile to the residents' current balance at the time of reconciliation. During an interview, the Business Office Manager admitted to not starting reconciliations until a specific month and could not provide any other documentation to support that reconciliations were performed.
Failure to Provide Timely Final Accounting of Resident Funds
Penalty
Summary
The facility failed to provide a final accounting of resident fund balances within thirty days to the individual or probate jurisdiction administering the resident's estate for one discharged resident and four expired residents. Specifically, Resident #1020 had a $30.00 balance that was not refunded within 33 days after discharge. Resident #1019 had a $50.00 balance that was refunded 81 days after expiration, with no documentation showing where the funds went. Resident #1023 had a balance of $929.88, which was not reported to the Department of Social Services, Third Party Liability Unit, and was instead used for back surplus and transferred to the facility operating account. Resident #1025 had a balance of $277.84 that was not reported to the Department of Social Services, Third Party Liability Unit, and there was no documentation showing where the funds went. Resident #1026 had a balance of $402.17 that was transferred to the facility operating account instead of being reported to the Department of Social Services, Third Party Liability Unit. During interviews, the Business Office Manager was unable to provide explanations for the delays and mismanagement of the funds. The manager admitted to not knowing the proper procedures for handling and reporting the funds to the Department of Social Services, Third Party Liability Unit. The facility's failure to properly manage and report resident funds resulted in non-compliance with regulatory requirements, as evidenced by the delayed refunds and lack of documentation for the transactions.
Inadequate Surety Bond for Resident Trust Fund
Penalty
Summary
The facility failed to maintain an adequate surety bond for the resident trust fund account, which should have been one and one half times the average monthly balance for the past 11 months. The average monthly balance was $26,000.00, requiring a bond of $39,000.00. However, the facility only had an approved bond of $4,000.00, dated 8/23/21. The current balance in the resident trust account for February 2024 was $13,782.56. During interviews, the Business Office Manager (BOM) indicated that the Administrator was responsible for ensuring the surety bond was appropriate, but the BOM did not know how often the Administrator reviewed the bond and mentioned there was no policy for the surety bond. The Administrator admitted he was unaware of the need for a $39,000.00 bond and stated he would get it increased.
Failure to Post Survey Results and Provide Access
Penalty
Summary
The facility failed to post the location of the state survey results and provide unrestricted access to residents and visitors. Observations conducted throughout the facility revealed no notices posted to notify residents or visitors where the survey results binder was located. The binder labeled Survey Results was found behind the front desk, and a review of the binder revealed incomplete documentation, missing the facility's plans of correction (POC). During an interview, the Administrator and Director of Nursing (DON) confirmed that the binder was kept behind the receptionist's desk due to a previous incident where the binder was taken when placed in the lobby area. The Administrator also stated that the complete survey results and POC were kept in his office.
Failure to Issue Accurate Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to issue an accurate Notice of Medicare Non-Coverage (NOMNC) when Medicare Part A service was ending for three residents. The facility used the directions for completion of the NOMNC from the Centers for Medicaid and Medicare Services (CMS) form number CMS-10123 as their policy. However, the facility issued a CMS-10095 to all three residents, which was the incorrect form. This error resulted in the NOMNCs lacking the type of current services that were ending and the necessary information about potential liability for services received after the last covered day (LCD). Additionally, the notices did not include the name, phone number, and TTY number of the Quality Improvement Organization (QIO). The MDS Coordinator, who was responsible for completing and issuing the NOMNCs, revealed that she was provided the CMS-10095 form by an advisor from Missouri University School of Nursing. She was unaware that she was using the incorrect form to notify residents and their representatives. This oversight could have led the residents or their responsible parties to miss the deadline to request an expedited appeal and review.
Misappropriation of Resident Funds by Business Office Manager
Penalty
Summary
The facility failed to ensure that three residents were free from misappropriation of their property when the Business Office Manager used resident funds for personal use. For Resident #1019, the Business Office Manager manipulated funeral home documents and instructed the resident's family member to cash a check and return a portion of the money in cash. The family member confirmed that the Business Office Manager received $2,000 in cash without providing a receipt. The funeral home and bank confirmed that the documents were altered and did not pertain to Resident #1019. For Resident #1010, the Business Office Manager issued checks and cash withdrawals without proper documentation or receipts. The resident and their Financial Power of Attorney (FPOA) confirmed receiving only a $1,000 check and no additional cash. The Business Office Manager attempted to have the FPOA falsely confirm receiving $1,000 in cash. The Activity Director also confirmed that no large cash withdrawals were requested or received for Resident #1010. For Resident #1008, the Business Office Manager issued checks to the resident's family member and instructed them to return a portion of the money in cash. The family member confirmed giving $2,000 in cash to the Business Office Manager and later receiving it back after questioning the transaction. The Activity Director confirmed that no large cash withdrawals were requested for Resident #1008, and the Business Office Manager's explanation for the withdrawal was inconsistent with the family member's account.
Failure to Screen New Hires for CNA Registry and Nursing Licenses
Penalty
Summary
The facility failed to ensure newly hired employees were properly screened for Federal Indicators, CNA registry, and nursing licenses. Specifically, three staff members were hired without a CNA registry check, and one RN and three LPNs were hired without their nursing licenses being verified. This deficiency was identified during a review of a sample of 10 employee files out of 200 new hires since the last survey. The facility's policy on abuse, neglect, exploitation, or misappropriation did not include procedures for employee background checks, licensing, or CNA registry verification. During interviews, the Business Office Manager/Human Resource Manager admitted to not knowing the correct website to use for these checks, and the Administrator was unaware that these checks were not being performed. This lack of proper screening could potentially lead to unqualified or unsuitable individuals being employed, posing a risk to resident safety and care quality.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure daily staffing information was posted timely and in a manner accessible to residents and visitors. The facility's policy required that within two hours of the beginning of each shift, the number of licensed nurses and unlicensed personnel directly responsible for resident care be posted in a prominent location. However, observations on multiple days and times revealed no daily staff posting of nursing hours anywhere in the building. During an interview, the Assistant Director of Nursing (ADON) admitted that neither she nor the Director of Nursing (DON) had completed or posted the daily nurse staffing hours for the week due to the survey process occurring.
Failure to Maintain Complete PASRR Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records, specifically the required Preadmission Screening and Resident Review (PASRR) Level I and Level II evaluations for mental illness or intellectual disabilities for three of 24 sampled residents. This deficiency was identified through record reviews and staff interviews. For instance, one resident with paranoid schizophrenia and a history of traumatic brain injury did not have a PASRR in their medical record, despite exhibiting disruptive and verbally abusive behavior. The social worker confirmed the absence of the PASRR documentation, although a Level II evaluation had been conducted previously without recommendations for specialized services. Another resident with bipolar disorder and dementia was found to have no PASRR documentation in their electronic medical record, despite being cognitively intact according to their quarterly Minimum Data Set (MDS) assessment. Similarly, a third resident with dementia and idiopathic psychosis also lacked a documented PASRR in their medical record. The social worker confirmed the absence of PASRR documentation for these residents as well, even though Level I and Level II evaluations had been conducted previously. These lapses in documentation increased the risk that residents with mental illness or intellectual disabilities would not receive the necessary specialized services.
Failure to Report Verbal Threat to State Survey Agency
Penalty
Summary
The facility failed to report to the State Survey Agency (SA) a verbal threat to shoot residents and staff made by a resident diagnosed with paranoid schizophrenia and a history of traumatic brain injury. The resident, who exhibited moderate cognitive impairment and was known for disruptive and verbally abusive behavior, made the threat after a physical altercation with another resident. Despite the severity of the threat, the Director of Nursing (DON) did not consider it credible and did not report it to the SA, as the resident did not have access to a gun. The facility's policy requires all reports of abuse, neglect, and mistreatment to be promptly reported to local, state, and federal agencies, but this protocol was not followed in this instance. The resident in question, who was admitted with a history of paranoid schizophrenia and traumatic brain injury, had a documented pattern of violent outbursts and verbal abuse. On two separate occasions, the resident was observed cursing and demanding cigarettes near the nurse's station. The staff, including a Certified Nurse Aid (CNA) and a Certified Medication Tech (CMT), confirmed that they struggled to manage the resident's behavior and often allowed him to smoke to prevent further escalation. The facility's electronic medical record (EMR) showed intermittent 15-minute checks as a care plan intervention to deescalate the resident's violent behavior. However, after the resident made a verbal threat to shoot everyone in the building following a physical altercation, the threat was not reported to the SA, contrary to the facility's abuse investigation and reporting policy.
Failure to Investigate Threats and Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate a verbal threat made by a resident (R54) to shoot staff and other residents. Despite R54's history of paranoid schizophrenia and traumatic brain injury, and his observed disruptive and verbally abusive behavior, the Director of Nursing (DON) did not consider the threat credible because R54 did not have access to a gun. No search of R54's person or room was conducted to rule out the presence of weapons, which the DON confirmed should have been part of a thorough investigation. Additionally, the facility failed to properly investigate an allegation of misappropriation involving the Business Office Manager (BOM). The Administrator did not immediately suspend the BOM upon receiving the complaint and allowed the BOM to return to work before speaking with all potential witnesses. The BOM made contact with one of the residents involved in the allegation multiple times, including in person, which is against the facility's policy. The investigation into the misappropriation was incomplete and poorly documented. The Administrator did not speak with all relevant family members and relied on incomplete statements. The BOM and other staff provided statements that did not address all allegations, and there were discrepancies in the financial records. The Administrator's actions and the facility's investigation did not adhere to their own policies, leading to an inadequate response to the serious allegations of misappropriation.
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 963 citations issued within 25 miles in the last 12 months — including the 28 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 Ferguson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Knoll Skilled Nursing & Rehabilitation Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Estates Of St Louis, Llc, The | 2 mi | ★★★★★ | 3 | 0 |
| Amberwood Estates Nursing And Rehabilitation | 2.1 mi | ★★★★★ | 37 | 0 |
| Heritage Care Center | 2.2 mi | ★★★★★ | 32 | 1 |
| Crestwood Health Care Center, Llc | 2.3 mi | ★★★★★ | 6 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.