Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Atrium Place Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to accurately transcribe and timely implement wound care provider orders and off‑loading interventions for multiple residents with pressure injuries. For a quadriplegic resident with impaired cognition and a sacral/right buttock pressure injury, the wound care physician’s order to change from calcium alginate to calcium alginate with silver was never updated on the POS/TAR, and the care plan did not reflect the current pressure injury. The same resident also received Bactrim DS instead of the amoxicillin‑clavulanate documented in the wound care physician’s notes, with no contemporaneous explanation in the record. Two other residents with severe cognitive and mobility impairments and incontinence had new Stage 3 pressure injuries for which calcium alginate with silver dressings were ordered, but these orders were not entered into the POS/TAR for several days, during which staff continued prior skin prep or zinc oxide treatments. One of these residents also had an order for off‑loading boots to be worn at all times, yet was observed without the boots in place, and staff reported the boots were in the laundry.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy by not wearing gowns during high-contact care activities for multiple residents who had wounds, feeding tubes, or tracheostomies and were posted for EBP. In several observed instances, an LPN, the Treatment Nurse, and CNAs performed skin assessments, wound treatments, personal care, bed baths, and incontinence care while wearing gloves only, despite EBP signage on room doors and gowns and gloves being readily available. Some staff later acknowledged they should have worn gowns, while others reported they were unaware gowns were required, even though the facility’s policy and physician orders specified gown and glove use for high-contact care under EBP.
Staff did not follow physician orders to obtain and document a resident's vital signs, despite the resident having complex medical needs including quadriplegia, malnutrition, multiple pressure ulcers, a suprapubic catheter, and an ostomy. Records showed missing or incomplete documentation of vital signs over several months. Interviews revealed inconsistent practices and lack of awareness among staff regarding the required monitoring.
A resident with multiple pressure ulcers and complex medical needs had numerous wound treatments and refusals that were not documented on the Treatment Administration Record as required. Despite facility policy and electronic prompts for documentation, staff left several entries blank, and interviews with the LPN, wound nurse, DON, and nurse practitioner confirmed that treatments and refusals should have been clearly recorded.
Staff failed to provide CPR to a resident with full code status after the resident was found unresponsive and not breathing following a transfer to bed. Despite the LPN informing the Nurse Manager of the resident's full code status, no resuscitation efforts were made, and the resident was pronounced dead without CPR, contrary to facility policy and physician orders.
A resident with a seizure disorder had critically low levels of seizure medications identified in lab results, but the physician was not notified and the Medical Director did not have access to these results in the system. The resident later experienced seizures. Additionally, when the resident developed new purple discoloration of the fingertips, nursing staff delayed notifying the on-call NP until after a fall occurred, and failed to document the initial assessment. The facility also did not check g-tube residuals for another resident as required.
Two residents were involved in a physical altercation during a smoke break at an LTC facility. The incident began when one resident attempted to rush past another, leading to a verbal exchange that escalated into physical aggression. Witnesses and staff provided varying accounts, and the facility's investigation could not conclusively determine if one resident's foot was run over by the other's wheelchair. Both residents have no prior history of altercations and expressed feeling safe in the facility.
The facility failed to maintain a safe and homelike environment, as evidenced by a leaking air conditioning unit causing water puddles in a resident's room, a non-functioning call light indicator delaying staff response, and disrepair in the 300 hall with chipped tiles and a broken doorframe. Maintenance was aware of some issues but had not addressed them, and renovations were halted by the current corporation.
The facility failed to provide adequate supervision during meals and smoke breaks, leading to a resident with dysphagia experiencing a coughing episode due to improper positioning, and multiple residents engaging in unsafe smoking practices without supervision. Staff did not ensure residents were upright during meals or present during smoke breaks, contrary to facility protocols.
The facility did not maintain the required RN staffing levels, failing to have an RN on duty for at least 8 consecutive hours a day, 7 days a week. This issue was identified in the PBJ Staffing Data Report for Q2 2024, with specific dates lacking RN coverage. The administrator and Corporate Staff B confirmed the report's accuracy, and although borrowing RNs from sister facilities was suggested, it was not executed, resulting in the deficiency.
The facility failed to maintain accurate records for controlled substances, with significant documentation gaps in narcotic books. The Controlled Substance Shift Change Count - Check Sheet showed numerous blanks for package counts and missing nurse initials. The DON acknowledged the issue, noting confusion due to shift length discrepancies, but expected adherence to policy.
A facility reported a 14.81% medication error rate due to improper administration practices. An LPN failed to prime an insulin pen before use, another crushed enteric-coated aspirin for a resident with a g-tube, and a CMT did not follow proper eye drop administration guidelines. The DON confirmed staff did not adhere to nursing practices.
The facility failed to properly label and store medications, with issues such as undated insulin pens, unidentified pre-popped medications, and expired drugs found in medication carts. The DON acknowledged these deficiencies, highlighting a lack of adherence to facility policies.
The facility failed to maintain an effective pest control program, leading to the presence of flies in the kitchen. Observations showed the backdoor left open, allowing flies into food prep areas and near the walk-in cooler. The administrator expected the kitchen to be fly-free and the door closed.
A resident with multiple diagnoses, including quadriplegia and depression, experienced a negative interaction with a CNA who used profanity and was reportedly rough while wiping the resident's face. The incident was witnessed by an LPN who heard cursing from both parties and saw the CNA toss a towel onto the resident's head. The facility's investigation could not substantiate abuse, but the CNA was terminated for policy violation.
A facility failed to obtain a physician order for a resident using a bi-pap machine and did not complete neuro check documentation for another resident who fell. The resident using the bi-pap had obstructed sleep apnea, but no physician order was documented. The resident who fell had severe cognitive impairment and a history of stroke, with incomplete neuro check documentation following the fall. Staff interviews confirmed that protocols were not fully followed.
A resident with a seizure disorder did not receive Vimpat, a seizure medication, for four and a half days due to the facility's failure to obtain it from the pharmacy in a timely manner. Despite the facility's policy requiring immediate action for unavailable medications, there was no documentation of physician notification or alternative treatment orders. Staff interviews revealed attempts to contact the pharmacy and MD, but the medication was delayed due to a lack of refills and the need for a new script.
A resident was left exposed in the hallway after a shower when a CNA refused to get a gown or blanket. The resident, who required assistance for showers and transfers, was left unclothed in a wheelchair, causing significant distress. Another CNA covered the resident and assisted them back to their room. The responsible CNA was terminated.
The facility failed to provide necessary treatment and services for residents with pressure ulcers, resulting in deficiencies. One resident with a left heel unstageable pressure ulcer did not receive timely care, and another resident with multiple pressure ulcers did not receive the prescribed wound treatment due to missing supplies. The staff did not follow physician orders or take immediate action to address open and draining wounds.
The facility failed to maintain acceptable nutritional status for a severely underweight resident with severe protein-calorie malnutrition and a wound. Staff did not accurately monitor or document the resident's weights and nutritional supplement administration, leading to the use of inaccurate information by the dietician. The facility also did not provide the ordered nutritional supplements, resulting in significant weight loss.
A resident with multiple diagnoses, including diabetes and arthritis, experienced unmanaged pain due to the facility's failure to administer prescribed pain medications in a timely manner. The facility did not follow its Medication Reordering and Physician's Orders policies, leading to a delay in receiving Oxycodone and a lack of alternative pain relief. Communication issues between the facility, pharmacy, and physician further exacerbated the problem.
The facility failed to provide necessary wound care for a resident with a foot wound, as per physician's orders. The resident, who had diabetes and neuropathy, reported that wound care was not being completed, and observations confirmed lapses in the treatment schedule. The LPN acknowledged the resident's ongoing issues with peeling skin and pain, and the administrator emphasized the importance of following physician's orders.
The facility failed to ensure that meals were served at safe temperatures, as evidenced by two residents receiving cold food. Despite initial food temperatures being correct, the lack of a heated cart and timely distribution led to meals being served below the required temperature standards.
Failure to Implement Wound Care Orders and Off‑Loading Interventions for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate transcription and implementation of wound care provider orders, timely initiation of new pressure injury treatments, and inclusion of a resident’s pressure injury in the care plan. For one quadriplegic resident with impaired cognition and total dependence for mobility and ADLs, a pressure injury to the sacral/right buttock area was identified in early November. The wound care company physician ordered a change in dressing from calcium alginate to calcium alginate with silver on 11/13, but the facility’s Treatment Nurse did not update the physician order sheet (POS) or treatment administration record (TAR). As a result, the TAR continued to list calcium alginate only through January, and staff nurses reported they would follow what was written on the TAR, meaning they may not have used the ordered calcium alginate with silver. The resident’s care plan also did not identify the presence of a current pressure injury despite documentation of a recurrent coccyx/right buttock wound and ongoing wound care. For the same resident, the wound care physician ordered amoxicillin‑clavulanate for the pressure injury on 1/2, but the POS and MAR instead showed Bactrim DS being administered twice daily starting 1/3, with no documentation explaining the change from the wound care physician’s written order. The DON later reported a verbal confirmation from the wound care physician that Bactrim DS was desired, but this clarification occurred after the period in which the MAR showed Bactrim being given in place of the originally ordered amoxicillin‑clavulanate. Throughout this time, the wound care physician’s subsequent notes continued to list amoxicillin‑clavulanate as the recommended antibiotic, while the facility records reflected Bactrim DS administration. The facility also failed to timely implement new wound care orders for two other residents and to ensure ordered off‑loading devices were in place. One resident with cerebral palsy, severe cognitive impairment, total dependence for mobility, and bowel and bladder incontinence had existing orders for skin prep to the left dorsal foot and left heel and for off‑loading boots to be worn at all times. On 1/2, the wound care physician documented new Stage 3 pressure injuries on the left dorsal foot and left heel and ordered calcium alginate with silver dressings once daily, along with continued use of pressure off‑loading boots. However, the POS and TAR were not updated to reflect the calcium alginate with silver until 1/5, and staff continued to document application of skin prep on 1/2–1/4. During observation on 1/5, the resident’s left dorsal foot and heel had open pressure injuries with dressings dated 1/2, and on 1/7 the resident was observed in bed without off‑loading boots; CNAs reported the boots had been sent to laundry and not yet returned, despite an order for boots to be on at all times. Another resident with a history of wound infection, diabetes, stroke, severe cognitive impairment, and total dependence for mobility had an order for zinc oxide ointment to the right buttock. On 1/2, the wound care physician documented a Stage 3 pressure injury on the right posterior thigh and ordered calcium alginate with silver once daily. The facility did not enter this new order on the POS and TAR until 1/5, and nurses continued to initial zinc oxide application on 1/2–1/4. On 1/5, observation showed open horizontal areas on the right posterior thigh without a dressing in place, and the Treatment Nurse acknowledged she had been on vacation when the wound care physician rounded and that the new order from 1/2 had not been added until her return. Across these cases, the facility’s own policies requiring prompt assessment, timely implementation of provider orders, and care plan updates for pressure injuries were not followed.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed its Enhanced Barrier Precautions (EBP) policy during high-contact resident care activities for residents requiring EBP. The facility’s written policy required the use of gowns and gloves for high-contact care activities such as dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use, and wound care for residents with wounds or indwelling medical devices. EBP signs were posted on the doors of residents requiring these precautions, and gowns and gloves were made available near or inside those rooms. The policy also stated that staff were trained on EBP upon hire and annually, and that the Infection Preventionist would periodically monitor adherence. For one resident with functional limitations in both upper and lower extremities, dependent in all ADLs, with a feeding tube and open areas on the right posterior thigh, surveyors observed an EBP sign on the door and PPE supplies inside the room. During a skin assessment, an LPN and the Treatment Nurse both donned gloves but did not wear gowns, despite the presence of a feeding tube stoma with a dressing and open skin areas. This resident’s record showed wound infection, diabetes, stroke, and tube feeding orders, but no specific physician order for EBP, even though the room was posted for EBP. Another resident with cerebral palsy, seizure disorder, total dependence in ADLs, incontinence of bowel and bladder, and a Stage 3 pressure ulcer had a care plan and physician order specifically requiring EBP with gown and gloves for high-contact care due to chronic wounds. Surveyors observed the Treatment Nurse performing a skin assessment and later wound treatment to open areas on the left dorsal foot and heel while wearing gloves but no gown, despite an EBP sign on the door and PPE available. On a separate occasion, two CNAs provided personal care and a bed bath to this resident while each wore gloves but no gowns. One CNA later stated awareness that a gown should have been worn, while the other CNA reported not knowing a gown was required during personal care. A third resident, totally dependent in ADLs with a history of stroke, seizure disorder, respiratory failure, a feeding tube, and a tracheostomy, had a physician order for EBP requiring gown and gloves for high-contact care. An EBP sign and PPE supplies were present at the room. During a skin assessment, an LPN and a CNA donned gloves but not gowns. While in the room, the resident had a large loose bowel movement, and both staff cleaned the resident and changed the incontinent brief without wearing gowns. A fourth resident with quadriplegia, dependence in all ADLs, and a sacral pressure injury had an EBP sign on the door and PPE supplies available. The Treatment Nurse performed a skin assessment of the sacral area while wearing gloves but no gown. In interviews, the Infection Preventionist, Treatment Nurse, DON, and Administrator all stated that staff were expected to follow the EBP signage and policy, and the Treatment Nurse and an LPN acknowledged that gowns should have been worn during these care activities.
Failure to Obtain and Document Resident Vital Signs per Physician Orders
Penalty
Summary
Facility staff failed to follow physician orders and professional standards by not obtaining and documenting a resident's vital signs as ordered. The resident, who was cognitively intact and dependent on staff for most activities of daily living, had significant medical conditions including quadriplegia, malnutrition, chronic osteomyelitis, multiple stage three and four pressure ulcers, a suprapubic catheter, and an ostomy. Physician orders required that a full set of vital signs be obtained and abnormalities reported to the nurse practitioner or physician, initially on a specific date and then monthly. However, review of the Treatment Administration Record (TAR) and electronic medical record (EMR) showed that vital signs were either not documented or marked as not applicable, with several months lacking any record of vital signs being obtained. Interviews with staff revealed inconsistent understanding and implementation of the vital sign orders. An LPN stated that vital signs are typically obtained every shift and as needed, while a CNA reported only taking vital signs when instructed by a nurse and was unaware of any routine or monthly orders for the resident. The wound nurse indicated that vital signs are obtained every shift for new admissions and then monthly, but the resident's care plan did not address obtaining vital signs. The DON and Medical Director both expected staff to follow physician orders and document vital signs, but acknowledged there was no facility policy specifically related to obtaining vital signs. The resident's death was documented, but there was no evidence that vital signs were consistently monitored or recorded as ordered prior to the event.
Failure to Document Wound Treatments and Refusals
Penalty
Summary
The facility failed to accurately document completed wound treatments or treatment refusals for a resident with multiple pressure ulcers and significant medical needs. Review of the Treatment Administration Record (TAR) revealed that, for several wound care orders, numerous entries were left blank, indicating that staff did not record whether treatments were completed or refused. Specifically, for multiple wound care orders, between two and fourteen out of the total opportunities for documentation were left blank. The resident's care plan noted a history of resistance to care and frequent refusals of wound treatments, but the TAR did not consistently reflect whether treatments were administered or refused. Interviews with facility staff, including an LPN, the wound nurse, the DON, and a nurse practitioner, confirmed that staff are expected to document all treatments or refusals in the TAR, and that the electronic medical record system prompts for a reason if a treatment is not completed. However, staff were unable to explain the blank entries, with one LPN suggesting it could be due to forgetting to chart. The lack of documentation was not in accordance with facility policy, which requires clear and accurate recording of all medical provider orders and treatments.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to provide basic life support, including cardiopulmonary resuscitation (CPR), to a resident who was identified as full code, meaning that in the event of cardiac or respiratory arrest, CPR should be initiated and emergency services summoned. The resident, who had severe cognitive impairment and multiple diagnoses including high blood pressure, seizures, and muscle weakness, was transferred from a wheelchair to bed by a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN). During the transfer, the resident's oxygen was removed, and after being placed in bed, the resident was found to be unresponsive and not breathing. The LPN checked for a pulse and, finding none, called the Nurse Manager (NM) to confirm the resident's status. The NM used a stethoscope and verified there was no heartbeat or pulse. Despite the LPN informing the NM that the resident was a full code, the NM stated that the resident had died and that two nurses could verify the death, so no CPR was performed. The resident was pronounced dead, and no attempts at resuscitation were made, even though facility policy and physician orders required CPR to be initiated for full code residents unless a Do Not Resuscitate (DNR) order was in place or there were obvious signs of irreversible death. Interviews with staff and review of facility policies confirmed that the expectation was for staff to assess unresponsive residents, check code status, and initiate CPR if the resident was a full code. The failure to initiate CPR was attributed to a misunderstanding by the NM, who incorrectly assumed the resident was a DNR, and a lack of urgency in communication. The deficiency was identified as Immediate Jeopardy due to the failure to follow physician orders and facility policy regarding life-saving interventions for residents with full code status.
Failure to Notify Physician of Critical Lab Results and Change in Condition
Penalty
Summary
The facility failed to notify the physician of a resident's critically low lab results for seizure medications and did not ensure that the Medical Director and other physicians had full access to lab results in the system they use. The resident, who had severe cognitive impairment and a history of seizures, had lab work drawn that showed subtherapeutic levels of both Keppra and Dilantin. There was no documentation that the physician was notified of these abnormal results, and no new orders were entered in response. Eighteen days later, the resident experienced seizure activity, and subsequent review revealed that the Medical Director was unaware of the low lab results due to incomplete transfer of information between electronic systems. Additionally, the facility failed to notify the physician promptly when the same resident exhibited a change in condition, specifically new purple discoloration to the fingertips. The change was first observed and reported to nursing staff at approximately 8:30 P.M., but the on-call Nurse Practitioner was not notified until about 4:30 A.M., after the resident had a fall. There was also a lack of documentation regarding the initial assessment of this change of condition in the medical record. Interviews with staff confirmed that the expectation was for abnormal findings and changes in condition to be reported to the physician or NP and documented accordingly, but this did not occur in this instance. Furthermore, the facility failed to check gastrostomy tube (g-tube) residuals for another resident with a g-tube, as required. The report details that the facility's policies require prompt notification of changes in condition, abnormal lab results, and proper documentation, but these were not followed. The sample included three residents, with a facility census of ninety-four.
Resident Altercation During Smoke Break
Penalty
Summary
The facility failed to ensure a resident's right to be free from abuse was not violated when two residents were involved in a physical altercation. The incident occurred during a smoke break when one resident attempted to rush past another, resulting in a verbal exchange that escalated into physical aggression. Both residents hit each other before being separated by staff and other nearby residents. The altercation was witnessed by several individuals, including staff and other residents, who provided varying accounts of the events leading up to the physical confrontation. Resident #1, who has diagnoses including hypertension, kidney failure, Parkinson's disease, malnutrition, schizophrenia, and asthma, reported that their foot was run over by Resident #2's motorized wheelchair, which led to the altercation. However, witnesses and staff interviews could not conclusively determine if the foot was indeed run over. Resident #2, who has moderate cognitive impairment and a history of smoking marijuana in the facility, denied running over Resident #1's foot and claimed that Resident #1 initiated the physical contact. Both residents have no prior history of physical altercations with each other or other residents. The facility's investigation into the incident included interviews with the involved residents, witnesses, and staff. The investigation concluded that there was a physical altercation between the two residents, but it could not be determined if the alleged running over of the foot occurred. The facility's policy on abuse, neglect, and exploitation was reviewed, highlighting the need for immediate investigation and protection of residents from harm. Despite the altercation, both residents continued their normal routines and expressed feeling safe in the facility.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. One resident experienced a leaking air conditioning unit in their room, which resulted in puddles of water under the bed and a persistent wet smell. Despite the maintenance staff being aware of the issue and initially inspecting the unit, no repairs were made, and the problem persisted over several days. The resident reported that staff placed a blanket under the bed to absorb the water, but the issue remained unresolved, contributing to an uncomfortable living environment. Another deficiency involved a resident whose call light indicator above their room door was not functioning, leading to delays in staff response. Although the call light was activated in the resident's room, the hallway indicator did not light up, and staff were unaware of the resident's need for assistance. The call bell system at the nurse's station was operational, but the lack of a functioning hallway indicator compromised timely staff response to the resident's needs. Additionally, the facility's 300 hall was observed to be in disrepair, with chipped and missing floor tiles, chipped baseboards, and a door frame that had pulled away from the wall. The Maintenance Director acknowledged these issues but was unaware of some specific problems, such as the broken doorframe and call light. The Administrator noted that renovations had been halted by the current corporation, leaving the 300 hall in a state that was not conducive to a homelike environment.
Inadequate Supervision During Meals and Smoke Breaks
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for its residents. One resident, diagnosed with dementia and dysphagia, was observed during a meal service in a tilted-back wheelchair, which was not corrected by staff. This improper positioning led to a coughing episode as the resident attempted to feed themselves, highlighting a lack of appropriate supervision and intervention by the staff present, including a speech pathologist who was aware of the resident's swallowing difficulties. Additionally, the facility did not adequately monitor smoke breaks, failing to ensure residents followed the facility's safe smoking protocol. During observed smoke breaks, residents were left unsupervised, resulting in unsafe practices such as flicking lit cigarettes into the grass and improper disposal of cigarette butts. The facility's policy required supervision for residents identified as needing it, but this was not consistently provided, as evidenced by the unsupervised smoking activities of several residents. Interviews with facility staff, including the Administrator, DON, and Activity Director, confirmed that supervision was required for residents during smoking breaks. However, the lack of staff presence and failure to correct unsafe smoking practices during the observed smoke breaks indicated a breach in protocol and supervision, contributing to the deficiency.
Failure to Maintain RN Staffing Requirements
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, as required. This deficiency was identified during a review of the facility's Payroll-Based Journal (PBJ) Staffing Data Report for the second quarter of 2024, covering January 1 to March 31. The report highlighted specific dates where no RN hours were recorded, including March 21, 22, 23, 24, 30, and 31. During interviews, the facility's administrator acknowledged that Corporate Staff B was responsible for the PBJ reports and confirmed their accuracy. Corporate Staff B admitted to assisting with the PBJ reports and suggested borrowing RNs from sister facilities to cover the missing hours, which was not implemented, leading to the deficiency.
Deficiency in Controlled Substance Record-Keeping
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically narcotics, as evidenced by the review of two narcotic books. The facility's policy, dated 9/1/21, mandates that controlled substances be monitored in compliance with state and federal regulations, with safeguards to prevent loss or diversion. However, the review of the Controlled Substance Shift Change Count - Check Sheet for July 2024 revealed significant documentation gaps. At Station 300, 73 out of 87 opportunities for recording the number of packages were left blank, and there were numerous instances where nurses' initials were missing. Similar issues were observed at Station 100/700, with 23 out of 87 opportunities left blank for the number of packages and missing initials for both oncoming and off-going nurses. During interviews, the Director of Nursing acknowledged that the oncoming nurse should count controlled substances with the off-going nurse, and both should document this on the count sheet. The Director expected the count to be completed without blanks, but noted that the form was set up for eight-hour shifts, which confused some nurses who worked 12-hour shifts. Despite this, the expectation was for staff to adhere to the facility's policy and procedures, which was not consistently followed, leading to the deficiency in maintaining accurate records for controlled substances.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 14.81% error rate. This was observed in the administration of medications to three residents. For one resident with diabetes, an LPN administered insulin lispro without priming the pen, contrary to the manufacturer's instructions, after checking the resident's blood sugar level. Another resident, who had severe cognitive impairment and was receiving medications via a gastrostomy tube, was given crushed enteric-coated aspirin and Vitamin C, which should not have been crushed according to the facility's medication administration policy. Additionally, a resident with intact cognitive skills was administered Fluorometholone eye drops by a CMT who did not follow the manufacturer's guidelines for application, failing to apply gentle pressure at the corner of the eye after administration. Interviews with the DON and LPNs confirmed that the staff did not adhere to acceptable nursing practices and manufacturer's recommendations for medication administration, contributing to the high medication error rate.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to professional standards and facility policy. During observations and interviews, it was found that medication carts contained several issues, including undated and opened insulin pens, pre-popped medications in cups without identification, and multiple bottles of medications and eye drops that were opened and undated. Additionally, some medications were found to be expired, such as allergy relief tablets, sodium bicarbonate tablets, and multivitamins. The Director of Nursing (DON) acknowledged these deficiencies, stating that insulin should be dated when opened, and medications should be checked for expiration dates and removed if expired. The DON also mentioned that eye drops should be dated when opened and are good for 30 to 45 days after opening, and liquid medications should be dated when opened. Despite these expectations, the facility did not adhere to its policies, resulting in improper storage and labeling of medications.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the kitchen. Observations on multiple occasions revealed that the backdoor to the outside was left open, allowing flies to enter the food preparation areas, outside the walk-in cooler, and inside the dry food storage room. These observations were made on three separate days, with flies consistently present throughout the kitchen and a swarm of flies noted outside the walk-in cooler. During an interview, the administrator acknowledged the expectation for the kitchen to be free of flies and for the backdoor to be closed.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure that all residents were treated with dignity and respect, as evidenced by an incident involving a resident who was cognitively intact and had multiple diagnoses, including neurogenic bladder, wound infection, quadriplegia, malnutrition, and depression. The resident was dependent on staff for various activities of daily living, including personal hygiene. During an interaction with a Certified Nurse Aide (CNA), the resident requested assistance with a towel, which led to a verbal altercation. The CNA reportedly used profanity and was rough while wiping the resident's face, which the resident perceived as aggressive and an assault. The incident was witnessed by a Licensed Practical Nurse (LPN) who heard cursing from both the resident and the CNA. The LPN observed the CNA tossing a towel onto the resident's head and leaving the room, stating an inability to work with the resident due to perceived rudeness. The resident reported feeling that the CNA was rough and aggressive during the face-wiping, and the CNA admitted to repeating the resident's profanity back to them. The CNA denied being rough or cursing directly at the resident, claiming to have only repeated what was said to them. The facility conducted an investigation, which included interviews with the involved parties and witnesses. The investigation concluded that while a negative interaction occurred, abuse could not be substantiated. The CNA was terminated for violation of policy and procedure. The resident continued to participate in their normal daily routine without any noted negative psychosocial impacts following the incident.
Deficiencies in Physician Orders and Neuro Check Documentation
Penalty
Summary
The facility failed to adhere to professional standards of quality by not obtaining a physician order for a resident using a Bi-level positive airway pressure (bi-pap) machine. The resident, who had a history of obstructed sleep apnea, was observed using the bi-pap machine without a corresponding physician order documented in the facility's records. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged that a physician order should have been obtained for the bi-pap machine. Additionally, the facility did not complete the required neurological check documentation for a resident who experienced a fall. The resident, who had severe cognitive impairment and a history of high blood pressure, stroke, and seizure disorder, was found on the floor after rolling out of bed. Although neuro checks were initiated, the documentation was incomplete, with several entries left blank for critical assessments such as level of consciousness, movement, pupil response, and vital signs. Interviews with facility staff, including a Licensed Practical Nurse and the Director of Nursing, revealed that the facility's protocol for post-fall assessments was not fully followed. The staff acknowledged that neuro checks should be conducted and documented for 72 hours following an unwitnessed fall, but the neuro check sheets were not completed as expected. This lapse in documentation and adherence to protocol represents a failure to provide services based on acceptable standards of practice.
Failure to Administer Seizure Medication Timely
Penalty
Summary
The facility failed to keep a resident with a seizure disorder free from a significant medication error when it did not obtain Vimpat, a medication used to prevent seizures, from the pharmacy in a timely manner. This resulted in the medication not being administered for four and a half days. The resident, who was cognitively intact and diagnosed with a seizure disorder, had an order for Vimpat 200 mg to be given twice daily. However, the medication was not documented as administered for several doses over a period of four days. The facility's Unavailable Medication Policy requires immediate action when a medication is unavailable, including notifying the physician and obtaining alternative treatment orders. Despite this policy, there was no documentation showing that the physician was made aware of the missed doses or that any alternative treatment or monitoring orders were obtained. Interviews with staff, including the Director of Nursing (DON), Licensed Practical Nurses (LPNs), and Certified Medication Technicians (CMTs), revealed that while attempts were made to contact the pharmacy and the medical doctor (MD) for a new prescription, the medication was not obtained in a timely manner. The pharmacy confirmed that the facility contacted them about the need for the medication, but there were no refills on the script, and a new script was required. The pharmacy reached out to the MD's office, and the script was eventually obtained, but not before the resident missed multiple doses. The DON stated that she expected staff to reorder medications when they were low and to follow the facility's policy and procedures, but this did not occur in this instance.
Resident Left Exposed in Hallway After Shower
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when a resident was left exposed in the hallway after a shower. The incident involved a resident who was cognitively intact and required partial/moderate assistance for showers and substantial/maximal assistance for transfers. After completing a shower, the resident was left unclothed in a wheelchair in the hallway by a CNA, who refused to get a gown or blanket for the resident. The resident was exposed in the hallway with other residents present, causing significant distress to the resident. The incident occurred when the CNA assisting the resident with the shower did not bring a gown or blanket into the shower room. The resident, feeling unsteady and concerned about falling, requested the CNA to bring the wheelchair closer, but the CNA refused and instructed the resident to walk to the wheelchair in the hallway. The resident, sliding on the wet floor, had no choice but to walk into the hallway naked to sit in the wheelchair. The CNA then left the resident exposed in the hallway, calling the resident difficult and rude. Another CNA noticed the resident sitting naked in the hallway and quickly covered the resident with a gown before assisting the resident back to their room. The incident was reported to the facility's administration, and an investigation confirmed the resident's account. The CNA responsible for the incident was terminated for poor customer service and discourteous behavior.
Failure to Provide Necessary Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident #2, who had diagnoses including diabetes and morbid obesity, was observed with a left heel unstageable pressure ulcer. Despite the presence of blood on the resident's heel and fitted sheet, no treatment orders were in place, and the wound nurse confirmed that the resident should have had a protective boot to prevent the area from opening. The resident reported that staff noticed the blood the previous day but did not take appropriate action to cover the wound or obtain treatment orders. The wound nurse eventually applied a bandage but acknowledged that the staff should have addressed the issue immediately when it was first noticed. Resident #7, who had diagnoses including severe protein-calorie malnutrition and multiple pressure ulcers, was also observed receiving inadequate care. The resident had orders for specific wound treatments, including the use of Vashe for cleansing. However, during an observation, the wound nurse was unable to find the Vashe and instead used a different wound cleanser. The nurse applied the new dressing without the prescribed Vashe, which was available the previous Friday but had gone missing over the weekend. The Director of Nursing confirmed that physician orders should be followed, and treatments should be completed as ordered. The DON also stated that it is unacceptable to leave a wound uncovered overnight until the wound nurse arrives the next day. The facility's failure to follow physician orders and provide timely and appropriate wound care for residents with pressure ulcers resulted in deficiencies. The staff did not take immediate action to address open and draining wounds, and the necessary treatment supplies were not reordered as needed. These actions and inactions led to the observed deficiencies in the care provided to Residents #2 and #7.
Failure to Maintain Nutritional Status and Administer Supplements
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident diagnosed with severe protein-calorie malnutrition, categorized as severely underweight, and who had a wound. The staff did not accurately monitor the resident's weights, failed to timely document weights obtained, and did not accurately document nutritional supplement administration. This led to the registered dietician using inaccurate weights and information to determine the resident's nutritional status and needs. Additionally, the facility did not provide the physician and dietician-ordered nutritional supplements to the resident, resulting in a weight loss of 3.9% from March to April 2024 and the resident's continued severely underweight status. The resident's care plan indicated nutritional problems, including chronic wounds and underweight status, with a goal to prevent significant weight loss. However, the resident's weight log showed inconsistencies and missing entries, and the weights documented were found to be incorrect. The resident's meal tickets did not consistently include the prescribed nutritional supplements, and observations confirmed that the resident did not receive the ordered supplements during meals. Interviews with staff revealed confusion about the administration of supplements, with some staff unaware of the specific orders or the availability of the supplements. The dietary manager acknowledged that the facility had been out of the prescribed supplement for several months and substituted ice cream instead. The new registered dietician was not aware of the resident's needs and had not been following the resident's case. The Director of Nursing confirmed that physician orders should be followed and that supplements should not be documented as administered if they were not given. The Medical Director emphasized the importance of proper nutrition for the resident, given their compromised condition due to low BMI and wounds.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide pain management consistent with professional standards of practice for a resident who required such services. The resident, who had multiple diagnoses including diabetes, arthritis, and a history of stroke, was on a scheduled pain medication regimen. However, the facility did not administer the prescribed pain medications, including Acetaminophen and Oxycodone, in a timely manner. The resident's pain was frequently rated as high as 8 out of 10, and the lack of timely medication administration exacerbated their discomfort and pain levels. The facility's Medication Reordering policy and Physician's Orders policy were not followed. The policies required timely reordering and administration of medications, including the use of emergency drug kits if necessary. Despite these guidelines, the resident's Oxycodone was unavailable for several days, and staff failed to offer alternative pain relief such as Tylenol, which was available in the facility. The resident reported significant pain, and staff interviews revealed confusion and lack of clarity regarding the medication reordering process and the status of the Oxycodone prescription. Interviews with facility staff, including an LPN and the Regional Nurse, indicated that there were communication issues between the facility, the pharmacy, and the physician. The pharmacy was awaiting a signed script from the physician, which had not been received, leading to a delay in medication delivery. The facility administrator acknowledged that there were lapses in following physician's orders and expected protocols, including the use of the Pyxis machine for emergency medication and timely reordering of medications to prevent lapses in administration. The resident's pain management was compromised due to these failures, resulting in prolonged periods of unmanaged pain.
Failure to Provide Consistent Wound Care
Penalty
Summary
The facility failed to provide necessary care and services to promote the healing of a foot wound for a resident. The resident, who had multiple medical conditions including diabetes and neuropathy, had a wound on the left plantar foot that required specific wound care treatments as per physician's orders. However, the wound care was not consistently provided, as evidenced by the resident's report and observations that the last treatment was received during a podiatrist visit, and not by the facility staff as required. The resident's care plan and physician's orders detailed the necessary wound care, including cleansing with normal saline, applying a Silver foam non-adhesive dressing, and wrapping with Kerlix gauze every other day. Despite these orders, the resident reported that wound care was not being completed, and observations confirmed that the dressing on the resident's foot was dated several days prior, indicating a lapse in the prescribed treatment schedule. The resident also experienced significant pain, which was not adequately managed, further complicating the wound healing process. During an interview, the LPN confirmed the treatment orders and acknowledged that the resident had an active blister and continued to peel the skin off the foot, causing pain and further injury. The facility administrator stated that staff are expected to follow physician's orders and that any failure to document or administer treatments as ordered is considered falsification of records. This deficiency in wound care management could hinder the resident's healing process and increase the risk of infection, as the necessary treatments were not consistently administered as prescribed.
Failure to Serve Meals at Safe Temperatures
Penalty
Summary
The facility failed to ensure that residents received meals that were palatable and at safe temperatures. Specifically, Resident #1 and Resident #3 reported receiving cold food. Resident #1, who has diagnoses including anemia, high blood pressure, acid reflux, paraplegia, and depression, stated that breakfast was cold and that this was a common occurrence. Observations confirmed that the food temperatures for Resident #1's meal were below the required levels, with dressing at 122.7°F, turkey at 111.0°F, and peas at 111.0°F. Similarly, Resident #3, who has multiple diagnoses including anemia, atrial fibrillation, coronary artery disease, heart failure, acid reflux, renal failure, diabetes, arthritis, and stroke, also reported that lunch was cold and that this was a frequent issue. The facility's policy mandates that hot foods be held at 135°F or greater and that food temperatures be recorded to ensure compliance. However, the dietary temperature log for the day in question showed that the food was initially at the correct temperatures when prepared. The Administrator acknowledged that the facility does not have a heated cart for transporting trays and relies on nursing staff to pass trays timely. Despite this, the food served to the residents did not meet the required temperature standards, indicating a failure in maintaining food temperatures during the distribution process.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 992 citations issued within 25 miles in the last 12 months — including the 29 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 Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Christian Extended Care & Rehabilitation | 0.4 mi | ★★★★★ | 0 | 0 |
| Crestwood Health Care Center, Llc | 1 mi | ★★★★★ | 6 | 1 |
| Hidden Lake Health Care Center | 1.4 mi | ★★★★★ | 2 | 0 |
| Delmar Gardens North | 1.6 mi | ★★★★★ | 17 | 0 |
| Lakeview Post Acute | 1.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.