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 Bentleys Extended Care during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment, depression, and one-sided weakness was allegedly abused during a shower when a CNA covered and twisted the resident’s mouth while the resident was crying. The resident later reported the incident to the DON, and the facility documented bruising to the mouth area with photos and observation findings. The investigation was substantiated, while another CNA heard the resident crying but did not assist or notify the nurse.
Surveyors found that nurse aides were being charged for CNA training and competency evaluation through a written assistance agreement requiring repayment of $720 in non‑refundable tuition via payroll deductions, and through direct payment for certification programs. Personnel file review and staff interviews showed that aides were hired into NA roles and then offered or required to participate in CNA programs funded upfront by the facility but repaid by the aides over time, or paid directly by the aides themselves, while the Administrator confirmed this reimbursement practice and the absence of an in‑house clinical training program.
A resident with epilepsy and quadriplegia, who was cognitively intact but had poor short-term memory, missed multiple doses of three prescribed anti-seizure medications (lamotrigine, levetiracetam, and lacosamide) over two days due to staff failures in medication ordering, administration, and communication. Lacosamide, a controlled drug requiring manual reorder 72 hours before the last dose, was allowed to run out and was not available for scheduled doses, and staff did not clearly document or notify the physician about its unavailability. On a day when the resident left on a leave of absence, morning and evening doses of all three anti-seizure medications were not given, medications were not sent with the family, and staff did not verify the resident’s return for the evening med pass. The following day, additional lacosamide doses were missed, there was no timely physician notification of missed doses, and the resident subsequently experienced prolonged seizure activity requiring EMS transport and hospitalization, where neurology attributed the breakthrough seizure to medication noncompliance related to missed antiepileptic doses.
A resident who was normally independent with transfers and ambulation was found unable to stand or walk and complained of pain after being discovered on the toilet. CNA G notified an RN, but the RN did not assess the resident, obtain vitals, document findings, or notify the physician for several hours. The resident was later sent to the hospital and diagnosed with a distal radius fracture, and hospital records also identified an L2 compression fracture.
Three residents with cognitive impairment and a history of falls experienced multiple incidents without thorough investigation or consistent implementation of fall prevention interventions. Care plans were not updated to reflect current physician orders, such as the use of soft helmets or floor mats, and staff were often unaware of required interventions due to outdated communication systems. Documentation of falls and follow-up actions was incomplete, and there was no effective process to ensure that new or modified interventions were put in place after each fall.
A resident who was normally independent with transfers and ambulation was found unable to stand or walk and complained of leg pain, but the RN did not assess the resident, check vitals, contact the MD, or give PRN pain medication during the day shift. The resident was later found with swelling, bruising, and pain, was sent to the hospital, and was diagnosed with a wrist fracture and an L2 compression fracture.
A resident with multiple medical conditions experienced a broken front tooth and reported pain and difficulty eating, but did not receive timely dental care. After an unsuccessful dental appointment due to transfer issues, no alternative arrangements were made, and the resident later developed a dental abscess treated only with antibiotics. Staff interviews revealed a lack of follow-up and communication, resulting in the resident waiting over a year without appropriate dental intervention.
A resident with Alzheimer's disease and severe cognitive impairment was subjected to alleged physical abuse by a CNA, who was observed yelling and holding the resident against the wall. Despite the incident being reported to the DON, the CNA was not immediately suspended and continued to provide care for several hours. Staff interviews revealed confusion about abuse reporting procedures, lack of timely investigation, and insufficient training on abuse prevention policies.
Staff failed to follow required two-person protocols during Hoyer lift transfers, resulting in a resident being struck in the face and later falling from bed due to missing fall mats, both causing injuries. In addition, staff did not perform required neurological assessments after head injuries, and new aides conducted unsafe transfers without proper training, leading to repeated hazards for a dependent resident with dementia and a history of falls.
A resident with severe cognitive impairment was involved in an incident where a CNA was observed physically restraining the resident and yelling. An RN reported the event to the DON, but the DON did not notify the state agency within the required two-hour timeframe, citing a need for more information and lack of awareness of the policy. Other leadership staff were not informed until hours later, resulting in a failure to promptly report the abuse allegation as required.
The facility did not submit complete and accurate direct care staffing information to CMS for three consecutive fiscal quarters. The Assistant Administrator admitted responsibility for the oversight, acknowledging awareness of the requirement but failing to act. The facility had a census of 47.
The facility failed to maintain resident dignity by allowing staff to use cell phones during care, contrary to policy. Observations showed staff texting while feeding residents and not providing necessary assistance, such as replacing dropped utensils. Residents reported feeling uncomfortable due to staff phone use during care.
The facility failed to develop comprehensive care plans for several residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. One resident's care plan lacked interventions for weight loss and catheter use, another's did not reflect falls and cognitive decline, and a third's did not address dietary needs and preferences.
The facility failed to provide adequate supervision and assistance to prevent accidents, as observed with residents being propelled in wheelchairs without leg rests, leading to discomfort and potential injury. Staff did not consistently use gait belts during transfers, posing a risk of injury. Additionally, a resident with a history of falls was not properly repositioned in their wheelchair, despite being observed leaning and slouched.
The facility did not maintain the required RN coverage for at least eight consecutive hours a day, seven days a week, as per their staffing policy. Staffing sheets showed multiple days without RN coverage, and the ADON acknowledged the difficulty in securing RNs despite posting requests. The Assistant Administrator expected RN staffing to be covered as required.
The facility failed to maintain accurate records for controlled drugs, with numerous shifts lacking the required dual nurse initials on narcotic count sheets. This non-compliance was observed on multiple medication carts, potentially affecting all residents with controlled substance orders. Staff interviews confirmed the expectation for two staff members to sign off on narcotic counts every shift.
The facility failed to maintain proper storage conditions for medications in the medication room refrigerator, as there was no system or temperature log in place. Medications were stored alongside food items, contrary to facility policy. Staff, including a CMT and an LPN, were unaware of the requirements for temperature monitoring and separate storage of medications and food.
Staff at the facility failed to perform proper hand hygiene during meal service, affecting 15 residents. Observations showed that staff, including an LPN and NAs, did not wash hands or use sanitizer before or after assisting residents with meals, contrary to the facility's policy. Interviews confirmed that staff were expected to follow hand hygiene protocols, but observations indicated non-compliance.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds, as staff did not wear gowns during high-contact care activities. Additionally, infection control standards were not followed during wound care, with an LPN using ungloved hands and uncleaned equipment. The facility also neglected to conduct required TB testing for several residents, as per its policy.
The facility did not offer or administer the pneumococcal vaccine to four residents, despite having a policy requiring assessment and vaccination within thirty days of admission. The ADON confirmed the expectation to offer the vaccine and document refusals, but records showed no documentation of screening or vaccination for residents with conditions like stroke, diabetes, and sepsis.
The facility failed to offer COVID-19 vaccines to four residents, despite having a policy requiring vaccination offers to all eligible individuals. The ADON, responsible for overseeing vaccination documentation, did not ensure that Residents #11, #38, #22, and #14 were screened or vaccinated, as their medical records lacked such documentation. This indicates a lapse in following the facility's vaccination policy.
The facility failed to ensure CNAs received the required 12 hours of annual education, with no training records available for sampled CNAs and CMTs. Interviews revealed a lack of formal tracking or documentation of in-service training, and the ADON admitted to not maintaining a system for tracking these trainings.
A facility failed to promptly notify a physician of a resident's abnormal lab results indicating a UTI, resulting in delayed antibiotic treatment. The resident and their representative were not informed about the UTI diagnosis or new medication orders. Interviews with staff revealed inadequate processes for handling lab results, especially on weekends, and a lack of documentation in the resident's EMR.
The facility failed to provide written notices of transfer/discharge to two residents transferred to the hospital for acute medical reasons, as required by their policy. Interviews with staff, including an LPN and the ADON, confirmed that while other paperwork is sent with residents, the practice of sending transfer/discharge notices had lapsed. The ADON and Assistant Administrator acknowledged the lack of documentation for these notices.
The facility failed to provide written bed hold policy notices to two residents transferred to the hospital, as required by its policy. Interviews with staff revealed that the practice of sending these notices had lapsed, despite expectations from the ADON and Assistant Administrator that they should be provided.
A resident in an LTC facility experienced significant unplanned weight loss and had unhealed pressure ulcers that were not accurately documented in their MDS assessment. The ADON misinterpreted the weight loss question and failed to record the pressure ulcers, focusing instead on the resident's bullous pemphigoid wounds. This resulted in an inaccurate assessment of the resident's health status.
The facility failed to maintain comprehensive care plans for four residents, despite changes in their care needs. Diagnosed with various conditions, these residents did not have updated care plans in the EMR, contrary to facility policy. Staff interviews revealed reliance on verbal instructions due to missing care plans, with the ADON citing an error in care plan creation.
The facility failed to ensure that all CPR-certified staff received training with hands-on practice and in-person skills assessment. Three staff members, including an RN and the ADON, obtained their CPR certification through an online provider, which does not meet regulatory requirements. The facility's policy lacked guidance on this issue, and staffing records showed these staff were often the only CPR-certified personnel scheduled. Interviews revealed a lack of awareness about the specific requirements for CPR certification.
A facility failed to provide proper care by not assessing the appropriate wheelchair size for a resident, resulting in skin irritation and indentations. The resident, with multiple health conditions, was left in the wheelchair for six hours without repositioning, despite complaints of pain. Additionally, another resident's dressing was not dated, leading to uncertainty about when it was applied. These actions reflect a failure to meet acceptable standards of practice in resident care.
Two residents in the facility experienced inadequate foot care, resulting in long nails and dry skin. One resident, with diabetes, had not seen a podiatrist in eight months, while another resident with severe cognitive impairment had refused podiatry care. Staff interviews revealed inconsistencies in documenting and addressing foot care needs, with both CNAs and LPNs responsible for this aspect of care.
The facility failed to follow physician orders for continuous oxygen usage for a resident with respiratory issues, as the resident was observed not wearing the nasal cannula despite the order. Additionally, the facility did not ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control, as observed with another resident receiving nebulizer treatments. Staff interviews confirmed expectations for monitoring and storage were not met.
The facility did not ensure that NAs employed for over four months were certified, affecting five NAs. Despite being enrolled in a 16-hour online course, delays in testing and lack of oversight by the ADON contributed to the issue. Some NAs faced challenges in finding testing sites, prolonging the certification process.
A resident was prescribed Haldol without proper documentation to support its clinical need, leading to an increase in falls and continued behavioral issues. The facility failed to monitor for adverse effects or medication effectiveness, and did not document the resident's ongoing obsession with dying. Staff interviews revealed a lack of behavior charting and follow-up with the psychiatrist, highlighting deficiencies in medication management and resident care.
The facility failed to maintain RN coverage for eight consecutive hours per day, seven days a week, and did not have a full-time Director of Nursing (DON). The ADON, an LPN, assumed DON responsibilities and consulted with a DON from a sister facility. Despite efforts to recruit, the facility did not meet regulatory requirements for RN coverage, as confirmed by staff interviews and record reviews.
Resident Sustained Facial Bruising After Alleged CNA Abuse During Shower
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when a CNA allegedly covered and twisted the resident’s mouth during a shower after the resident was crying. The resident had moderate cognitive impairment, depression, a history of stroke with hemiplegia/hemiparesis, and required assistance with bathing. The resident’s care plan included supervision, cueing, and interventions for mood and behavior concerns, including crying, yelling, and verbalizations of hopelessness. According to the investigation, the incident occurred in the shower room while the resident was being bathed by CNA C. The resident later reported to the DON that the CNA put a hand over the resident’s mouth because the resident was crying. The facility documented a bruise to the right side of the mouth, and photographs showed a purple bruise about one inch long. During observation, bruising was still present on the right side of the mouth and chin, and bruising was also noted around the left eye socket, which the resident said was from a prior fall. The facility’s investigation concluded the allegation was substantiated. The resident stated that CNA C grabbed and twisted the resident’s mouth, and the resident’s account was consistent across interviews. CNA C denied squeezing, pinching, or twisting the mouth and said the resident cried during showers and repeated that he/she wanted to die. CNA B reported hearing the resident crying in the shower room but did not assist with the shower or notify the nurse. The DON and Administrator both stated it was never appropriate to cover a resident’s mouth and confirmed that abuse occurred.
Nurse aides charged for CNA training and competency evaluation
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure that nurse aides were not charged for a competency evaluation program, as required. Review of the facility’s CNA Training Program Assistance Agreement, dated 2025, showed that the agreement required the student to pay CNA training program fees set at $720.00, payable in installments per pay period, with fees described as non‑refundable and no course completion granted until the cost to the facility was reimbursed. The agreement also stated that if the student did not complete the course, no refund would be issued. Review of the active employee list and personnel files showed three nurse aides employed by the facility, including one aide enrolled in a certification program outside the facility and another aide with a signed CNA Training Program Assistance Agreement. In interviews, one NA reported working in laundry for about a year before moving into an NA position and stated the facility offered to pay the CNA program cost upfront with a repayment plan deducted from his or her paycheck, although this aide was not yet enrolled and had not received funds. Another CNA reported being hired as an NA in 2024 and stated the facility required him or her to pay for the CNA certification program, and that he or she is now certified. The Administrator confirmed that the facility did not have its own clinical program for NAs in training and that the facility’s practice was to pay the certification program cost upfront and then have NAs sign an agreement to reimburse the facility over a 12‑week period. These interviews and document reviews demonstrated that NAs were being charged, directly or through repayment agreements, for CNA training and competency evaluation programs.
Missed Anti-Seizure Medications Lead to Breakthrough Seizure and Hospitalization
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with a seizure disorder was free from significant medication errors when multiple doses of prescribed anti-seizure medications were missed. Facility policies required medications to be ordered from the pharmacy on a timely basis, with refills requested 72 hours prior to the last dose, and required that all physician orders be followed as prescribed, with reasons for any deviations documented in the medical record. The resident had a care plan identifying a seizure disorder related to spinal cord injury and epilepsy, with interventions including administering medications as ordered and monitoring for effectiveness and side effects. Despite these policies and care plan interventions, the resident’s anti-seizure medication lacosamide, a controlled drug, was not reordered in time, resulting in the medication running out. Record review showed that the resident had physician orders for lamotrigine, levetiracetam, and lacosamide, all scheduled twice daily at 8:00 A.M. and 8:00 P.M. The controlled drug receipt for lacosamide showed that on 4/4/26 one tablet was given and zero tablets remained, and the MAR documented that on 4/6/26 both the 8:00 A.M. and 8:00 P.M. doses of lacosamide were missed, with a reference to progress notes. Progress notes on 4/6/26 documented that a medication was on order and later noted as not available, but did not specify which medication. There was no documentation that the physician was notified of the missed anti-seizure medications on 4/5/26 or 4/6/26 prior to the resident’s seizure activity. Interviews indicated that staff believed lacosamide would be automatically reordered, even though it was a controlled medication requiring a manual reorder 72 hours before the last dose. Additional missed doses occurred when the resident left the facility on a leave of absence. The Leave of Absence sheet showed the resident was signed out by family in the morning with an anticipated return in the late afternoon. The MAR documented that on that day, the 8:00 A.M. and 8:00 P.M. doses of lamotrigine, levetiracetam, and lacosamide were missed due to the resident being absent from the facility without medication. The family was not provided with the resident’s medications to administer while out, and the family member later reported only learning from the hospital that doses had been missed. A CMT stated they were not aware the resident had left until attempting the 8:00 A.M. med pass, did not check the Leave of Absence sheet, and did not recall looking for the resident for the 8:00 P.M. med pass, assuming the resident was still gone. An LPN working that evening reported the resident returned around dinner time and that they were not informed the resident had missed seizure medications earlier in the day, and could not explain why the evening doses were not administered when the resident was back in the facility. On the following day, the resident experienced seizure activity characterized by twitching, drooling, unresponsiveness to verbal stimuli, and convulsions lasting several minutes, followed by a second episode. EMS was called, and the resident was transported to the hospital. The hospital discharge summary documented that the resident, who had a history of seizure disorder and other neurologic conditions, was admitted for a breakthrough seizure and that EMS reported the resident had not received antiepileptic medications for two to three days due to supply issues at the facility. Neurology concluded the breakthrough seizure was likely due to medication noncompliance. The resident’s physician later documented that the resident had uncontrolled seizure secondary to missed doses of medication, specifically noting missed lamotrigine, and stated that they had not been informed by the facility of the missed doses of lamotrigine, levetiracetam, and lacosamide prior to the hospitalization. The DON acknowledged that lacosamide had not been reordered in a timely manner and that the resident left the facility without receiving any of the day’s medications, with no explanation for why evening doses were not given after the resident’s return. The facility’s own policies required that if a medication was ordered but not present, staff should call the pharmacy or supervisor to obtain the medication, and that all physician orders be followed with reasons for any deviations documented in the medical record. Interviews with nursing staff and the DON confirmed that CMTs were responsible for notifying nurses when medications were unavailable, and nurses were expected to contact the pharmacy, notify the DON and/or physician, and obtain further instructions if medications could not be delivered. In this case, there was no documentation that the physician was notified of the missed anti-seizure medications before the resident’s seizure, and staff interviews revealed gaps in communication about the resident’s leave of absence, the lack of medication supply, and the missed doses. These actions and inactions resulted in the resident missing multiple doses of critical anti-seizure medications over two days, culminating in a breakthrough seizure and hospitalization, with neurology attributing the seizure to medication noncompliance and the physician documenting uncontrolled seizure secondary to missed doses.
Failure to Assess and Notify Physician After Resident Change in Condition
Penalty
Summary
The facility failed to ensure RN B assessed a resident and notified the physician after CNA G reported a change in condition. The resident, who had severe cognitive impairment, Alzheimer’s disease, and non-Alzheimer’s dementia, was normally independent with transfers and ambulation and was described by staff as walking throughout the facility. On 1/31/26, CNA G found the resident in the restroom on the toilet unable to stand or walk and complaining of pain. CNA G and another aide assisted the resident into a wheelchair and brought the resident to the nurse’s station, where CNA G told RN B that something was wrong because the resident could not stand or walk and was complaining of leg pain. RN B did not document any assessment, vital signs, pain assessment, range of motion, or other observations during the day shift after being informed of the resident’s change in condition. Staff interviews indicated the resident remained in a wheelchair at the nurse’s station for hours, and the evening nurse later observed swelling to the left wrist, inability to bear weight, bruising, and pain. The evening nurse documented that the day shift nurse had been informed earlier that morning that the resident had been found unable to walk or stand, and that the change in health had occurred during the prior day shift. The resident was sent to the hospital later that afternoon and was diagnosed with a nondisplaced distal radius fracture. Hospital records also showed the resident returned with increased difficulty bearing weight and was later found to have an acute L2 compression fracture. Facility interviews and records showed the resident’s baseline was independent ambulation and transfers, and staff stated that if the resident could no longer stand or walk, that would have been a change in condition requiring assessment and physician notification. The report also noted that no pain medication administration was documented on 1/31/26 despite the resident’s complaints of pain.
Failure to Investigate Falls and Update Care Plans for Fall Prevention
Penalty
Summary
The facility failed to thoroughly investigate and evaluate each resident fall to determine the cause and did not implement new or modify existing interventions to prevent future falls or reduce the risk of injury. Additionally, the care plans for residents with a history of falls were not updated to reflect current fall interventions, and there was no effective system in place to communicate these interventions to staff. These deficiencies were identified in three residents with a history of falls, all of whom experienced multiple incidents without adequate follow-up or documentation of interventions. One resident with severe cognitive impairment and a history of dementia experienced several falls, some resulting in injuries such as lacerations and hematomas. Despite physician orders for interventions like a soft helmet and floor mats, these were not consistently documented in the care plan or implemented by staff. Observations revealed that required safety equipment was sometimes missing or not used as ordered, and staff were unaware of current interventions due to outdated or missing communication tools. Interviews with CNAs indicated confusion about when and how to use fall prevention measures, and the Director of Nursing confirmed that interventions were not always added to care plans or communicated effectively. Another resident with moderately impaired cognition and a diagnosis of cancer experienced multiple falls, including incidents where the resident fell from bed or a wheelchair, sometimes sustaining injuries. Documentation of these events was inconsistent, and interventions such as fall mats were not always present or documented in the care plan. A third resident with severe cognitive impairment and mobility limitations also experienced a fall, but there was insufficient documentation regarding the circumstances of the fall or the use of safety equipment like side rails. The facility lacked a consistent process for post-fall investigation and failed to ensure that all staff were informed of and implemented appropriate fall prevention interventions.
Failure to Assess and Treat Pain After Change in Condition
Penalty
Summary
The facility failed to provide safe, appropriate pain management for a resident who experienced a change in condition. On 1/31/26, CNA G found the resident in the restroom on the toilet and unable to stand or walk as usual. The resident said his/her leg was sore and later reported pain when trying to stand. CNA G informed RN B that something was wrong with the resident, but RN B did not assess the resident, obtain vital signs, contact the physician, or administer pain medication during the day shift. The resident had a history of Alzheimer's disease and dementia and was documented as normally independent with transfers and ambulation, despite severe cognitive impairment. The resident's care plan identified independent locomotion on the unit and extensive assist only for toilet use. Facility records showed no observations or assessments, including pain and vital signs, documented by RN B during the 7:00 A.M. to 3:00 P.M. shift. The resident had a PRN order for acetaminophen, but there was no documentation that it was given on 1/31/26. Later that afternoon, the evening shift nurse observed swelling to the left wrist, inability to bear weight, bruising to the right arm and side, and pain to the back and right hip. The resident stated, "I fell right here," and was sent to the hospital. Hospital records showed a probable nondisplaced distal radius fracture on 1/31/26 and, after a return visit, an acute L2 compression fracture. Interviews with CNA G, CNA E, LPN H, LPN C, LPN R, the DON, and the Medical Director confirmed that the resident's inability to stand or walk and complaints of pain represented a change in condition that should have been assessed and reported earlier.
Failure to Provide Timely Dental Care Following Tooth Injury
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who experienced a chipped front tooth while at the facility. The resident, who was cognitively intact but dependent for transfers, dressing, and wheelchair locomotion, had multiple diagnoses including diabetes, hemiplegia, stroke, seizures, and malnutrition. The resident's oral/dental status was left blank on the Minimum Data Set, and there was no documentation regarding oral care in the care plan. After the tooth broke, the resident reported pain and difficulty eating, and repeatedly communicated these issues to staff, but did not receive timely dental care. The resident's dental needs were not addressed promptly. Although a dental appointment was scheduled, the resident was unable to be seen due to an inability to transfer to the dental chair. No alternative arrangements were made, and the resident continued to experience pain and embarrassment about the appearance of the tooth. Staff interviews revealed a lack of follow-up and communication regarding the resident's ongoing dental issues, with the social worker and nursing staff each assuming the other was responsible for arranging care. The resident and family made several requests for dental care, but these were not acted upon in a timely manner. The resident eventually developed a dental abscess, for which a physician prescribed antibiotics. However, there was no evidence of further dental intervention or resolution of the underlying dental problem. Staff were unaware of the resident's ongoing pain and the need for dental care, and there was no documentation of follow-up or reassessment after the initial failed dental appointment. The lack of coordination and follow-through resulted in the resident waiting over a year without appropriate dental care.
Failure to Protect Resident from Abuse and Delay in Investigation
Penalty
Summary
The facility failed to protect a resident from abuse when an allegation of physical abuse was made against a CNA. A registered nurse heard yelling, banging, and a loud slap coming from a resident's room, followed by the CNA holding the resident against the wall. The nurse reported the incident to the DON, who instructed the nurse not to send the CNA home due to staffing shortages. The CNA continued to provide care to other residents for over five hours after the allegation was reported, and no immediate investigation was initiated. The resident involved had Alzheimer's disease, severe cognitive impairment, and required substantial assistance with activities of daily living. The care plan indicated the resident could be resistive to care and potentially physically aggressive, but interventions were in place to de-escalate situations and avoid physical confrontation. Despite these interventions, staff interviews revealed that some staff believed it was necessary to use a loud voice or physical restraint, and the CNA admitted to raising their voice and physically holding the resident against the wall during care. Interviews with facility staff, including the DON, ADON, and other personnel, revealed a lack of timely notification, investigation, and adherence to abuse prevention policies. The DON did not immediately suspend the accused CNA or begin an investigation, and several staff members were unclear about their responsibilities in reporting and responding to abuse allegations. Additionally, some non-nursing staff had not received recent training on abuse policies and were uncertain about their role in reporting suspected abuse.
Failure to Ensure Safe Mechanical Lift Transfers and Accident Prevention
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision to prevent accidents, specifically during mechanical lift (Hoyer) transfers. In one incident, a Certified Nurse Aide (CNA) performed a Hoyer lift transfer for a resident without the required assistance of a second staff member. During this transfer, the lift struck the resident in the face, resulting in a laceration, bruising, and swelling. The CNA did not report the incident to the nurse on the evening shift, and neurological assessments were not performed for 72 hours following the injury, contrary to facility policy. The resident involved had a history of repeated falls, muscle weakness, dementia, and was dependent for transfers, with physician orders for fall mats and a low bed, but these interventions were not consistently implemented or documented in the care plan. In a separate event, a Certified Medication Technician (CMT) also performed a Hoyer lift transfer for the same resident without a second person and failed to ensure that physician-ordered fall mats were in place at the bedside. After the transfer, the resident fell from bed, sustained a head injury, and required stitches. The CMT admitted to not following the two-person transfer protocol and not placing the fall mats before leaving the room. The care plan did not include the use of fall mats and a low bed as interventions, despite physician orders and the resident's high fall risk status. Additionally, direct observation revealed that staff did not consistently use proper Hoyer lift techniques during transfers. Two nurse aides, both new to the facility, attempted a two-person Hoyer transfer without adequate training, resulting in the lift tilting multiple times and the resident being bumped and dropped rapidly onto the bed. The aides reported not receiving hands-on training at the facility and relied on previous experience or observation. These failures in supervision, adherence to policy, and staff training led to multiple incidents where the resident was exposed to significant accident hazards.
Failure to Timely Report Alleged Abuse to State Agency
Penalty
Summary
The facility failed to report an allegation of abuse involving a resident to the State Survey Agency within the required timeframe. According to the facility's policy, all alleged violations involving abuse must be reported immediately, but not later than two hours if the alleged violation involves abuse or has resulted in serious bodily injury. On the day of the incident, a registered nurse (RN) heard yelling, threatening language, and a loud slap coming from a resident's room. Upon entering, the RN observed a certified nurse aide (CNA) physically holding the resident against the wall. The resident, who had severe cognitive impairment, was unable to provide clear information about the incident. The RN reported the observation to the Director of Nurses (DON) shortly after the event. Despite being informed of the situation, the DON did not report the allegation to the Department of Health and Senior Services (DHSS) within the required two-hour window, stating that more details were needed before making a report and expressing a lack of awareness of the reporting requirement. Other facility leaders, including the Assistant Director of Nurses (ADON) and Assistant Administrator, were not made aware of the allegation until several hours later. The facility's failure to promptly report the abuse allegation as required by policy and regulation constituted the deficiency.
Failure to Submit Staffing Data to CMS
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for three consecutive fiscal quarters preceding the annual survey. The specific quarters in question were fiscal year quarter 1, 2024 (October 1 to December 31), fiscal year quarter 2, 2024 (January 1 to March 31), and fiscal year quarter 3, 2024 (April 1 through June 30). During an interview, the Assistant Administrator acknowledged that it was his responsibility to submit the Payroll Based Journal (PBJ) report to CMS and admitted that he was aware of the requirement but had not fulfilled it. The facility had a census of 47 at the time of the survey.
Failure to Maintain Resident Dignity Due to Staff Cell Phone Use
Penalty
Summary
The facility failed to uphold the dignity of its residents by allowing staff to use cell phones during care, which was against the facility's policy. Multiple observations were made where staff members, particularly Nurse Aide (NA) E, were seen using their phones while attending to residents. For instance, NA E was observed texting while feeding a resident with severe cognitive impairment, not paying attention to the resident's needs. Another resident with moderate cognitive impairment felt uncomfortable when NA E entered their room and used their phone without interacting with them. Additionally, a cognitively intact resident reported feeling uneasy when NA E was on a phone call during their care. The facility also failed to ensure that staff were appropriately seated while feeding residents, which is essential for maintaining dignity and respect. Observations showed that NA C stood over residents with severe cognitive impairments while feeding them, rather than sitting at their level. This practice was noted during multiple instances, indicating a lack of adherence to the facility's dignity policy. Furthermore, the facility did not ensure that residents received necessary assistance during meals. A resident with severe cognitive impairment and dystonia was observed struggling to eat with their hands after dropping their spoon, without receiving help from staff to replace the utensil. This lack of assistance persisted throughout the meal, highlighting a failure to provide dignified care. Interviews with staff and residents confirmed that cell phone usage during care was a common issue, despite the facility's policy prohibiting it.
Deficiencies in Comprehensive Care Planning
Penalty
Summary
The facility failed to develop comprehensive care plans with resident-specific interventions for five residents, leading to deficiencies in addressing their medical, physical, and psychosocial needs. For one resident, the care plan did not include specific interventions for significant weight loss, use of an indwelling catheter, and active wounds, despite the resident having multiple medical conditions such as stroke, diabetes, and pressure ulcers. Observations and interviews revealed that the resident had a catheter, was on a pureed diet, and had unplanned weight loss, yet these were not reflected in the care plan. Another resident with severe cognitive impairment and a history of falls, including a hip fracture, had a care plan that was not updated to reflect these incidents or the resident's current use of a wheelchair. The resident also exhibited ongoing thoughts about death and dying, which were not addressed in the care plan. Staff interviews indicated that the resident's condition had declined, and the resident frequently expressed anxiety and confusion about dying, yet the care plan lacked specific interventions to manage these behaviors. A third resident, who was underweight and had significant weight loss, had a care plan that failed to address the resident's dietary needs and preferences, such as eating with hands and refusing assistance. Despite receiving dietary supplements and having a divided plate to aid in eating, these interventions were not documented in the care plan. Observations showed the resident eating with hands and dropping food, while staff interviews confirmed the resident's refusal of assistance and significant weight loss.
Inadequate Supervision and Transfer Protocols
Penalty
Summary
The facility failed to ensure adequate supervision and assistance to prevent accidents for several residents. Two residents were observed being propelled in wheelchairs without leg rests, causing their feet to drag on the floor. This occurred despite the residents' difficulty in keeping their legs elevated, leading to discomfort and potential injury. Staff members were aware of the issue but did not consistently use leg pedals or other appropriate measures to prevent the residents' feet from dragging. Additionally, the facility staff did not use gait belts during assisted transfers for three residents, which is a standard safety protocol. Observations showed staff lifting residents by their arms or clothing, which is inappropriate and poses a risk of injury. Interviews with staff and the Assistant Director of Nursing confirmed that gait belts should be used during transfers, yet this practice was not consistently followed. Furthermore, a resident with a history of falls was not appropriately repositioned in their wheelchair, despite being observed leaning and slouched in the chair on multiple occasions. Staff interviews revealed an expectation for frequent rounds and repositioning to ensure the resident's safety, but these measures were not adequately implemented. The lack of a written policy regarding transfer protocols further contributed to these deficiencies.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing policy, revised in April 2007, mandates adequate staffing to meet the care and service needs of the resident population, including the availability of licensed RN and nursing staff to provide and monitor resident care services. However, a review of staffing sheets from October 1 to October 21, 2024, revealed multiple days without RN coverage, specifically on October 1, 2, 3, 4, 6, 8, 10, 11, 13, 14, and 19. During interviews, the Assistant Director of Nursing acknowledged the requirement for RN coverage and cited difficulties in securing RNs to work, despite posting requests on the agency website. The Assistant Administrator also expressed an expectation for RN staffing to be covered as required.
Deficiency in Controlled Drug Reconciliation
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation on two out of three medication carts reviewed. This deficiency was identified during a review of the facility's Controlled Substances policy, which mandates compliance with laws and regulations related to the handling, storage, disposal, and documentation of controlled substances. The policy requires nursing staff to count controlled medications at the end of each shift, with both the nurse coming on duty and the nurse going off duty participating in the count. However, the review of Narcotic Count Sheets from 10/1 through 10/19/24 revealed significant non-compliance, with numerous shifts lacking the required dual nurse initials on the shift change count. Specifically, on the 400 and 500 medication carts, 22 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Similarly, on the 100, 300, and 600 medication carts, 23 out of 57 shifts had no nurse initial, and 28 shifts had only one nurse initial. Interviews with staff, including a Certified Medicine Technician and a Licensed Practical Nurse, confirmed that the expected practice was for two staff members to sign the narcotic book and complete the count every shift. The Assistant Director of Nursing also stated that she expected narcotics to be counted and documented by two different staff members every shift. This failure in documentation and procedure had the potential to affect all residents with controlled substance orders, with the facility census being 47.
Improper Storage of Medications and Lack of Temperature Monitoring
Penalty
Summary
The facility failed to ensure that drugs and biologicals stored in the medication room refrigerator were maintained at the proper temperature, as there was no system or temperature log in place. During an observation, it was noted that the refrigerator contained a thermometer hanging on the inside of the door, but there was no record of temperature monitoring. Certified Medication Technician (CMT) F and Licensed Practical Nurse (LPN) A both confirmed the absence of a temperature log and were unaware of who was responsible for checking the refrigerator's temperature. Additionally, the facility did not adhere to the policy of storing medications separately from food items. The medication room refrigerator contained not only medications such as insulin vials, tuberculin testing serum, and Ativan but also several cartons of nutritional supplements like Nepro, Boost, and Med Pass, as well as a clear plastic bowl of applesauce. The Assistant Administrator and the Assistant Director of Nursing (ADON) admitted that they were not aware of the requirement to store medications separately from food items and confirmed the lack of a system to monitor the refrigerator's temperature.
Failure to Perform Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was performed by staff during meal service, affecting 15 residents. Observations during breakfast and lunch revealed that staff members, including a Licensed Practical Nurse (LPN) and Nurse Aides (NAs), did not perform hand hygiene before or after assisting residents with meals, handling food, or touching residents and their belongings. This was contrary to the facility's hand hygiene policy, which mandates handwashing or the use of an alcohol-based hand rub before and after direct contact with residents and handling food. During breakfast, a Nurse Aide was observed assisting multiple residents with their meals and personal items without performing hand hygiene. The aide repositioned residents, handled their silverware, and assisted with feeding without washing hands or using hand sanitizer. Similar observations were made during lunch, where another Certified Nursing Assistant (CNA) and a Nurse Aide were seen assisting residents with their meals and personal items without adhering to hand hygiene protocols. Interviews with staff members, including a CNA, a Certified Medication Technician (CMT), and a Licensed Practical Nurse (LPN), confirmed that the expectation was for staff to perform hand hygiene before entering the dining room, after passing each plate, and after touching any items. The Assistant Director of Nursing (ADON) and the Administrator also stated that they expected all staff to follow the hand hygiene policy. Despite these expectations, the observations indicated a failure to comply with the facility's hand hygiene procedures, leading to the deficiency.
Infection Control and TB Testing Deficiencies
Penalty
Summary
The facility failed to implement proper infection prevention and control practices, particularly in the use of Enhanced Barrier Precautions (EBP) for residents with urinary catheters and wounds requiring treatment. Specifically, staff did not adhere to the Centers for Disease Control and Prevention (CDC) and Centers for Medicare and Medicaid Services (CMS) guidelines for EBP, which require gown and glove use during high-contact resident care activities. Observations revealed that staff did not wear gowns while providing care to residents with urinary catheters and wounds, and there was no EBP signage outside the residents' rooms. Interviews with staff, including CNAs, LPNs, and the Assistant Director of Nursing (ADON), indicated a lack of awareness and training regarding EBP. In addition to the failure to implement EBP, the facility did not follow acceptable infection control standards during wound care procedures. For instance, an LPN was observed using ungloved hands to handle unpackaged dressings and scissors that were not cleaned before use. The LPN also failed to label or date the wound dressing after application. These actions were contrary to the facility's wound care policy, which requires hand hygiene, the use of gloves, and the cleaning of equipment before use. Furthermore, the facility did not conduct tuberculosis (TB) testing for several residents as required by its TB policy. The policy mandates TB screening for all residents upon admission, with a two-step tuberculin skin test (TST) or a blood assay for Mycobacterium tuberculosis (BAMT). However, records showed that five residents had no documentation of TB screening or testing. The ADON acknowledged the oversight and stated that TB screening and testing should be completed for all residents upon admission and annually thereafter.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and administer the pneumococcal vaccine to four out of five sampled residents, despite having a policy in place that mandates offering the vaccine to eligible residents. The policy, revised in August 2016, requires that residents be assessed for vaccine eligibility upon or prior to admission and be offered the vaccine within thirty days unless contraindicated or previously vaccinated. However, the medical records for Residents #12, #11, #38, and #22 showed no documentation of screening or vaccination, despite their various medical conditions, including stroke, diabetes, heart failure, sepsis, and respiratory failure. The Assistant Director of Nursing (ADON), responsible for screening and checking vaccine status, confirmed that residents should be offered the vaccine if eligible and that refusals should be documented. Additionally, education about the vaccine's benefits and potential side effects should be provided to residents or their representatives, with documentation in the medical record. The lack of documentation and action regarding the pneumococcal vaccine for these residents indicates a failure to adhere to the facility's vaccination policy.
Failure to Offer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to four out of five residents sampled for immunizations, despite having a policy in place that mandates offering the vaccine to all eligible residents. The policy, revised in May 2023, requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already fully vaccinated. The Assistant Director of Nursing (ADON) is responsible for overseeing the education, documentation, and reporting of vaccination status. However, the medical records of Residents #11, #38, #22, and #14 showed no documentation of screening or vaccination, indicating a lapse in following the facility's policy. Resident #11, admitted with diagnoses including sepsis and acute respiratory failure, had no documentation of being screened or offered the vaccine. Similarly, Resident #38, with conditions such as adult failure to thrive and diabetes, and Resident #22, with sepsis and long-term antibiotic use, also lacked documentation of screening or vaccination. Resident #14, who had received initial doses of the COVID-19 vaccine in early 2021, had no further documentation of additional vaccinations or screenings. The ADON confirmed during an interview that it was expected for residents to be offered the vaccine and for refusals to be documented, highlighting a deficiency in the facility's adherence to its vaccination policy.
Deficiency in CNA Training Documentation
Penalty
Summary
The facility failed to ensure that Certified Nursing Assistants (CNAs) received the required minimum of 12 hours of ongoing education annually. This deficiency was identified for five out of five sampled CNAs, with a facility census of 47. The facility was unable to provide a policy related to the 12-hour training requirement for CNAs. Employee files for CNAs and Certified Medication Technicians (CMTs) showed no records of in-service training. Interviews revealed that the facility provides in-services, but there is no formal tracking or documentation system in place. The Assistant Director of Nursing (ADON) acknowledged that it is her responsibility to maintain a system for tracking in-service training but admitted to not doing so, and could not provide any documentation of completed in-services.
Failure to Notify Physician and Resident of Abnormal Lab Results
Penalty
Summary
The facility failed to promptly notify the physician of abnormal lab results for a resident diagnosed with a urinary tract infection (UTI). The resident's urinalysis and culture results, which indicated the presence of Citrobacter farmeri bacteria, were collected and reported to the facility but were not communicated to the physician until two days later. This delay in communication resulted in a delay in receiving new orders for antibiotic treatment. Additionally, the facility did not inform the resident or the resident's representative about the abnormal lab results and the new medication orders. The resident reported experiencing intense burning and was unaware of the UTI diagnosis until after starting the antibiotic treatment. The resident's power of attorney (POA) was also not informed about the UTI diagnosis or the new medication orders. Interviews with facility staff, including an LPN, the Assistant Director of Nurses (ADON), and the Assistant Administrator, revealed that there were expectations for timely lab collection and communication of results. However, the facility's process for handling lab results, especially those received on weekends, was inadequate, leading to a lack of timely notification to the physician and the resident. Documentation of communication with the physician, resident, and responsible party was also lacking in the resident's electronic medical record (EMR).
Failure to Provide Written Notices of Transfer/Discharge
Penalty
Summary
The facility failed to provide emergency written notices of transfer or discharge to two residents who were transferred to the hospital for acute medical reasons. The facility's policy, revised in December 2016, requires that residents and/or their representatives receive a 30-day written notice of an impending transfer or discharge, or as soon as practicable in cases of urgent medical needs. However, for Resident #31, there was no documentation of written notice for transfers to the hospital on two occasions, and for Resident #19, there was no documentation of written notice for a transfer to the hospital. Interviews with facility staff, including an LPN and the Assistant Director of Nurses (ADON), revealed that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of sending a notice of transfer/discharge had lapsed. The ADON confirmed the absence of documentation for the required notices for the residents in question. The Assistant Administrator also stated the expectation that residents and/or their representatives should receive a notice of transfer/discharge when a resident is transferred to the hospital.
Failure to Provide Bed Hold Policy Notices
Penalty
Summary
The facility failed to provide written information on its bed hold policy to residents and/or their representatives at the time of transfer to a hospital for two residents. The facility's policy, revised in March 2017, mandates that residents or their representatives be informed in writing about the bed-hold and return policy prior to any transfers or therapeutic leaves. However, for two residents who were transferred to the hospital for acute medical reasons, there was no documentation indicating that they or their representatives received the required written notice. Specifically, Resident #31 was transferred to the hospital on two occasions, and Resident #19 was transferred once, with no evidence of the bed hold policy being communicated in writing during these transfers. Interviews with facility staff revealed a lapse in the process of providing bed hold notices. An LPN mentioned that while paperwork such as the resident's face sheet and medication list is sent with the resident to the hospital, the practice of including a bed hold notice had ceased some time ago. The Assistant Director of Nurses confirmed the absence of documentation for the bed hold notices for the two residents in question and expressed an expectation that such notices should be provided. Similarly, the Assistant Administrator stated that residents and/or their representatives should receive a bed hold notice upon hospital transfer, indicating a discrepancy between expected procedures and actual practice.
Inaccurate Resident Assessment Leads to Oversight of Health Issues
Penalty
Summary
The facility failed to ensure an accurate assessment for a resident, resulting in the oversight of significant health issues. The resident experienced an unplanned significant weight loss of 18.48% over six months, dropping from 147.2 pounds to 120.0 pounds. Despite this, the resident's Minimum Data Set (MDS) inaccurately indicated that the weight loss was part of a physician-prescribed regimen. Additionally, the resident had a Stage II pressure ulcer on the left buttock and a Stage IV pressure ulcer on the sacrum, which were not documented in the MDS. Instead, the focus was incorrectly placed on the resident's bullous pemphigoid wounds, leading to the omission of these critical skin conditions. The Assistant Director of Nurses (ADON), responsible for completing the MDS assessments, admitted to misinterpreting the weight loss question and failing to accurately document the resident's pressure ulcers. The ADON's focus on the bullous pemphigoid areas contributed to the oversight of the pressure ulcers. The Assistant Administrator also expressed an expectation for accurate resident assessments, highlighting a lapse in the facility's assessment process for this resident.
Failure to Maintain Comprehensive Care Plans
Penalty
Summary
The facility staff failed to review and revise the care plans for four residents, despite changes in their care needs. The facility's policy mandates that a comprehensive, person-centered care plan be developed within seven days of the comprehensive assessment and revised as the resident's condition changes. However, the review of the electronic medical records (EMR) for Residents #38, #46, #22, and #32 revealed that they did not have comprehensive care plans, which is a violation of the facility's policy. Resident #38, diagnosed with cerebral aneurysm, diabetes, high blood pressure, depression, and seizures, was admitted on a specified date, but the EMR review showed no comprehensive care plan. Similarly, Resident #46, with diagnoses including depression, dementia, and anxiety, also lacked a comprehensive care plan in the EMR. Resident #22, with moderately impaired cognition and diagnoses of type two diabetes mellitus and depression, and Resident #32, diagnosed with depression, dementia, weakness, high blood pressure, and anemia, were also found without comprehensive care plans in their EMRs. Interviews with facility staff, including LPNs and CNAs, revealed that while they have access to the EMR and are expected to view care plans, they often rely on verbal instructions from charge nurses due to the absence of care plans in the EMR. The Assistant Director of Nursing (ADON) acknowledged that the care plans were not in the EMR due to an error during their creation, and confirmed that care plans should be completed within the appropriate time frame as per the facility's policy.
Deficiency in CPR Certification Training
Penalty
Summary
The facility failed to ensure that all staff certified in cardiopulmonary resuscitation (CPR) received their certification through a provider whose training includes hands-on practice and in-person skills assessment. Out of 10 CPR-certified staff, three were found to have obtained their certification through an online provider, which does not meet the regulatory requirements for CPR training. This deficiency was identified during a review of the facility's CPR certification records and interviews with staff, including the Assistant Director of Nurses (ADON) and a Registered Nurse (RN). The facility's Advance Directives policy lacked guidance on ensuring CPR certification included hands-on practice and in-person skills assessment. The review of nurse staffing sheets revealed that on multiple occasions, the only CPR-certified staff scheduled were those with online certifications. Interviews with the ADON and Assistant Administrator confirmed that they expected CPR-certified staff to have received training that includes hands-on practice, but they were unaware of the specific regulatory requirements. The facility had 22 residents with full code status, indicating the importance of having properly certified staff available.
Inadequate Wheelchair Assessment and Undated Dressing
Penalty
Summary
The facility failed to provide services consistent with acceptable standards of practice for a resident when staff did not accurately assess the appropriate wheelchair size, leading to skin irritation and indentations on the resident's legs. The resident, who had a diagnosis of dementia, depression, high blood pressure, high cholesterol, peripheral vascular disease, and was overweight, was observed sitting in a wheelchair that was not their property. The resident complained of pain in their bottom, back, and legs, and was unable to reposition themselves. Staff failed to reposition the resident for six hours, despite the resident's repeated requests to be moved to bed. Observations revealed indentations and reddened areas on the back of the resident's calves and thighs, attributed to the wheelchair's foot pedal brackets applying pressure. Additionally, the facility failed to date a dressing for another resident, who had a diagnosis of diabetes, high blood pressure, high cholesterol, kidney disease, amputation, and dementia. The resident was observed with a dressing on their right lower leg that was not dated on multiple occasions. Staff were unable to identify when the dressing was applied, and it was later noted that the abrasion occurred on a specific date. The Assistant Director of Nursing expected the nursing staff to date the dressing when the treatment was performed. These deficiencies highlight the facility's failure to adhere to acceptable standards of practice in assessing and addressing residents' needs, particularly in ensuring appropriate equipment and documenting care procedures. The lack of proper assessment and documentation led to discomfort and potential harm to the residents involved.
Inadequate Foot Care for Residents
Penalty
Summary
The facility failed to provide adequate foot care for two residents, resulting in long nails and dry feet. Resident #44, who is cognitively intact and has diabetes, reported having dry, flaky skin and excessively long toenails, which caused discomfort and difficulty wearing shoes. Despite being at the facility for eight months, Resident #44 had not yet seen a podiatrist, and the issue was not documented in the resident's most recent skin evaluation. Resident #21, who has severe cognitive impairment and multiple diagnoses including dementia and COPD, also exhibited long, jagged toenails and dry, flaky skin. The resident's care plan included interventions for nail care, but the most recent shower sheets and skin evaluation did not document any concerns. Although the resident refused podiatry care at the last appointment, family members expressed concern about the condition of the resident's nails. Interviews with facility staff, including CNAs and LPNs, revealed that both groups are responsible for foot care, with nurses specifically tasked with trimming nails for diabetic residents. Documentation of foot care issues should occur on shower sheets or skin assessments, but this was not consistently done. The Assistant Director of Nursing acknowledged the oversight in ensuring residents' foot care needs were met and noted that Resident #44 was on the list to see the podiatrist but was not seen during the last visit.
Failure to Follow Oxygen Therapy Orders and Infection Control Protocols
Penalty
Summary
The facility failed to ensure physician orders were followed for a resident with an order for continuous oxygen usage. Resident #44, who was cognitively intact and diagnosed with anxiety, asthma, and acute respiratory failure, had a physician's order for continuous oxygen at 2 liters via nasal cannula. However, observations over several days showed the resident in bed with the oxygen concentrator on but not wearing the nasal cannula. Interviews with staff, including a CNA, LPN, and the ADON, revealed that the resident frequently removed the nasal cannula, and there was an expectation for frequent monitoring to ensure the resident wore it. The care plan did not address the resident's behavior of removing the nasal cannula. Additionally, the facility failed to ensure proper storage of oxygen masks and routine changing of oxygen tubing for infection control purposes. Resident #14, who had severe cognitive impairment and diagnoses including wheezing and dementia, had an order for nebulizer treatments. Observations showed the nebulizer mask uncovered on a side table, contrary to staff expectations that it should be stored in a plastic bag when not in use. Interviews with staff confirmed the expectation for proper storage of the nebulizer mask, but the care plan did not include the resident's nebulizer use.
Failure to Certify Nursing Assistants Within Required Timeframe
Penalty
Summary
The facility failed to ensure that Nursing Assistants (NAs) employed for more than four months were certified, affecting five NAs in total. The facility's assessment, reviewed in July 2023, indicated that staff training and education, including certification and licensure requirements, were necessary to provide the required level of care. However, a review of the hire dates for the NAs showed that none of them were certified within the required four-month period. Interviews with the NAs revealed that they were either waiting to test out or waiting for approval to retake the test, indicating a delay in the certification process. The Assistant Director of Nursing (ADON) stated that all NAs were enrolled in a 16-hour online course and were responsible for completing the program and the test. Some NAs had failed their tests and needed to retake the course. The ADON mentioned that she could not track the progress of the NAs' online training and was unaware of any requirement to sign off on their completion. Additionally, some NAs faced challenges in finding a testing site, leading to a prolonged period between finishing the course and taking the test.
Inadequate Documentation and Monitoring of Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, as evidenced by the prescription of Haldol without appropriate documentation to support its clinical need. The resident, who had a history of major depressive disorder and anxiety disorder, was prescribed Haldol despite the absence of documented behaviors or symptoms that would justify its use. The facility's policy on antipsychotic medication use requires thorough documentation and evaluation of a resident's behavior and symptoms before such medications are prescribed, which was not adhered to in this case. The resident experienced an increase in falls following the adjustment of psychotropic medications, including the addition of Haldol, yet there was no documentation of monitoring for adverse consequences or medication effectiveness. The resident's medical record showed multiple falls and hospitalizations for a fractured femur, but there was no evidence of follow-up visits with the psychiatrist after the medication changes. The facility's care plan for the resident did not include documentation related to the resident's expressed thoughts or anxiety about dying, which was a significant behavior noted by staff. Observations and interviews with staff revealed that the resident was frequently confused and obsessed with thoughts of dying, a behavior that had been ongoing since the resident's admission. Despite the prescription of Haldol, the resident continued to exhibit these behaviors, indicating a lack of effectiveness of the medication. The facility did not utilize behavior charting, which could have provided valuable insights into the resident's condition and the impact of the medication. The lack of documentation and monitoring highlights a deficiency in the facility's management of psychotropic medications and resident care.
Failure to Maintain RN Coverage and Designate a Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) for eight consecutive hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis. This deficiency had the potential to affect all residents, with a census of 50. The facility's list of Department Heads showed no DON employed, and daily assignment sheets indicated no RN coverage on several days. Interviews with staff, including a Certified Nursing Assistant (CNA), Licensed Practical Nurse (LPN), and the Assistant Director of Nursing (ADON), confirmed the absence of a DON for several months and inconsistent RN coverage. The ADON, who is an LPN, assumed the responsibilities of the DON and consulted with a DON from a sister facility as needed. The ADON acknowledged the requirement for RN coverage and the facility's ongoing search for a DON and full-time RNs. The Assistant Administrator also confirmed the lack of a DON and stated that the facility used staffing agencies to meet RN needs. Despite these efforts, the facility did not meet the regulatory requirement for RN coverage, as confirmed by multiple staff interviews and record reviews.
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Illustrative
What surveyors actually found near you
We read the 937 citations issued within 25 miles in the last 12 months — including the 24 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Overland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, Maryland Heights | 1.8 mi | ★★★★★ | 6 | 0 |
| St Johns Place | 2.1 mi | ★★★★★ | 14 | 0 |
| River Crossing Rehab And Healthcare Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Stonebridge Maryland Heights | 2.7 mi | ★★★★★ | 4 | 0 |
| Parkwood Skilled Nursing And Rehabilitation Center | 3 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.