Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bernard Care Center during CMS and state inspections, most recent first.
The facility discontinued services with a long-standing attending physician and reassigned all affected residents to another physician despite many residents and their representatives clearly expressing a desire to remain with the original provider. Social Services documented that residents and guardians were informed of their right to choose a physician and were told they could continue with the original physician through outside appointments with facility-assisted transportation, yet medical records were changed to list a different PCP, and no transportation was actually arranged. Several cognitively intact or partially impaired residents, and guardians for residents with severe cognitive impairment and complex conditions such as HTN, DM, stroke, CP, schizophrenia, and dementia, reported wanting to keep the original physician but felt compelled to accept the change due to statements that the physician would no longer be allowed in the facility and lack of practical means to access outside care. The DON later confirmed that residents were switched to a new PCP because of a corporate deadline and that no transportation had been set up for those wishing to remain with the original physician.
Multiple deficiencies were observed, including excessive noise from loud announcements and a slamming smoke room door, unsanitary conditions such as soiled briefs left on a bathroom floor and a clogged, dirty toilet that remained unaddressed for days, and widespread maintenance issues like dirt buildup, chipped paint, broken fixtures, and exposed wiring throughout the facility. Staff interviews confirmed that short staffing and lack of a set deep cleaning schedule contributed to the failure to maintain a clean and comfortable environment for residents.
Missing Code Status and Advance Directive Documentation: The facility failed to verify and maintain code status and signed advance directive forms for multiple residents on admission. Records for several residents showed full code orders but no signed advance directive documentation, and one resident had no code status order at all. Staff interviews showed confusion about where the code status form should be kept and whether it was included in the admission contract.
Incomplete and inaccurate care plans for residents with dementia, hospice, and falls. A resident with COPD and dementia had a care plan that did not address the dementia diagnosis. Another resident with DM, AKI, muscle weakness, severe cognitive impairment, and hospice status had no hospice care addressed in the care plan. A third resident with severe cognitive impairment, a history of falls, and multiple unwitnessed falls had a care plan that only addressed one fall with hip fracture and did not include the prior falls or the safety interventions in place, per the DON.
The facility failed to follow physician orders by not obtaining yearly EKGs for eight residents with diagnoses including schizophrenia, schizoaffective disorder, bipolar disorder, diabetes, lung disease, stroke, CKD, MS, and dementia. The facility also did not document or carry out a palliative care referral for a resident with multiple serious conditions, including HF, kidney failure, CVA, hemiplegia, seizure disorder, malnutrition, and depression, despite hospital documentation noting palliative care follow-up.
Failure to Provide Functional Restorative Nursing Services: The facility did not maintain a functional RNP or ensure residents with limited mobility received restorative assessments, orders, or ongoing exercises. Several residents with stroke-related weakness, contractures, wheelchair dependence, or other mobility impairments had blank or missing RNP care plans, no restorative orders, and no documented restorative services, while staff and rehab leadership acknowledged the program had not been functional for months.
Several residents with cognitive impairment and chronic conditions did not receive proper foot care, including podiatry services, as required by facility policy and physician orders. Observations showed long, thick toenails and extremely dry feet, while interviews revealed that residents had not been seen by a podiatrist and desired better foot care. Staff interviews confirmed inconsistent assessment, documentation, and referral practices, resulting in unmet foot care needs.
The facility did not maintain proper food temperatures or palatability during meal service, as observed with cold and unappetizing food items and confirmed by two residents with multiple medical and mental health diagnoses. Staff interviews revealed that elevator malfunctions led to delays in food delivery, resulting in meals being served below required temperatures and in an unpalatable state.
A resident with bilateral leg amputations was unable to access their electric wheelchair while it was being repaired in the basement due to a nonfunctional elevator. The resident, who requires total assistance and has no trunk control, was left in bed without a suitable alternative mobility device, leading to frustration and distress.
The facility did not maintain a functioning exhaust system in the indoor smoke room, resulting in cigarette smoke and odor spreading into hallways and dining areas. Multiple staff and residents reported strong smoke odors and visible smoke outside the smoke room, and ventilation fans were found to be either turned off or not working due to power issues.
Surveyors found that multiple hallways and areas lacked required handrails or had handrails that were loose, broken, or missing. Observations included missing handrails near dining rooms, nurses' stations, and restrooms, as well as handrails pulled away from the wall. Interviews with the Maintenance Director and Administrator confirmed awareness of the issue and ongoing replacement efforts, but also revealed gaps in knowledge regarding handrail placement requirements.
Resident trust funds were not accurately reconciled, with monthly bank statement balances not matching trust report balances and unresolved outstanding checks and corporate reimbursements affecting the account. The facility also allowed negative balances for three residents’ trust accounts, while the BOM, AD, and Administrator gave conflicting explanations about how resident petty cash and account balances were tracked.
Failure to complete annual MDS assessment timely for a resident. Record review showed multiple quarterly MDS assessments were completed, but no comprehensive assessment was completed after August 2025. The DON/administrator stated MDS should be completed timely and accurately, and staff should complete the correct type of MDS.
A resident's quarterly MDS was not completed within the required 92-day timeframe. Record review showed a quarterly MDS, a significant change MDS, and a late quarterly MDS with an ARD that was overdue. The administrator stated MDS should be completed timely and accurately, and staff should complete the correct type of MDS.
A resident receiving hospice services had an inaccurate MDS that marked life expectancy of 6 months or less as "No" even though the hospice physician certified the resident as terminally ill with a prognosis of 6 months or less. The MDS also documented diabetes, acute kidney failure, muscle weakness, dementia, and severe cognitive impairment, while the DON stated the MDS should accurately reflect the resident’s prognosis.
A resident with documented depression, psychotic disorder, schizophrenia, major depressive disorder, and disorganized schizophrenia did not have a DA-124 Level One Screen or PASARR Level Two Screen in the record. The SS Director said PASARRs are uploaded in the chart and believed the resident was grandfathered in, while DHSS/COMRU confirmed the last PASARR on file was from 11-1997 and that a new application would be needed. The Administrator stated the DA-124 should be completed upon admission or before.
Failure to Provide Needed ADL and Grooming Care: The facility did not ensure dependent residents received needed ADL care, including nail care and grooming. A resident with schizophrenia and diabetes had long, jagged fingernails with debris and said the nails needed cleaning and trimming; another resident with multiple chronic conditions had long nails with dirt and a curved thumb; a resident with COPD and dementia had a strong odor and a disheveled beard; and a severely cognitively impaired resident with diabetes and kidney failure was observed with long, stringy hair and an unkempt beard. Staff and the DON acknowledged that nail care, shaving, and care plan documentation were expected, but the residents’ care plans did not consistently reflect these needs.
A resident with a feeding tube, multiple chronic conditions, and recent hospitalization for HHS/DKA, septic shock, respiratory failure, pneumonia, and severe hypernatremia had tube feeding running at 55 ml/hr, but staff did not ensure physician orders were obtained for water flushes and did not document the date and time the formula was hung. Observations also showed changing water flush settings on the pump, and the DON stated staff were expected to follow physician orders and document the formula details on the bottle.
Failure to report and manage resident pain: A resident with multiple chronic conditions, including stroke, hemiplegia, PVD, and aphasia, cried out and verbalized pain during personal care and transfer, with facial grimacing and moaning noted throughout the interaction. Two CNAs continued care and transferred the resident with a Hoyer lift without notifying the nurse, and the resident did not receive documented PRN pain medication. Interviews with the ADON, LPN, CNA, resident, and DON confirmed staff expected pain complaints to be reported and assessed, but that did not occur.
AV Fistula Assessment Not Completed by Licensed Nurse: A resident receiving hemodialysis had an AV fistula that was supposed to be checked for bruit and thrill every shift, but the MAR showed a CMT documented the assessment as completed on day and night shifts. The CMT said he/she only checked for bleeding and was not sure what the assessment was, while an LPN and the DON stated only a nurse should complete and document the AV fistula assessment.
Unsecured Medication Room Allowed Access to Discontinued Medications: The facility failed to keep medications marked for destruction secured in the 300 hallway med room. The door was ajar and the keypad was broken, while an open bin on the counter held liquid risperidone and discontinued medication cards. Three CNAs entered the room without using the keypad and placed personal belongings inside, and staff reported the room is often left unmonitored and used to store an ice cooler and other items.
Failure to follow up on pharmacy recommendations for one resident with HTN and chronic AFib. Pharmacy reviews noted persistent elevated BP and recommended increasing losartan, and later considering a beta blocker, but the MAR showed the same losartan dose continued with no revised orders. The resident reported BP checks had stopped, and when an LPN obtained a manual BP it was 160/78. The DON said she and the ADON handled pharmacy recommendations and were awaiting a physician response.
Failure to Offer Pneumococcal Vaccinations: The facility failed to offer and vaccinate two residents who were eligible for the pneumococcal vaccine. One resident had diabetes, schizophrenia, anxiety, HTN, and kidney disease, and the other had impulsiveness, anxiety, schizophrenia, and HTN. Their records had no documentation of screening, receipt of the vaccine, or refusal, despite the facility policy requiring pneumococcal immunization to be offered upon admission unless medically contraindicated, already documented, or refused.
A resident with a suprapubic catheter experienced pain after an LPN flushed the catheter without a physician's order, contrary to facility policy. The resident's medical records lacked documentation of the procedure, and the incident led to an ER visit where trauma from the manipulation was suspected. Staff interviews confirmed the deviation from protocol.
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Withdrawals for personal spending were not properly authorized, and items purchased with these funds were not found in the residents' possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds.
The facility failed to follow general accounting principles by not addressing outstanding checks during monthly resident trust fund reconciliations. Multiple checks, some dating back to 2015, remained outstanding, indicating a lapse in following procedures. The Financial Coordinator was not trained to investigate these checks and lacked the authority to void them, leading to the deficiency.
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which residents found difficult to use. Additionally, a resident was given a visibly dirty wheelchair, and multiple resident rooms were observed to be unclean with sticky floors, dirty privacy curtains, and dusty air conditioning units. Staff interviews confirmed these deficiencies.
The facility failed to update care plans to reflect the needs of three residents who smoke and one resident who frequently refuses medications. Despite observations and staff interviews confirming these behaviors, the care plans did not include this critical information.
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for a resident, did not use functional equipment during mechanical lift transfers for two residents, and did not apply gait belts properly during transfers or assisted ambulation for three residents. Additionally, the facility did not ensure residents were routinely and accurately assessed for smoking safety.
The facility failed to ensure that residents using side rails were appropriately assessed for safety, as required by their policy. Four residents were observed with side rails without proper assessments or documentation in their care plans. Staff interviews revealed confusion about the responsibility and frequency of these assessments, indicating a systemic issue in policy adherence.
The facility failed to maintain accurate records for controlled substances, as manual end-of-shift narcotic counts were not consistently completed for two out of three medication carts. Staff interviews confirmed the requirement for daily counts, but records showed multiple instances of non-compliance.
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, a resident who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Another resident, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, and did not ensure the ice machine had an air gap. Observations revealed water pooling, trash, food debris, and grime in various areas, with dietary staff and management confirming cleaning responsibilities were not met.
The facility failed to obtain and document necessary medical orders for a resident with severe cognitive impairment and multiple medical conditions, leading to lapses in care for PICC line, nephrostomy tube, and suprapubic catheter. Additionally, a required yearly EKG was not completed due to a backlog with the service provider.
The facility failed to ensure residents requiring assistance with ADLs received necessary services to maintain personal hygiene. One resident was left soiled for an extended period, resulting in a rash, while three other residents were observed with poor personal hygiene, including unshaven faces and long, jagged nails. Staff interviews revealed inconsistencies in care practices and documentation.
The facility failed to identify and obtain treatment orders for newly acquired skin issues in two residents, despite multiple observations and interactions with staff. The residents' care plans and progress notes did not document the skin conditions, and staff interviews confirmed that the required protocols for reporting and treating new skin issues were not followed.
The facility failed to ensure proper catheter care for two residents, leading to potential contamination and UTIs. Catheter bags were observed above the bladder and tubing was frequently in contact with the floor, contrary to the facility's policy.
The facility failed to ensure proper dialysis care and communication for a resident with end-stage renal disease. The resident did not have appropriate physician orders for pre and post-dialysis assessments, and there was a lack of documentation and communication with the dialysis center. Interviews with staff revealed inconsistencies in the documentation process, and the Director of Nursing confirmed that a new communication form was not consistently used.
The facility failed to follow infection control standards during peri-care for a resident and catheter treatment for another. A CNA did not change gloves or perform hand hygiene after providing peri-care, and an LPN did not clean scissors before using them to cut a dressing for a catheter site. Staff interviews confirmed these practices were against facility policies.
The facility failed to ensure all call lights were in working order, affecting a resident with multiple diagnoses including MS and hemiplegia. Despite the resident's care plan indicating the need for a functioning call light, the issue remained unresolved for about three weeks. Staff interviews revealed a lack of proper reporting and communication regarding the non-functioning call light.
Failure to Honor Residents’ Choice of Attending Physician After Termination of Physician Privileges
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to choose their own attending physician after corporate leadership discontinued privileges for Physician A, who was caring for 35 residents. The facility’s Resident Rights policy states that residents have the right to choose a personal attending physician, be fully informed in advance about care and treatment and any changes that may affect their well-being, and participate in planning care and treatment. In early March, the DON and Administrator received an email from the corporate CNO stating that, effective at the end of the month, Physician A would no longer have privileges with the organization and instructing them to notify residents of the change and determine whether they wanted to stay with Physician A. Despite this, all of Physician A’s residents were changed to Physician B by the facility due to a corporate deadline, and no letter was issued to residents regarding the change. Multiple residents and their representatives expressed a clear preference to remain under the care of Physician A, but the facility did not coordinate continued access to that care. One cognitively intact resident with anxiety and depression was informed by Social Services that Physician A would no longer maintain privileges and that continued care would require outside appointments, with the facility assisting with transportation. The resident stated a desire to stay with Physician A, citing satisfaction and desire for continuity, yet the medical record listed Physician B as the PCP, and the resident later reported being told by the Activity Director that he had to change physicians because Physician A could no longer practice at the facility and the office was too far away. Another resident with moderate cognitive impairment, high blood pressure, anxiety disorder, and schizophrenia similarly expressed a preference to remain with Physician A, and Social Services documented that transportation assistance would be provided; however, the medical record also showed Physician B as the PCP, and the resident’s family member reported not being notified of the PCP change and wanting the resident to keep Physician A. Additional residents and guardians experienced the same pattern. A resident with no cognitive impairment, high blood pressure, and schizophrenia had a guardian who was notified that Physician A would lose privileges and who clearly stated a preference to keep Physician A, yet the resident’s record listed Physician B as PCP, and the guardian believed Physician A was still the PCP. Two other residents with severe cognitive impairment and diagnoses including stroke, cerebral palsy, high blood pressure, diabetes, and dementia were informed, along with their family, that Physician A would no longer have privileges and that continued care would require outside appointments with transportation assistance from the facility. Both residents expressed a preference to remain with Physician A, but their records listed Physician B as PCP. Their guardian reported being told that Physician A would no longer be allowed in the facility and, lacking a car to transport the residents, felt there was no real choice and agreed to the change. The DON later acknowledged that transportation had not been set up for residents who wanted to stay with Physician A and that, to her knowledge, Physician A did not have an office, while Physician A’s office manager stated that Physician A had not had an examination office for about 15 years and preferred to see residents onsite in the facility. These actions and omissions resulted in residents’ stated choices to remain with Physician A not being honored or facilitated.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations and interviews. Excessive noise levels were noted, including loud overhead announcements that interrupted resident conversations and a smoke room door that repeatedly slammed shut, disturbing residents in the vicinity. Despite previous attempts to fix the door, the issue persisted, and the noise was audible even in the administrator's office. No complaints were reported regarding the overhead speakers, but residents expressed discomfort with the noise disruptions. Sanitation and cleanliness issues were observed throughout the facility. In one instance, a resident's bathroom contained soiled briefs on the floor over multiple days, with staff indicating that residents were expected to request trash bags for disposal, and that housekeeping would not remove soiled briefs from bathrooms. Another resident's toilet was clogged and dirty with feces and toilet paper for at least two days, resulting in a strong odor permeating the room. The resident, who had diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, and was moderately cognitively impaired, reported being unable to use the toilet during this time. Widespread maintenance and cleanliness deficiencies were documented in various facility areas, including hallways, dining rooms, bathrooms, and common spaces. Observations included dirt buildup on floors and cove bases, chipped and missing paint, broken fixtures, exposed wiring, cracked tiles, and dirty or damaged windows. Staff interviews revealed that short staffing, particularly in housekeeping and floor technician roles, contributed to lapses in deep cleaning and maintenance. Housekeeping and laundry staff were often required to cover for each other, and there was no set schedule for deep cleaning. Staff acknowledged that the environment was not being maintained to expected standards, with visible dirt, dust, and damage throughout the facility.
Missing Code Status and Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that residents’ code status orders and signed advance directive documentation were verified upon admission and maintained in the medical record for 13 of 29 sampled residents. The cited residents included #2, #5, #7, #9, #12, #14, #15, #20, #35, #113, #115, #120, and #138. Review of the records showed that most of these residents had orders for full code, but the medical record contained no documentation of a signed advance directive or code status form; Resident #138 had no code status order and no documentation of a signed advance directive. The facility’s Communication of Code Status policy stated that resident code status should be documented in the medical record, that the nurse documenting the physician order was responsible for entering the directions in all relevant sections, and that code status should be reviewed at least quarterly. During interviews, the Social Worker stated code status should be reviewed and signed annually and that the medical record should contain a signed code status form. The Social Services Director said she believed the code status form was included in the admission contract and scanned into the record, but later learned it needed to be separated from the admission contract and could not locate the forms for the cited residents. The Administrator stated she expected all residents to have a code status form in the medical record and that code status was expected to be reviewed annually.
Incomplete and inaccurate care plans for residents with dementia, hospice, and falls
Penalty
Summary
The facility failed to ensure comprehensive care plans were updated and accurate to reflect resident needs for 3 of 29 sampled residents. Resident #5’s quarterly MDS showed diagnoses of COPD and dementia with moderately impaired cognition, but the care plan in use at the time of survey did not address the resident’s dementia diagnosis. During interview, the DON stated she expected the care plan to include dementia and to have goals and interventions so the resident could receive appropriate care related to the condition. Resident #6’s significant change MDS showed diagnoses of diabetes, acute kidney failure, muscle weakness, and dementia with severe cognitive impairment, and the POS showed an order admitting the resident to hospice care, but the care plan did not address hospice care. Resident #100’s quarterly MDS showed severe cognitive impairment, wheelchair use, history of falls, and diagnoses including uterine cancer, protein calorie malnutrition, Alzheimer’s disease, depression, unsteadiness on feet, and wandering. The resident had multiple falls, including an unwitnessed fall with head strike and another unwitnessed fall after readmission, and was moved closer to the nurse’s station with bed alarm and floor mat in place. The updated care plan addressed only the unwitnessed fall with left hip fracture and did not address the prior falls or the interventions in place. The DON stated the resident had multiple falls and often attempted to self-transfer, and that the care plan should have reflected the resident’s falls and interventions.
Failure to Follow Physician Orders for EKGs and Palliative Care Referral
Penalty
Summary
The facility failed to ensure physician orders were followed by not obtaining yearly EKGs for eight residents. The affected residents had diagnoses that included major depressive disorder, schizoaffective disorder, bipolar disorder, schizophrenia, diabetes, lung disease, stroke, chronic kidney disease, multiple sclerosis, dementia, and other chronic conditions. Each of the reviewed records contained a physician order for a yearly EKG, but the records showed no documentation that the EKGs were completed in 2025, or no documentation that an EKG was completed at all for some residents. The facility also failed to follow recommendations for a palliative care referral for one resident. That resident had multiple serious diagnoses, including heart failure, kidney failure, diabetes, hyperkalemia, cerebrovascular accident, hemiplegia, seizure disorder, malnutrition, depression, and other conditions, and had been hospitalized for HHS, DKA, septic shock, respiratory failure due to pneumonia, and severe hypernatremia. The hospital record documented a goals-of-care conversation with palliative care and noted an outpatient palliative care referral as an active issue requiring follow up, but the resident's progress notes after discharge contained no documentation of a palliative care referral and the physician order sheet did not include an order for palliative care evaluation or referral.
Failure to Provide Functional Restorative Nursing Services
Penalty
Summary
The facility failed to follow its restorative nursing program (RNP) policy and did not ensure residents with limited mobility received restorative nursing services to maintain or improve their highest practical level of functioning. The report states that the facility also did not have a functional restorative nursing program to ensure recommended restorative exercises were provided on a continual basis, and it did not have a system in place to ensure residents received assessments and referrals for restorative therapy. Resident #3 had a physician order for skilled therapy services and a restorative nursing care program entry for BLE PROM and gentle stretching three times a week, but the plan of care was blank and the update to the plan of care was blank. The resident had moderate cognitive impairment, used a wheelchair, required full staff assistance for multiple ADLs, and had diagnoses including GT, protein calorie malnutrition, respiratory failure, abnormal posture, bilateral knee contractures, muscle wasting, and altered mental status. The record showed the resident did not receive restorative services or skilled therapy in November or December 2025. The restorative nursing screen dated 12/2/25 showed no interventions were selected, and the PT and OT evaluations dated 12/3/25 indicated the resident was not appropriate for skilled therapy and had severe contractures and poor rehabilitation potential. Resident #16 had severe cognitive impairment, upper and lower extremity impairment on one side, used a wheelchair, and needed staff assistance with eating, personal hygiene, transfers, and dressing. PT discharge summaries showed the resident was discharged with RNP established and trained, including a restorative ambulation program, but the care plan in use did not address the RNP exercises. During observation and interview, the resident was seen in a wheelchair with a sling on the right arm and stated the sling was worn daily due to a stroke, that therapy had not been received for several months, and that staff did not provide additional stretching, exercises, or walking. The record contained no restorative nursing assessment, no orders for the sling, and no restorative nursing orders. Resident #75 was cognitively intact, used a wheelchair, needed assistance with dressing, hygiene, transfers, and mobility, and had diagnoses including stroke and right-sided paralysis. The care plan addressed assistance with daily care and therapy screening quarterly and PRN, but there were no POS orders for skilled therapy or RNP and no RNP assessments or therapy interventions in the record. During observation and interview, the resident had a weak right arm, no splints were in place, and stated therapy had stopped months earlier due to insurance coverage and that the resident wanted to participate in the RNP to maintain strength. Resident #83 had diabetes, schizoaffective disorder, MS, and moderately impaired cognition. The care plan noted limited physical mobility and inability to walk, but the POS had no restorative therapy orders and the EMR showed no skilled or restorative therapy and no RT assessments. Interviews with the Interim Regional Director of Rehabilitation Services and the DON confirmed the facility should have an RNP, that residents with contractures or weakness should be assessed, and that the RNP had not been functional for several months due to budget cuts and staffing shortages.
Failure to Provide Proper Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide appropriate foot care to five residents, as evidenced by observations, interviews, and record reviews. Residents with moderate cognitive impairment and various diagnoses, including diabetes, peripheral vascular disease, and schizophrenia, were found to have unaddressed foot care needs. Despite facility policies requiring assessment, routine care, and referral to a podiatrist for residents with complicating conditions, there was no documentation of podiatry visits or consults for these residents, even when physician orders allowed for podiatrist visits. Direct observations revealed that several residents had excessively long, thick, jagged, and curled toenails, as well as extremely dry feet with large flakes of skin. Some residents wore socks with holes or soiled socks, and in one case, a resident reported discomfort due to a long toenail rubbing against footwear. Interviews with residents confirmed that they had not received podiatry services or adequate foot care, and some expressed a desire for their feet to be moisturized or toenails to be trimmed by a professional. Staff interviews indicated that while there were expectations for nurses and aides to assess, moisturize, and refer residents for podiatry care, these actions were inconsistently carried out. Staff acknowledged that refusals of care should be documented, but there was no evidence of such documentation or follow-up in the medical records. The lack of documented podiatry visits, inadequate routine foot care, and failure to address residents' expressed needs and physician orders led to the deficiency.
Failure to Serve Palatable and Properly Heated Food
Penalty
Summary
The facility failed to ensure that food was served at a palatable and appetizing temperature during tray service, as required by their dietary food preparation policy. Observations revealed that hot foods, such as sausage patties and scrambled eggs, were served below the acceptable temperature threshold, with the sausage patty measuring 93°F and the eggs at 115.9°F, both of which felt cold. Additionally, lunch service included chicken strips that tasted rubbery, limp and damp bread, and mashed potatoes that were dry, bland, and powdery without gravy. These issues were directly observed during meal service on different halls. Interviews with two residents confirmed dissatisfaction with the food, citing that it was often cold and unpalatable. One resident, with diagnoses including major depressive disorder, schizoaffective disorder, and epilepsy, reported that the food was not always warm and tasted bad. Another resident, with bipolar disorder, major depressive disorder, type two diabetes, and schizoaffective disorder, stated that the food was frequently cold and could be better. The Food Service Manager attributed the temperature issues to frequent elevator breakdowns, which forced staff to carry food up the stairs, causing delays in meal delivery.
Failure to Maintain Elevator Results in Resident's Loss of Wheelchair Access
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable condition by not ensuring the consistent operation of the elevator. This deficiency was observed when the elevator became nonfunctional, preventing access between floors. As a result, a resident who is a bilateral knee amputee and relies on an electric wheelchair for mobility was unable to access their wheelchair while it was being repaired in the basement. The repair could not be performed in the resident's room or hallway, and the elevator outage meant the wheelchair remained inaccessible to the resident. The resident, who has a history of high blood pressure, chronic atrial fibrillation, and bilateral leg amputations, was left in bed without access to an appropriate alternative mobility device. The resident expressed frustration and distress about being confined to bed, especially given a previous prolonged period of immobility due to a wound. Staff interviews confirmed that the resident was offered a geri-chair, but it was not suitable due to the resident's lack of trunk control and the absence of a proper reclining or seatbelt-equipped chair to ensure safe positioning.
Failure to Maintain Proper Ventilation in Smoke Room
Penalty
Summary
The facility failed to maintain an appropriate exhaust system to remove cigarette smoke from the indoor smoke room, resulting in smoke and odor permeating areas frequented by residents and staff. Multiple observations over several days showed that residents and staff entered and exited the smoke room, with several residents smoking inside. The odor of smoke was detected from the lobby entrance, throughout the hallway, and inside and outside the 300 Hall dining room. On one occasion, a visible haze of smoke was observed outside the smoke room. Two floor fans and two garage fans intended to ventilate the area were not turned on during these observations. Interviews with residents, staff, and facility leadership confirmed the presence of smoke odor and visible smoke in the hallways and dining areas. One resident reported smelling smoke in their room when the door was open, and a housekeeper and CNA both noted strong smoke odors and visible smoke outside the smoke room. The Maintenance Director acknowledged that the fans should have been operating but were either turned off by residents or not functioning due to a power issue. The Administrator confirmed that the exhaust fans were broken and that the smoke odor was more pronounced during colder weather when more residents smoked indoors.
Failure to Maintain and Secure Corridor Handrails
Penalty
Summary
The facility failed to ensure that all corridors had handrails and that existing handrails were securely affixed to the walls, as observed during multiple walkthroughs. Specific deficiencies included missing handrails between rooms and common areas, around the perimeters of nurses' stations, and in various hallways across the 100, 200, 300, and 400 halls. Additionally, several handrails were found to be loose, broken, or pulled away from the wall. These issues were directly observed by surveyors at different times throughout the facility. Interviews with the Maintenance Director and the Administrator revealed that the facility was aware of the missing and damaged handrails. The Maintenance Director stated that handrails were checked every three months and acknowledged the absence of necessary replacement parts, as well as the ongoing process of replacing plastic handrails with wooden ones. Both the Maintenance Director and the Administrator were not fully aware of the requirement for handrails to be present outside nurses' stations and on both sides of all corridors used by residents. The facility's area audit and preventative maintenance inspection listed handrails as an item for staff to inspect, but deficiencies persisted.
Resident Trust Funds Not Reconciled and Negative Balances Allowed
Penalty
Summary
The facility failed to maintain resident trust funds in accordance with proper accounting principles by not keeping an accurate accounting of monies held in the resident trust fund account and by not reconciling the account each month. Review of the facility’s attempted monthly reconciliations from 12/1/24 through 11/30/25 showed that the bank statement ending balances did not match the current balances on the trust reports for each month reviewed. During interviews, the BOM stated the corporate BOM audited the reconciliations and that there were outstanding checks and reimbursements owed by the corporation that had not been paid, while the Administrator stated the bank statements should reconcile with the resident trust fund balance and was not aware of the reimbursements owed by the corporation. The corporate BOM acknowledged the outstanding checks and owed reimbursements and said she had made numerous requests for the reimbursement money, but Accounts Payable had been slow to provide it. The facility also allowed negative balances in resident trust accounts for three residents. Resident #88’s trust statement showed a balance that dropped below zero and remained negative, with the account opening at $50.07 and later showing balances of -$17.92, -$111.92, and a closing balance of -$111.91, followed by additional negative balances in the subsequent transaction history. Resident #80’s trust statement showed an opening balance of $27.00 and a balance of -$700.00. Resident #55’s trust statement showed an opening balance of $1,961.89 and later balances that became negative, including -$35.09, -$45.09, and -$0.09. The BOM stated the negative balances occurred because residents’ Medicaid checks were less than the amount charged for room and board, while the AD stated he distributed petty cash using a ledger provided by the BOM and did not know how much money residents had in their trust accounts. The Administrator stated resident trust accounts should never have negative balances and that there should be a daily accounting of each resident’s balance.
Failure to Complete Annual MDS Assessment Timely
Penalty
Summary
Facility staff failed to complete an annual MDS assessment timely for one resident, Resident #20. Review of the resident’s record showed multiple quarterly MDS assessments were completed, but no comprehensive assessment was completed after August 2025. The CMS RAI Manual states that the annual assessment must be completed on an annual basis, at least every 366 days, unless an SCSA or SCPA has been completed since the most recent comprehensive assessment. During interview, the administrator stated she would expect MDS to be completed timely and accurately and that staff should complete the correct type of MDS.
Late Quarterly MDS Completion
Penalty
Summary
Facility staff failed to complete the quarterly MDS for one resident, Resident #120, within the required 92-day timeframe. The report states that the RAI manual requires the Quarterly assessment, an OBRA non-comprehensive assessment, to be completed at least every 92 days after the previous OBRA assessment of any type, and that the ARD must not be more than 92 days after the ARD of the most recent OBRA assessment. Review of Resident #120's record showed a quarterly MDS, a significant change MDS, and a late quarterly MDS due in August 2025 with an ARD of 9/22/25. During interview, the administrator stated she would expect MDS to be completed timely and accurately and that staff should accurately complete the correct type of MDS.
Inaccurate MDS Hospice Prognosis Entry
Penalty
Summary
The facility failed to ensure an accurate MDS for one hospice resident. Review of the resident’s initial certification of terminal illness showed the hospice physician certified the resident as terminally ill with a life expectancy of 6 months or less if the disease ran its normal course, and the document was signed by the physician. However, the resident’s significant change MDS listed diagnoses of type two diabetes, acute kidney failure, muscle weakness, and dementia, noted severe cognitive impairment, and marked Section J, asking whether the resident had a life expectancy of 6 months or less, as "No." The facility’s MDS policy stated Section J is completed by nursing staff and includes prognosis and other health conditions affecting quality of life and functional status. During interview, the DON stated the MDS should be accurate and reflect whether the resident has a life expectancy of 6 months or less.
Missing PASARR Screening for Resident With Serious Mental Illness
Penalty
Summary
The facility failed to ensure that a resident with documented mental health diagnoses had a DA-124 Level One Screen completed to determine whether a PASARR Level Two Screen was required. Resident #113’s record showed diagnoses including depression, psychotic disorder, schizophrenia, major depressive disorder, and disorganized schizophrenia, but the medical record contained no DA-124 Level One Screen and no PASARR Level Two Screen. The quarterly MDS dated 11/28/25 also reflected serious mental illness diagnoses, and the resident’s face sheet listed other specified mental disorders due to known physiological condition. During interviews, the Social Services Director stated that PASARR assessments are uploaded into the medical record and later said the resident had been admitted during a period when PASARR was not needed and was “grandfathered in,” adding that she was not aware of a new psychiatric diagnosis since admission. An email exchange with DHSS and COMRU showed that COMRU could not provide a copy of the prior PASARR because the last one completed was in 11-1997 and that the SNF would need to submit a new online application. The Administrator stated she would expect the DA-124 to be completed upon admission or before.
Failure to Provide Needed ADL and Grooming Care
Penalty
Summary
The facility failed to ensure dependent residents received ADL care, including nail care, grooming, and personal hygiene, for four sampled residents. The facility’s Nail Care policy stated that routine cleaning and inspection of nails would be provided during ADL care on an ongoing basis, and that routine nail care, including trimming and filing, would be provided on a regular schedule. The policy also stated that the resident’s care plan would identify the frequency of nail care, the type of nail care provided, and who was responsible for providing it. Resident #27 had moderate cognitive impairment, schizophrenia, and diabetes, required supervision with bathing and personal hygiene, and had no care plan address for refusal of care. Observations showed fingernails on both hands approximately 0.5 inches long, jagged, and with dark matter underneath the nails. The resident stated the nails needed to be cleaned and trimmed. A CMT stated the resident occasionally refused showers and nail care, and that nail care should be done anytime a resident requires it, with staff attempting again later if refused. Resident #120 had mild cognitive impairment and multiple diagnoses including heart failure, PVD, kidney failure, diabetes, CVA, hemiplegia, malnutrition, and depression, and required moderate assistance with oral hygiene, toileting, bathing, dressing, and personal hygiene. Observations showed long fingernails with dirt underneath the nail bed on multiple days, and the right thumb was thick and curved forward. Resident #5 had COPD and dementia, moderately impaired cognition, and required staff supervision for bathing and personal hygiene; the care plan did not include ADL care needs. The resident was observed with a strong odor, a disheveled beard, and stated a desire to have the beard shaved off. Resident #6 had diabetes, acute kidney failure, muscle weakness, and dementia, was severely cognitively impaired, and was dependent on staff for showering and personal hygiene. The resident’s admission photo showed short hair and a clean-shaven face, but later observations showed long, stringy hair and an unkempt beard. An LPN stated the resident needed a haircut and that staff were responsible for setting up barber appointments, while the DON stated any nursing staff could assist with shaving and expected care plans to reflect ADL needs and interventions.
Feeding Tube Orders and Documentation Not Followed
Penalty
Summary
The facility failed to ensure physician orders were obtained for feeding tube water flushes and failed to ensure staff documented the date and time the tube feeding formula was hung for one of two residents sampled with feeding tubes, Resident #120. The resident’s quarterly MDS dated 9/22/25 showed mild cognitive impairment and diagnoses including anemia, heart failure, hypertension, peripheral vascular disease, kidney failure, diabetes, hyperkalemia, hyperlipidemia, aphasia, CVA, hemiplegia, seizure disorder, malnutrition, and depression. The resident weighed 103 pounds and had a feeding tube. The resident’s care plan identified aspiration risk and dehydration or potential fluid deficit related to an NPO diet, with interventions including continuous tube feeding and water flushes per orders. The hospital record showed the resident was hospitalized from 11/19/25 to 12/2/25 for HHS/DKA, septic shock, respiratory failure due to RUL pneumonia, and severe hypernatremia, and underwent g-tube replacement on 12/1/25 after the tube was dislodged. The discharge record indicated continuous tube feed at 55 ml/hr of Glucerna 1.5 cal, but no documentation of water flushes, rate, or frequency. The physician orders for December 2025 included NPO status, Glucerna 1.5 at 55 ml per hour, a prior order for 150 cc water flush via g-tube every four hours, discontinuation of that flush order, and a later order for 150 cc free water every four hours via pump related to hyperkalemia. During observations from 12/15/25 through 12/19/25, the resident was seen with tube feeding infusing at 55 ml/hr, but the formula bottle had no documentation of the time it was hung and started infusing on multiple occasions. The g-tube pump also showed varying water flush settings, including 100 cc every hour and 150 cc every four hours. The DON stated she expected staff to ensure the resident had physician orders for water flushes, to follow physician orders, and to document the date, time, infuse rate, and formula type on the bottle; she also stated that when the resident returned from the hospital, he/she was on 100 ml water flush.
Failure to Report and Manage Resident Pain
Penalty
Summary
The facility failed to ensure pain management was provided for a resident who experienced pain and reported it to staff, and staff failed to report the resident's pain to the nurse. The facility's Pain Management policy stated that pain management must be provided consistent with professional standards, the resident's care plan, and the resident's goals and preferences, and that staff would recognize pain and manage or prevent it through a systematic approach. Resident #120's record showed mild cognitive impairment, diagnoses including heart failure, hypertension, PVD, aphasia, stroke, hemiplegia, seizure disorder, and depression, and moderate assistance needs with toileting, dressing, and personal hygiene. The resident's care plan included acute pain with interventions to evaluate pain and use non-medication interventions. During observation, two CNAs provided personal care and repositioning to the resident, and the resident cried out each time staff moved him/her. The resident stated that his/her legs hurt and later said he/she had pain in the left hip, legs, and buttock that increased when lying down. The resident continued to moan and cry out with facial grimacing during care and transfer with a Hoyer lift, including when the resident's legs were curled up and the CNA pushed the resident's legs under the lift bar, scraping the resident's left knee. The resident was then transferred to the chair still moaning and grimacing, and the CNAs walked away without going to the nurse to report the pain. Interviews confirmed the breakdown in communication and response. The ADON stated that if the resident had pain, staff would typically know because he/she would rub his/her leg and that staff should report it to the nurse, and the resident gets PRN Tylenol. The LPN said staff did not report the resident's pain on the day of the observation and that if the resident complained during care, staff should stop and get the nurse to assess the resident first in case of injury. The CNA said he/she was unsure whether the nurse was told. The resident later stated he/she did not believe staff brought pain medication and that when staff are aware of pain, they do not normally bring anything. The Administrator and DON stated they would expect staff to report complaints of pain to the nurse and to stop and assess if the resident complained during care.
AV Fistula Assessment Not Completed by Licensed Nurse
Penalty
Summary
The facility failed to ensure that a resident receiving hemodialysis had the arterial venous (AV) fistula assessed by a licensed nurse. The resident’s quarterly MDS identified kidney failure and hemodialysis as an active treatment. The care plan directed staff to check and change the dressing at the access site daily and to monitor for signs or symptoms of infection, including redness, warmth, swelling, or drainage. The facility’s hemodialysis policy stated that the nurse would monitor and document the status of the resident’s access site upon return from dialysis to observe for bleeding or other complications. The resident’s MAR showed an order to check bruit and thrill of the AV fistula every shift, days and nights, but the assessments were documented as completed by a CMT on day and night shifts throughout the reviewed period. A licensed nurse did not document the bruit and thrill assessment as completed. During observation, the resident had an undated dressing over the AV fistula site on the left upper arm. The CMT stated he/she only checked the site for bleeding, was not sure what the bruit and thrill assessment was, and signed it off as completed. An LPN stated only a nurse should complete the bruit and thrill assessment and that it should not be documented as completed when the staff member is not sure what the assessment is. The DON stated only a nurse is expected to assess the AV fistula for bruit and thrill and document it on the MAR, and that CMTs should not be assessing or documenting it.
Unsecured Medication Room Allowed Access to Discontinued Medications
Penalty
Summary
The facility failed to maintain medications identified to be destroyed in a safe and secure location inaccessible to unauthorized staff in the 300 hallway medication room. Observation of the room showed the medication room door was ajar and rested loosely on the door frame, with a keypad on the door. On the counter was a red plastic bin with an open plastic bag containing eight bottles of liquid risperidone 1 ml and 28 medication cards containing discontinued medications. An ice cooler on a wheeled cart was also present in the medication room. During the observation, three CNAs entered the medication room without using the keypad, placed personal belongings on the medication room counter, and left the room. The door remained loosely ajar. LPN O stated the medication room door does not close completely and the keypad code is broken. LPN O also stated staff frequently store the ice cooler and personal belongings in the medication room, and that the nurse is frequently away from the nurse's station, leaving the door unmonitored. LPN O said the nurse and CMT should be the only staff able to access the medication room. The DON stated the medication room doors should be closed and secured, that nurses and CMTs on the units have access codes, and that unlicensed staff should not have access to the med room. The DON also stated staff should not keep personal belongings in the medication rooms and that all discontinued medications should be secured in the medication room and not left accessible on the counter. The DON said she is notified when the red bin has discontinued medications and she destroys the medications.
Failure to Follow Up on Pharmacy Recommendations for Elevated Blood Pressure
Penalty
Summary
The facility failed to ensure pharmacy recommendations were followed up on in a timely manner for one of five sampled residents reviewed for pharmacy recommendations. Resident #2 had diagnoses including hypertension and chronic atrial fibrillation and was ordered losartan potassium 50 mg daily for hypertension. The facility’s Medication Regimen Review policy required a licensed pharmacist to review each resident’s drug regimen at least monthly, include the medical chart, and communicate recommendations and irregularities within 10 working days. The resident’s care plan identified risk for altered cardiovascular status related to chronic atrial fibrillation, with interventions to monitor and report signs and symptoms as needed. The resident’s blood pressure records showed elevated readings, including 148/78 on 10/8/25 and 152/92 on 11/5/25. Pharmacy reviews dated 10/15/25 and 11/12/25 noted that the resident’s blood pressure remained elevated and recommended increasing losartan to 100 mg daily, with the later review also suggesting starting a beta blocker such as carvedilol because the pulse was elevated. The December 2025 MAR showed losartan 50 mg continued to be administered with no new or revised orders. During survey, the resident stated staff had stopped taking blood pressure and did not explain why. When the nurse later obtained a manual blood pressure, it was 160/78 with a pulse of 78. The DON stated she and the ADON handled pharmacy recommendations and expected a physician response regarding the resident’s pharmacy recommendation.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer and vaccinate eligible residents for the pneumococcal vaccine for two of five residents sampled for immunizations, Resident #28 and Resident #18. The facility’s Influenza and Pneumococcal Immunizations policy stated that residents are to be offered influenza and pneumococcal immunizations as part of the admission process and that pneumococcal immunization is to be offered upon admission unless medically contraindicated, already documented as received, or refused by the resident or legal representative. Resident #28’s record showed diagnoses of diabetes, schizophrenia, anxiety, high blood pressure, and kidney disease, but there was no documentation that the resident was screened for or received a pneumococcal vaccine. Resident #18’s record showed diagnoses of impulsiveness, anxiety, schizophrenia, and high blood pressure, but there was no documentation that the resident was screened for or received a pneumococcal vaccine. During interview, the DON stated she was responsible for ensuring residents receive recommended vaccines, that social services is involved in obtaining consents, and that she would expect residents to receive the appropriate vaccines per CDC guidelines; refusals are documented in the medical record.
Improper Catheter Care Without Physician Orders
Penalty
Summary
The facility failed to provide catheter care consistent with physician orders for a resident with a suprapubic catheter. The resident, who had diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infections, did not have a physician order to flush the suprapubic catheter. Despite this, an LPN flushed the catheter due to clotting issues, which was not documented in the resident's Treatment Administration Record or progress notes for November and December 2024. The facility's policies require that catheter care, including flushing, be performed only under physician orders and documented accordingly. However, the resident's medical records showed no such orders or documentation of the flushing procedure. The resident later presented to the emergency room with pain at the suprapubic catheter site, which was suspected to be due to trauma or mechanical pain from the catheter manipulation rather than a urinary tract infection. Interviews with facility staff revealed that the LPN acknowledged flushing the catheter without a physician's order, and the Director of Nursing confirmed that such actions should be documented and only performed with proper orders. The incident highlights a failure to adhere to established protocols for catheter care, leading to potential harm to the resident.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to ensure that personal funds withdrawn from the resident trust account were appropriately accounted for and used exclusively for the residents. Specifically, the facility did not ensure that withdrawals for personal spending were authorized by the resident or their legal guardian and signed off by the appropriate facility staff. This deficiency affected three residents, all of whom had cognitive impairments and were listed as their own financial responsible parties despite having legal guardians. The facility's policy required that personal funds be safeguarded and used exclusively for the resident, with proper authorization and documentation, which was not followed in these cases. For Resident #36, a withdrawal of $2,000 was made without proper authorization, and the funds were used to purchase gift cards. The receipts for these purchases were not signed by the resident, and there was a discrepancy of $10 between the withdrawal and the receipt totals. Additionally, items purchased with another withdrawal of $1,000 were not found in the resident's possession, and the resident's inventory sheets were not updated. Similar issues were found with Resident #48, where a $2,000 withdrawal was used to purchase gift cards, and the receipts were not signed by the resident. Items purchased with another $1,000 withdrawal were also not found in the resident's possession, and the inventory sheets were not updated. Resident #26 also experienced similar issues, with a $2,000 withdrawal made without proper authorization and used to purchase items that were not found in the resident's possession. The facility's Financial Coordinator and Life Enrichment Director admitted to mixing up gift cards and receipts, leading to improper accounting of resident funds. The Administrator was unaware of these practices and expected proper authorization and accurate record-keeping for all transactions involving resident funds. The facility's failure to follow its own policies and procedures resulted in the mismanagement of resident funds and a lack of accountability for the purchases made with those funds.
Failure to Address Outstanding Checks in Resident Trust Fund
Penalty
Summary
The facility failed to ensure general accounting principles were followed by not addressing outstanding checks during monthly resident trust fund reconciliations. The facility's policy required the Resident Trust Clerk to void and reissue checks that were outstanding for over two months. However, a review of the facility's monthly resident trust reconciliation from April 2023 through March 2024 revealed multiple checks, some dating back to 2015, that remained outstanding. These checks ranged in amounts from $10.00 to $2,740.00, indicating a significant lapse in following the established procedures for managing resident trust funds. Interviews with the Financial Coordinator and the Administrator revealed that the monthly reconciliation was performed by an accountant from the facility's management company. The Financial Coordinator, who was responsible for factoring outstanding checks into the reconciliation, was not trained to investigate these checks and did not have the authority to void them. The Administrator expected the accountant to notify the Financial Coordinator of any issues, but there was no follow-up on the outstanding checks, leading to the deficiency in managing the resident trust funds properly.
Failure to Provide Homelike Environment and Maintain Cleanliness
Penalty
Summary
The facility failed to provide a homelike environment by serving meals on Styrofoam plates with plastic utensils, which was observed during multiple meal times. Residents expressed dissatisfaction with the use of these materials, stating that they would not use them at home and found them difficult to use. One resident, who had hemiplegia, struggled to eat with the plastic utensils, resulting in a significant portion of their meal being uneaten. Another resident, who was totally dependent on staff for eating, had difficulty consuming their meal as the plastic fork could not cut through the food properly. Staff interviews confirmed that the use of Styrofoam and plastic utensils was not considered homelike, and the Dietary Manager acknowledged that the dishwasher was fixed but residents were still using disposable items until she felt comfortable with the dishwasher's performance. The facility also failed to provide clean and properly maintained equipment. One resident was transferred to a new wheelchair that was visibly dirty, with white crusty and reddish-brown stains on the seat and thick cobwebs on the wheels. Staff interviews revealed that the night shift CNAs were responsible for cleaning wheelchairs, but the provided wheelchair was not cleaned before being given to the resident. The Director of Nurses stated that she expected staff to provide clean wheelchairs to residents. Additionally, the facility did not maintain clean resident rooms. Observations of three different rooms showed sticky floors, dirty privacy curtains with brown stains, dusty air conditioning units, and trash debris. One resident expressed distress over the state of their room, which had not been cleaned adequately. Staff interviews indicated that housekeeping was expected to follow cleaning schedules, but the observed conditions did not meet these expectations. The Housekeeping Supervisor and the Administrator both stated that they expected residents' rooms to be clean and orderly, but this was not the case during the survey observations.
Care Plan Deficiencies for Smoking and Medication Refusals
Penalty
Summary
The facility failed to ensure each resident's care plan was updated and accurate to reflect the resident's needs. This deficiency affected three residents whose care plans did not identify their smoking status and one resident whose care plan did not identify medication refusals. The facility's policy requires comprehensive care plans to be completed within 14 days of admission and baseline care plans within 48 hours of admission, with information gathered from direct observation, communication with the resident, and input from the interdisciplinary team (IDT). However, these requirements were not met for the affected residents. Resident #283, who has diagnoses including high blood pressure, COPD, and a history of stroke, was observed smoking multiple times in the facility's smoking area. Despite this, the resident's care plan did not include any information about their smoking status. Interviews with facility staff confirmed that the resident is a smoker and that smoking should be included in the care plan to ensure staff are aware of the resident's specific health conditions. Resident #65, who has diagnoses including hemiplegia, multiple sclerosis (MS), and high blood pressure, had a history of medication refusals documented in their progress notes. Despite this, the resident's care plan did not address medication or treatment refusals. Interviews with facility staff confirmed that the resident frequently refuses medications and treatments, and this information should be included in the care plan to direct staff approaches during medication administration and treatments. Additionally, Residents #64 and #18, both listed as smokers, were observed smoking in the facility's smoking area, but their care plans did not address their smoking status. Interviews with the MDS Coordinator, DON, and Administrator confirmed that smoking and medication refusals should be included in the care plans to address each resident's unique health concerns.
Failure to Assess and Investigate Falls, Use Functional Equipment, and Apply Gait Belts Properly
Penalty
Summary
The facility failed to appropriately assess and investigate a series of falls resulting in head injuries for one resident. The resident experienced multiple falls, each resulting in head injuries, but the facility did not document investigations regarding the specific circumstances of these falls or hold care plan meetings to discuss fall interventions. Additionally, the resident's care plan did not identify the resident's transfer status, behavior of lowering him/herself to the floor, or updated interventions following the falls, such as the use of a low bed and fall mat. The facility also failed to ensure appropriate techniques and functional equipment were utilized during mechanical lift transfers for two residents. One resident reported feeling unsafe using a broken sit-to-stand lift, which staff continued to use despite its malfunctioning legs. Observations confirmed that staff manually pushed the lift's legs open, and the lift was wobbly. Another resident was transferred using a Hoyer lift without the wheelchair brake being locked, and the wheelchair was tilted backward, posing a safety risk. Furthermore, the facility did not ensure staff applied and used gait belts properly during transfers or assisted ambulation for three residents. Observations showed that staff lifted residents under their arms without using gait belts, and one resident's gait belt was left too loose during ambulation. Additionally, the facility failed to ensure residents were routinely and accurately assessed for smoking safety for three residents, as required by their policy.
Failure to Assess Side Rail Safety
Penalty
Summary
The facility failed to ensure that residents using side rails were appropriately assessed for safety in accordance with the facility's policy. This deficiency was observed in four residents, who were not properly evaluated for the risks and benefits of side rail use. The facility's policy mandates that all residents using side rails must have a Restraint/Entrapment Assessment completed upon initial use, quarterly, and as needed if there is a significant change in the resident's condition. However, these assessments were either missing or incomplete for the residents in question. Resident #125, who had severe cognitive impairment and physical limitations due to a stroke, was observed with side rails raised on multiple occasions. Despite this, there were no entrapment or side rail assessments found in the resident's medical record, and the care plan did not identify the use of side rails. Interviews with CNAs revealed that they were unsure why the resident had side rails and indicated that nurses were responsible for informing them about such interventions. Similarly, Resident #36, who had severe cognitive impairment and multiple physical disabilities, was observed with a U-shaped rail raised on the bed. The entrapment assessment for this resident was incomplete, and the care plan did not document the use of side rails. Interviews with CNAs and the DON indicated that side rails were added during a recent hospitalization without proper assessment. Residents #30 and #46 also had incomplete or outdated assessments, and their care plans did not reflect the use of side rails. Staff interviews revealed a lack of clarity on the frequency and responsibility for conducting these assessments, highlighting a systemic issue in the facility's adherence to its own policies.
Failure to Maintain Accurate Controlled Substance Records
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to enable accurate reconciliation for two out of three medication carts reviewed. Specifically, the controlled substance count sheets for the 400 and 300 halls showed that manual end-of-shift narcotic counts were not completed and documented per facility policy. For the 400 hall, the count was incomplete on multiple days in March and April, with some shifts not being counted at all. Similarly, the 300 hall had several days in April where the narcotic count was not completed for all shifts. This failure to adhere to the policy was confirmed through interviews with staff, including a Certified Medication Technician (CMT), a Licensed Practical Nurse (LPN), and the Director of Nursing (DON), all of whom acknowledged the requirement for narcotic counts to be conducted every shift, every day, with one oncoming and one off-going staff member participating in the count. The facility's Medication Storage and Destruction Policy mandates that a manual end-of-shift narcotic count be completed with the oncoming nurse counting and the outgoing nurse verifying. The policy also states that any nurse leaving the facility without properly conducting the narcotic count will face disciplinary action. Despite these clear guidelines, the review of the controlled substance count sheets revealed significant lapses in compliance. The DON confirmed that she expected the CMTs and nurses to follow the policy, but the records showed numerous instances where the counts were either partially completed or not done at all, indicating a systemic issue in maintaining accurate records for controlled substances.
Failure to Ensure Palatable and Properly Tempered Food
Penalty
Summary
The facility failed to ensure that food delivered to residents was palatable and at the required temperatures. Observations and interviews revealed that food served to residents in their rooms on the 300 and 400 hallways was often unappetizing, bland, and not at the proper temperatures. For instance, Resident #125, who is dependent on assistance with eating and has diagnoses including stroke and dysphagia, was served rubbery grits that could not be cut with a fork and pureed food that was unidentifiable and unpalatable. Resident #84, who requires setup or clean-up assistance with eating and has similar diagnoses, reported that the food was
Facility Fails to Maintain Kitchen Cleanliness and Ice Machine Safety
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen, walk-in refrigerator, and bulk storage areas, as well as ensure the ice machine had an air gap. Observations on multiple dates revealed water pooling, trash, food debris, and grime in various areas of the kitchen and storage rooms. Specifically, the bulk storage room had water pooling and dirty lids on bulk bins, while the walk-in refrigerator had caked-on grime and food debris on the floor and shelves. The main kitchen area and pots room also had food debris and dried liquid stains. Additionally, the ice machine lacked an air gap, with its piping going straight into the drain, which could lead to contamination issues. Interviews with dietary staff and management confirmed that all dietary staff were responsible for cleaning duties, including deep cleaning the walk-in refrigerator, floors, and bulk bin room. The cook was specifically tasked with cleaning the deep fryer after each use. Despite these responsibilities, the observations indicated that the cleaning schedules and policies were not being followed. The Dietary Manager and Administrator both expressed expectations that the kitchen and appliances should be clean and that staff should adhere to the facility's cleaning policies and schedules. The Maintenance Director was unaware of the missing air gap in the ice machine and acknowledged the expectation for it to be present to prevent contamination.
Failure to Obtain and Document Necessary Medical Orders
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice by not obtaining necessary medical orders for a resident upon admission. Specifically, the facility did not obtain orders for Peripherally Inserted Central Catheter (PICC) line care and nephrostomy tube care. Additionally, the facility did not ensure that suprapubic catheter care orders were correctly documented in the Treatment Administration Record (TAR). This resulted in the resident not receiving appropriate care for these medical devices, as observed on multiple occasions when the resident did not have a dressing around the suprapubic catheter site. The resident in question had severe cognitive impairment and multiple medical conditions, including multiple sclerosis, seizures, high blood pressure, and schizophrenia. The resident was readmitted from the hospital with a urinary tract infection and bacteremia, and had a PICC line, nephrostomy tube, and suprapubic catheter in place. Despite these conditions, the facility failed to obtain and document the necessary care orders for these medical devices, leading to lapses in care. Furthermore, the facility did not complete a required yearly electrocardiogram (EKG) for the resident, who was on high-risk medications such as antipsychotics and antidepressants. The EKG was not performed due to a backlog with the EKG service provider. The Director of Nursing acknowledged that staff did not place the orders correctly in the computer system, which contributed to the failure in providing the required care and completing the EKG.
Failure to Provide Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to ensure residents who required assistance with activities of daily living (ADLs) received necessary services to maintain adequate personal hygiene. One resident was left soiled for an extended period, resulting in a saturated bedspread, blanket, and clothing, as well as a bright red and inflamed rash under the resident's pannus. The resident expressed not knowing when they were last assisted with changing their brief, and the Certified Nursing Assistant (CNA) confirmed the resident had likely been left wet the entire night and morning. The CNA also noted that staff are expected to check and change incontinent residents at least every two hours, but this was not done for this resident. The Certified Medication Technician (CMT) and Licensed Practical Nurse (LPN) provided conflicting information about the resident's ability to care for themselves and any refusals of care, indicating a lack of proper documentation and communication among staff. Three other residents were observed with poor personal hygiene, including unshaven faces with food particles in their beards and long, jagged nails with dark matter underneath. These residents had severe cognitive impairments and were dependent on staff for personal hygiene and other ADLs. The care plans for these residents indicated the need for assistance with personal hygiene, but observations showed that staff did not provide the necessary care. Interviews with staff revealed that residents' nails had not been clipped because nail clippers could not be found, and shaving and nail care were supposed to be completed on shower days but were not consistently done. The Director of Nursing (DON) confirmed that staff are expected to change soiled residents in a timely manner and document any behaviors related to refusals of incontinence care. The DON also stated that staff should shave and provide nail care on residents' shower days and as needed. However, the observations and interviews indicated that these expectations were not being met, leading to deficiencies in the care provided to the residents.
Failure to Identify and Treat Skin Issues
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards when staff did not identify newly acquired skin issues and obtain treatment orders for two residents. Resident #64, who has severe cognitive impairment and multiple diagnoses including multiple sclerosis and schizophrenia, was observed with an open area on the right anterior abdominal area. Despite multiple observations and interactions with staff, the open area was not documented, and no treatment orders were obtained. The resident's care plan did not address the skin condition, and there was no documentation in the progress notes or physician order sheets regarding the open area. Resident #44, who has mild cognitive impairment and diagnoses including viral hepatitis and schizophrenia, was found with a saturated incontinence brief and a bright red, inflamed rash under the abdominal fold. The resident was unaware of the rash, and there were no treatment orders or documentation of the rash in the progress notes or physician order sheets. Staff interviews revealed that aides are expected to report new skin issues to nurses, who should then call the physician for new orders, but this protocol was not followed. Interviews with staff, including an LPN and the DON, confirmed that weekly skin assessments are required and that any new skin issues should be reported immediately to obtain new orders. However, the facility did not adhere to these procedures, resulting in the failure to address the skin issues of the two residents in a timely and appropriate manner.
Improper Catheter Care and Positioning
Penalty
Summary
The facility failed to ensure that catheter bags remained positioned below the bladder and that catheter bags and tubing remained off the floor for two residents with indwelling urinary catheters. This failure was observed during multiple instances, including when CNAs were assisting residents with clothing changes and during Hoyer transfers. The improper handling of catheter bags and tubing created a potential for contamination and urinary tract infections (UTIs). The facility's Catheter Care policy, revised on 6/29/23, mandates that urinary drainage bags be kept below the level of the bladder and that they do not touch the floor, but these guidelines were not followed in the observed cases. Resident #64, who has moderate cognitive impairment and a supra-pubic catheter, was observed on two occasions where CNAs raised the urinary catheter bag and tubing above the resident's waist, causing cloudy urine to flow back towards the resident's abdomen. The resident's care plan included monitoring for signs of infection and ensuring proper catheter maintenance, but these protocols were not adhered to during the observed incidents. Resident #36, who has lower extremity impairment and uses a wheelchair, was observed with catheter tubing and bags frequently in contact with the floor. During a Hoyer transfer, the catheter bag was placed on the resident's stomach and later fell to the floor, with tubing dragging along the floor for approximately 50 feet. Multiple observations throughout the day showed catheter tubing coiled on the floor in various locations, including the resident's room and the dining room. Interviews with CNAs and nursing staff revealed a lack of understanding and adherence to proper catheter care procedures, contributing to the risk of infection for the residents involved.
Failure to Ensure Proper Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that residents requiring dialysis had appropriate physician orders for assessment and monitoring of dialysis access sites and did not maintain ongoing communication with dialysis centers. This deficiency was identified for one resident out of a sample of two residents receiving dialysis. The facility's policy required ongoing assessment and monitoring of residents before and after dialysis treatments, including checking vital signs and assessing the vascular access site for signs of infection or complications. However, the facility did not have physician orders for pre and post-dialysis assessments for the resident, and there was a lack of documentation of these assessments in the resident's medical records for several months. The resident, who had moderate cognitive impairment and a diagnosis of end-stage renal disease, reported that upon returning from dialysis treatments, the facility staff did not assess their dialysis site or check their vital signs. Interviews with facility staff, including LPNs and RNs, revealed inconsistencies in the documentation and communication processes. Some staff mentioned that pre and post-dialysis assessments were documented on the Treatment Administration Record (TAR), while others stated that a new communication form was being used to document these assessments and communicate with the dialysis center. However, there was no evidence of consistent use of these forms or documentation in the resident's electronic medical record (EMR). The Director of Nursing (DON) confirmed that nurses were expected to assess residents before and after dialysis and document these assessments. The DON also mentioned that a new form had been introduced to facilitate communication with the dialysis center, but there was no evidence that this form was consistently used or that the information was uploaded into the resident's medical record. The lack of proper documentation and communication led to the deficiency in providing safe and appropriate dialysis care for the resident.
Infection Control Deficiencies in Peri-Care and Catheter Treatment
Penalty
Summary
The facility failed to follow acceptable infection control standards when providing peri-care for one resident and when providing treatment for a supra-pubic catheter for another resident. In the first instance, a CNA provided peri-care to a resident with severe cognitive impairment and multiple diagnoses, including diabetes and dementia. The CNA did not change gloves or perform hand hygiene after providing peri-care, and continued to touch clean items, dress the resident, and assist with a transfer while wearing the same soiled gloves. This was against the facility's policy, which mandates changing gloves and performing hand hygiene after providing peri-care and before touching clean items. In the second instance, an LPN provided treatment for a resident with a supra-pubic catheter and severe cognitive impairment. The LPN did not clean the scissors used to cut a dressing before applying it to the resident's catheter site. The scissors had been placed on the resident's bathroom sink, a potentially contaminated surface, before being used. This action was contrary to the facility's infection control policy, which requires cleaning equipment with antibacterial wipes before use in wound care. Interviews with staff, including another CNA and the DON, confirmed that the observed practices were not in line with the facility's infection control policies. Both the CNA and the LPN acknowledged that they should have changed gloves and cleaned equipment as per the guidelines. The DON reiterated the expectation for staff to follow proper infection control practices, including changing gloves and performing hand hygiene after providing peri-care and cleaning equipment before use in wound care.
Non-Functioning Call Light in Resident Room
Penalty
Summary
The facility failed to ensure that all call lights in the facility were in working order, including a visual notification above the door and an audible notification at the nurse's station. This deficiency was observed in one of 17 resident rooms surveyed, affecting one resident diagnosed with hemiplegia, pseudobulbar affect, multiple sclerosis (MS), and hypertension. The resident required moderate assistance from staff with dressing and bathing tasks and used a wheelchair for locomotion. Despite the resident's care plan indicating the need for a functioning call light due to fall risk and musculoskeletal status, the call light in the resident's room had been non-functional for about three weeks. The resident reported this issue to staff, but it remained unresolved, and the call light did not illuminate or provide an audible alarm at the nurse's station during multiple observations over several days. Interviews with facility staff, including a CNA, RN, Maintenance Director, and the Director of Nursing (DON), revealed that the non-functioning call light had not been properly reported or addressed. The CNA and RN were unaware of the specific call light issue in the resident's room, although they acknowledged that a call light on the same hall had been reported that day. The Maintenance Director confirmed that he had not been informed of the non-functioning call light prior to that day. Both the DON and Administrator stated that they expected all resident call lights to function normally and provide both visual and audible notifications. The lack of communication and follow-through in addressing the non-functioning call light led to the deficiency noted in the report.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grand Manor Health Care Center | 1.2 mi | ★★★★★ | 7 | 1 |
| Life Care Center Of St Louis | 1.4 mi | ★★★★★ | 14 | 0 |
| Delhaven Manor | 1.7 mi | ★★★★★ | 1 | 0 |
| Blue Circle Rehab And Nursing | 1.9 mi | ★★★★★ | 3 | 0 |
| Beauvais Rehab And Healthcare Center | 2.3 mi | ★★★★★ | 1 | 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.