Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Bluebird Wellness And Rehabilitation during CMS and state inspections, most recent first.
A resident with quadriplegia, fully dependent on staff for ADLs, was left unattended on their side by a CNA who left the room to obtain supplies. During this time, the resident experienced a spasm and fell from the bed, hitting their head on the bedside table and sustaining a contusion. Staff interviews confirmed the resident required two-person assistance, but this protocol was not followed, leading to the incident.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
Medication Labeling and Storage Deficiencies: Surveyors found multiple expired OTC meds and a bottle of Pro-Stat left in med carts, one insulin pen without a resident name, and several items that required refrigeration—Latanoprost eye drops, Lorazepam oral concentrate, and an opened vial of PPD—stored outside the refrigerator. Staff and the DON acknowledged the proper storage requirements, but the items remained improperly labeled or stored.
A resident with cerebral palsy, learning disorder, and paraplegia was admitted with a PASARR Level II evaluation that recommended specific supports and services, including medication therapy and crisis intervention. These recommendations were not included in the resident's care plan, and staff interviews revealed confusion about who was responsible for ensuring PASARR recommendations were addressed.
Staff did not consistently follow physician orders or honor a resident’s preferences and goals, resulting in care that was not individualized or aligned with the resident’s needs.
Staff did not consistently document required pre- and post-dialysis assessments, including monitoring of the dialysis access site for a resident with end stage renal disease. The care plan lacked details on access site location and documentation of bruit and thrill, and several required assessment forms were left incomplete, contrary to facility policy and physician orders.
A resident with an ankle wound did not receive daily dressing changes over the weekend, and another resident with a cancer-related forehead lesion was found with the wound exposed or improperly covered on multiple observations, with treatment documentation missing on several days. The facility also failed to follow its weight-monitoring policy for a resident with nutritional concerns, documenting one weight without required follow-up weights and later obtaining a much lower weight on a Hoyer scale.
The facility failed to ensure timely physician response to consultant pharmacist medication review recommendations for two residents. One resident with severe dementia, depression, and psychotic disorder had blank physician response sections on pharmacy forms recommending gradual dose reduction reviews for hydroxyzine, trazodone, and quetiapine, with no MD documentation of review. Another resident with dementia and depression had blank response sections on pharmacy forms recommending a gradual dose reduction review for quetiapine, and the record showed no physician review or follow-up documentation after a psychiatric NP visit. The DON stated pharmacy consults should be reviewed within seven days.
Failure to provide ordered chocolate milk with meals. A resident with dysphagia after a stroke and DM had chocolate milk listed on meal tickets as a nectar-thick beverage, but multiple meal trays were delivered with only orange juice and no chocolate milk. Staff set the trays down without checking for accuracy, and the resident repeatedly had to ask for the beverage that was already ordered.
A CMT administered Imodium to a resident experiencing severe diarrhea without a physician's order or documentation on the MAR, despite facility policy requiring such an order. The CMT believed there was a standing order, but upon review, none existed. The nurse was only notified after the medication was given, and the DON confirmed that this was not in line with facility expectations.
A resident with chronic diarrhea and multiple medical conditions did not receive timely laboratory testing as ordered by their physician due to missed appointments, refusals to provide specimens, and issues with specimen labeling. Facility staff attempted to accommodate the resident's preference for an outside lab, but documentation was inconsistent, and there was a lack of timely communication with the physician regarding missed or refused laboratory services.
A CMT failed to perform hand hygiene, use gloves, or clean the injection site while checking a resident's blood sugar and administering insulin. The CMT entered the room, conducted the procedures, and exited without following infection control protocols as required by facility policy.
The facility failed to provide adequate pressure ulcer care, resulting in a resident developing an unstageable pressure injury that required hospitalization. Despite CNAs alerting nurses, the necessary assessments and physician notifications were not made. Additionally, the wound care company did not communicate new treatment orders or provide timely progress notes, leading to delayed care for two residents.
The facility failed to promptly assess and treat wounds for two residents, leading to delayed care. One resident's right hip wound was not assessed until a day after it was reported, and another resident's sore bottom was not assessed until two days later. Both residents indicated that the largest available incontinent briefs were too small and caused the wounds. Additionally, a resident with a right palm laceration waited about an hour without receiving treatment. The facility had a census of 156.
The facility failed to conduct appropriate nursing assessments for two residents with tracheostomies, who were diagnosed with respiratory infections and vomiting. This deficiency was identified through interviews and record reviews, affecting two out of three sampled residents with tracheostomies.
The facility did not have enough skilled licensed nurses on duty each shift, particularly in the rehab building, leading to four residents not receiving tube feedings and medications as ordered. Additionally, three residents did not receive necessary tracheostomy care.
The facility did not ensure that a resident wore a compression suit nightly to manage edema and circulation, and failed to provide another resident with a glucose monitoring device as ordered. These deficiencies were identified during a survey of 28 residents.
The facility failed to administer seizure medication to three residents, antibiotics to one resident, and an anticoagulant to another resident. Additionally, the staff did not notify the physician or resident representative about these medication errors, putting residents at risk for unreported significant medication errors.
The facility failed to maintain complete and accurate records for a resident who experienced a change in condition and was hospitalized, with missing documentation in the EHR regarding the event. Additionally, two residents' eMAR and eTAR were incomplete, with numerous unexplained blanks, contrary to facility policies.
The facility failed to ensure that treatments for pressure ulcers were completed as ordered by the physician for three residents. Nursing staff documented that the treatments were completed, although they were not. The facility identified 15 residents with pressure ulcers, and upon sampling four residents, deficiencies were found in the care of three residents.
The facility failed to maintain a medication error rate below 5%, resulting in an 8.0% error rate during a survey. This was based on 25 opportunities for errors, with two errors occurring. The deficiency involved a resident and remains uncorrected, as noted in a previous Statement of Deficiencies. The facility's census was 164.
The facility did not accurately document pressure ulcer treatments for three residents, as treatments were not completed as ordered. Additionally, a resident received pain medication without proper documentation of its administration, including the pain's location and intensity. This indicates a failure in maintaining accurate medical records.
The facility failed to complete pressure ulcer treatments as ordered for three residents, despite documentation indicating otherwise. Observations revealed that dressings were not changed as required, and interviews with staff highlighted a lack of communication and follow-through on treatment responsibilities.
The facility failed to promptly assess and treat wounds for several residents, leading to deficiencies in care. One resident's hip wound was not assessed until the day after it was reported, and another resident's sore bottom was not checked for two days. Both residents complained about tight incontinent briefs causing skin issues. Additionally, a resident with a hand laceration did not receive timely treatment, highlighting a lack of nursing attention and proper documentation.
The facility failed to provide adequate care and assessment for two residents with tracheostomies, leading to significant health issues. Despite facility policies requiring documentation and physician notification of changes in condition, staff did not consistently document or report respiratory issues and vomiting. This resulted in delayed medical intervention and hospitalization for one resident with sepsis and pneumonia.
The facility failed to provide sufficient nursing staff, resulting in four residents not receiving necessary tube feedings, medications, and tracheostomy care. This deficiency was due to the absence of a licensed nurse on the night shift in the rehab building, leading to multiple instances of unprovided care as documented in the residents' eMAR and eTAR.
A facility failed to maintain a medication error rate below 5%, resulting in a 16.28% error rate. Errors involved multiple residents not receiving prescribed medications, with discrepancies noted in the medication administration records. Interviews revealed issues with medication stock management and adherence to facility policies.
The facility failed to accurately document medication administration for several residents, leading to discrepancies in the MAR. CMTs did not administer prescribed medications due to stock issues but documented them as given. Interviews revealed a lack of adherence to facility policies, resulting in inaccurate records and insufficient communication about medication availability.
A CNA misappropriated a resident's debit card, making unauthorized charges totaling $3,051.32. The resident, who was alert and oriented, was unaware of the card's misuse until a family member discovered the charges. The facility's investigation identified the CNA through video surveillance, revealing the card's use at various stores and facility vending machines. Despite policies to protect residents' property, the CNA exploited the resident's trust, leading to significant unauthorized expenditures.
The facility failed to apply a compression suit for a resident with edema and did not provide a glucose monitoring device for another resident with diabetes. Despite orders and documentation, the compression suit was not applied due to staff misunderstanding and lack of awareness. Additionally, a nurse failed to follow up on a rejected order for a glucose monitoring device, resulting in the resident not receiving it. These deficiencies indicate a lapse in communication and adherence to physician orders.
The facility failed to administer necessary medications to several residents due to staffing issues, resulting in significant medication errors. On a particular night, no nurse was available in the rehab building to administer medications through g-tubes. The staffing coordinator was aware but did not ensure coverage, leading to missed doses and lack of documentation or notification to physicians or resident representatives.
Failure to Provide Adequate Supervision and Assistance During Resident Repositioning
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and assistance to prevent accidents for a resident with quadriplegia. The resident, who was alert and oriented but completely dependent on staff for activities of daily living (ADLs), required two-person assistance for bed mobility and personal care. Despite this, a CNA attempted to reposition the resident alone and left the resident unattended on their side while leaving the room to obtain supplies. During the period the resident was left unattended, the resident experienced a spasm, causing their legs to move and resulting in a fall from the bed. The resident landed on the floor, hitting their head on the bedside table and sustaining a contusion to the back of the head. The incident was unwitnessed, and the resident reported pain in the neck and back of the head after the fall. The CNA's actions were inconsistent with the resident's care plan, which specified the need for two-person assistance for all ADL care, including turning and personal hygiene. Multiple staff interviews confirmed that the resident required two-person assistance and that staff were expected to gather all necessary supplies before entering the room to provide care. The CNA involved did not follow these protocols, resulting in the resident being left in a vulnerable position and subsequently falling. The incident was reported to nursing staff, and the resident was assessed and sent to the hospital for evaluation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not labeled and stored in accordance with accepted professional principles. During observation of four medication carts and two medication rooms, surveyors found multiple expired over-the-counter medications left in active storage, including bottles of Lactobacillus tablets, fish oil, calcium citrate, niacin, zinc, vitamin C, oral pain relief gel, Pro-Stat, and oyster shell calcium. A bottle of Pro-Stat protein drink was opened and dated 7/14/25 with an expiration date of 2/15/25. One insulin pen was not labeled with a resident's name, and staff stated they did not know who it belonged to. Staff also identified that both nurses and CMTs were responsible for checking expiration dates, but expired items remained in the carts. Surveyors also found medications that required refrigeration stored outside of refrigeration, including Latanoprost eye drops, Lorazepam oral concentrate, and an opened vial of PPD. Staff stated these items should be refrigerated, and the DON confirmed that PPD, liquid lorazepam, and latanoprost eye drops should be stored in the refrigerator. The facility's policy required medications and biologicals to be stored safely and properly, with refrigerated medications kept between 36 F and 46 F, and expired medications removed from active supply and destroyed.
Failure to Incorporate PASARR Level II Recommendations into Care Plan
Penalty
Summary
The facility failed to ensure that recommendations from a Level II Pre-admission Screening and Resident Review (PASARR) were incorporated into the care plan for a resident with diagnoses including cerebral palsy, learning disorder, and paraplegia. The PASARR Level II Summary of Findings specified that the resident required supports and services such as medication therapy, crisis intervention services, discharge planning, structured development, and a personal support network. However, review of the resident's care plan at the time of survey showed that these recommendations were not addressed. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for following up on PASARR recommendations. The Social Worker Assistant, Social Services Director, Admission Coordinator, and MDS Rehab nurse each described different understandings of their roles in the PASARR process, with none taking responsibility for ensuring the recommendations were incorporated into the care plan. The DON confirmed that the care plan should reflect the PASARR Level II recommendations, but this was not done for the resident in question.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that staff did not consistently follow prescribed care plans or honor the expressed wishes and goals of the resident. The lack of adherence to orders and resident preferences resulted in care that was not aligned with the individualized needs of the resident.
Failure to Document Pre/Post Dialysis Assessments and Access Site Monitoring
Penalty
Summary
Facility staff failed to follow their dialysis care policy by not consistently documenting pre- and post-dialysis assessments for a resident with end stage renal disease who required hemodialysis. The policy required monitoring and documentation of the dialysis access site for color, warmth, redness, tenderness, pain, edema, drainage, and bruit once per shift, as well as maintaining all dialysis-related documentation in the resident's medical record. Review of the resident's care plan showed it did not specify the location of the access site or require documentation of bruit and thrill once per shift. Physician orders were in place for pre-dialysis assessments to be completed and sent with the resident to dialysis, but documentation was missing on several dates. Record review revealed multiple instances where required documentation was incomplete or missing, including blank entries for pre- and post-dialysis assessments, and lack of documentation regarding the access site assessment. Interviews with the ADON and DON confirmed that pre- and post-dialysis assessments were expected to be completed and documented, including the location of the access site and assessment of bruit and thrill. However, the records did not consistently reflect these practices, resulting in a failure to adhere to the facility's dialysis care policy.
Wound Care and Weight Monitoring Failures
Penalty
Summary
The facility failed to provide wound care as ordered for a resident with a right medial malleolus wound. The resident had an order for daily cleansing, xeroform, and dry dressing changes, but observation showed the dressing dated 8/1 remained in place during an interview on 8/4, and the resident stated staff did not change the dressing every day. When the wound nurse completed care on 8/5, the wound was pink with no inflammation or drainage, and the wound nurse stated weekend nursing staff should provide treatments on weekends, while she only performed them Monday through Friday. The facility also failed to keep a cancer-related forehead wound covered and treated as ordered for another resident with a history of malignant melanoma, cerebrovascular disease, and dementia. The resident had an order for daily wound care to the left forehead with cleansing, petroleum gauze, and a dry dressing. The eMAR showed treatment documented only on 8/1 and 8/4, with no documentation on the other days reviewed and no PRN documentation. Observations over several days showed the wound exposed without a dressing at times, and when a bandage was present it was sometimes dated, soiled, or shifted away from the wound. Staff stated the resident sometimes removed the bandage and that the wound team or nursing staff would apply the dressing when available, but documentation did not reflect treatment when the dressing was absent or removed. The facility further failed to obtain resident weights according to its policy and documented an inaccurate weight for a resident with nutritional concerns. The resident had diagnoses including CHF, aphasia, dysphasia, and altered mental status, and the care plan identified nutritional problems and signs of malnutrition to monitor. The facility policy required admission weights and weekly weights for four weeks, then monthly. The record showed only one weight of 152.6 pounds on 6/5/25 with no documentation of additional weights or subtraction of wheelchair weight. When the resident was later weighed using a Hoyer lift, the scale showed 103.8 pounds, which differed substantially from the documented weight. Staff also noted the resident had poor intake on some days, and there was no documentation that the dietician was notified or that the resident was assessed after the weight issue was identified.
Delayed Response to Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to implement its policy and procedure for monthly drug regimen review by not ensuring timely physician or designee response to pharmacy recommendations for two sampled residents. The facility policy required consultant pharmacist recommendations to be communicated in a timely fashion, with responses documented before the next medication regimen review, and stated that if a prescriber did not respond within 30 days, the DON and/or consultant pharmacist could contact the Medical Director. Survey review found that the physician response sections on the consultant pharmacist recommendation forms were left blank, and progress notes did not document that the recommendations were reviewed by the MD for either resident. Resident #3 had severe cognitive impairment and diagnoses including non-Alzheimer's dementia, depression, and psychotic disorder. The resident's care plan addressed psychotropic medication use and included consultation with pharmacy and consideration of dosage reduction when clinically appropriate. The consultant pharmacist issued recommendations that hydroxyzine 50 mg three times daily, trazodone 50 mg at bedtime, and quetiapine 25 mg twice daily should have gradual dose reduction evaluations documented. The forms were blank, and the record showed no documentation that the MD reviewed the recommendations during the review periods. Resident #145 had memory problems, worsened behavior compared to prior assessment, and diagnoses of dementia and depression. The resident was receiving Prozac 20 mg daily and Seroquel 25 mg at bedtime, and the care plan addressed mood problems and antidepressant use. The consultant pharmacist recommended a gradual dose reduction evaluation for quetiapine, but the physician response section was blank on both review forms. A psychiatric NP later noted no psychotic symptoms or staff reports of agitation and planned to reduce Seroquel to bedtime only, but the resident's record showed no follow-up documentation after that visit and no change in the current Seroquel dose. During interviews, the ADON stated pharmacy recommendations were given to the DON and then distributed to nursing staff, and the DON stated she expected pharmacy consult recommendations to be reviewed within seven days and that they should have been reviewed timely.
Failure to Provide Ordered Chocolate Milk With Meals
Penalty
Summary
The facility failed to ensure that a resident received food and beverage choices that matched documented preferences. Resident #171 had diagnoses including dysphagia after a stroke and diabetes, and a nutritional communication form documented an in-room meal location preference and moderately thick liquids. The resident stated that chocolate milk was listed on the meal ticket for each meal, but it was not being provided. Review of the resident’s meal tickets for breakfast, lunch, and dinner showed chocolate milk ordered as a nectar-thick beverage, yet the resident repeatedly reported that the tray arrived without it. During multiple observations, the resident’s meal trays were delivered with orange juice and no chocolate milk. Staff set the trays down and left the room without checking the meal ticket for accuracy or ensuring the ordered beverage was present. On one occasion, after the resident requested chocolate milk, a staff member overheard the request and later brought a cup of thickened chocolate milk to the room. The Dietary/Kitchen Director stated that dietary staff check meal tickets in dietary and nursing staff should also check trays when passing them out, and that the resident should have been receiving chocolate milk with meals and should not have had to ask for it.
Medication Administered Without Physician Order
Penalty
Summary
A Certified Medication Technician (CMT) administered Imodium to a resident without a physician's order, contrary to the facility's medication administration policy, which requires all medications to be given only with a valid physician or licensed practitioner order. The resident, who had a history of benign neoplasm of the colon, diabetes, depression, and a left foot abscess, reported experiencing severe diarrhea, likely related to IV antibiotics for a foot wound. The CMT informed the resident that Imodium could be given twice daily upon request, but there was no corresponding physician order or documentation on the medication administration record (MAR) for this medication. Upon review, the electronic physician order sheet and the MAR showed no order or record of Imodium administration for the resident. The CMT initially claimed there was a standing order for Imodium but, upon checking, found none for the resident. The CMT stated that the nurse was supposed to call the physician and enter the order, but the nurse confirmed that this notification only occurred after the medication had already been given. The Director of Nursing confirmed that medications, including stock medications like Imodium, should not be administered without a physician's order and that the nurse should have been notified immediately.
Failure to Provide Timely Laboratory Services for Resident
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of a resident with multiple diagnoses, including diabetes, stroke, acid reflux, and major depressive disorder. The resident had ongoing gastrointestinal symptoms, specifically diarrhea for nine months, and was under physician orders to complete specific stool laboratory tests. Despite these orders, there were repeated issues with the completion of the required laboratory tests, including missed appointments, refusal by the resident to provide specimens, and problems with specimen labeling and submission to the outside laboratory. Documentation in the resident's medical record showed inconsistent follow-through on laboratory orders. There were late entries regarding the receipt of orders and attempts to complete the labs, as well as notes indicating the resident's refusal to provide a stool specimen and missed appointments at the outside laboratory. The facility staff attempted to accommodate the resident's preference for an outside lab, but the resident continued to reschedule or refuse appointments. There was also a lack of documentation regarding the reason for missed appointments, education provided to the resident about the importance of the tests, and timely notification to the physician about missed or refused laboratory services. Interviews with facility staff and the resident revealed further issues. The resident expressed concern about not being able to complete the physician-ordered laboratory tests and cited inconsistent transportation as a barrier. Staff interviews confirmed the resident's refusals and preference for a specific laboratory, as well as the facility's attempts to schedule and reschedule appointments. However, there was no evidence that the facility consistently documented refusals, communicated with the physician about missed appointments, or ensured that laboratory services were provided in a timely manner to meet the resident's needs.
Failure to Follow Infection Control Procedures During Blood Sugar Testing and Insulin Administration
Penalty
Summary
Certified Medication Technician (CMT) H failed to follow established infection prevention and control procedures during blood sugar testing and insulin administration for a resident diagnosed with diabetes, acid reflux, and anxiety. The CMT entered the resident's room with the necessary equipment but did not perform hand hygiene upon entry, did not don gloves, and proceeded to wipe the resident's finger with an alcohol wipe before obtaining a blood sample. After checking the blood sugar, the CMT drew up insulin without performing hand hygiene or wearing gloves, and administered the injection without cleaning the resident's abdomen with an alcohol wipe. Throughout the process, the CMT did not perform hand hygiene at any point, did not use gloves, and did not clean the injection site prior to administering the insulin. After completing the procedure, the CMT capped the syringe and exited the resident's room without performing hand hygiene. The Director of Nursing confirmed that these actions were not in accordance with facility policy, which requires hand hygiene and glove use before such procedures.
Failure in Pressure Ulcer Care and Communication
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, as evidenced by the case of a resident who developed an unstageable pressure injury on the right ischium. Despite Certified Nursing Assistants (CNAs) alerting nurses about the resident's skin issues and documenting open areas on bath sheets, the nurses did not assess or notify the physician. Additionally, the resident requested an assessment from the facility's former Wound Nurse, which was refused. This lack of action led to the resident being hospitalized for an infected pressure injury that required intravenous antibiotics and surgical debridement. Further deficiencies were noted in the facility's communication and implementation of treatment orders. The wound care company failed to communicate new treatment orders to the facility before leaving on the days they made rounds, resulting in delayed implementation for two residents. One of these residents did not have their dressing changed as ordered. Additionally, the wound care company did not provide timely progress notes for all three residents involved. The facility identified 14 residents with pressure ulcers, and failures were found in the care of three out of six sampled residents.
Delayed Assessment and Treatment of Wounds
Penalty
Summary
The facility failed to adhere to its policies by not promptly assessing a resident's right hip wound after it was reported by a CNA to an LPN. The wound was not assessed until the following day, delaying the start of treatment. Another resident reported soreness on their bottom to the staff, but it was not assessed until two days later when a wound was identified. Both residents complained that the facility's largest incontinent briefs were too small and contributed to the wounds. Additionally, the staff did not promptly assess and treat a resident with a right palm laceration, resulting in the resident waiting approximately one hour without receiving treatment before returning to their room. The facility had a census of 156 at the time of these incidents.
Inadequate Nursing Assessments for Residents with Tracheostomies
Penalty
Summary
The facility failed to provide appropriate nursing assessments for residents with tracheostomies, specifically those diagnosed with respiratory infections and vomiting. This deficiency was identified through interviews and record reviews. Out of seven residents with tracheostomies, three were sampled, and failures were found in the care of two residents. The facility's census at the time was 156.
Insufficient Nursing Staff Leads to Care Deficiencies
Penalty
Summary
The facility failed to ensure a sufficient number of skilled licensed nurses were on duty each shift to provide necessary nursing care to all residents in accordance with their care plans and the facility assessment. Specifically, the facility did not have a licensed nurse on duty for each shift in the rehab building. This deficiency resulted in four residents not receiving their prescribed tube feedings and medications. Additionally, three residents did not receive the required tracheostomy care. The sample size for this observation was 28, with a total census of 156 residents.
Failure to Provide Compression Suit and Glucose Monitoring Device
Penalty
Summary
The facility failed to meet professional standards of practice by not ensuring that a resident wore a compression suit on the lower extremities every night for one hour, which is necessary to reduce edema and increase circulation. Additionally, the staff did not provide another resident with a glucose monitoring device as ordered. These deficiencies were identified during a survey involving a sample size of 28 residents, with a total census of 156.
Failure to Administer Medications and Notify Physician
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as identified through interviews and record reviews. Specifically, staff did not administer seizure medication to three residents, antibiotics to one resident, and an anticoagulant to another resident. Additionally, the facility staff did not notify the physician or the resident representative about these medication errors. This oversight put the residents at risk for significant medication errors going unreported, which could lead to complications related to missed doses. The sample size for this review was 28, with a total facility census of 156.
Deficiency in Resident Record Maintenance and Documentation
Penalty
Summary
The facility failed to maintain complete and accurate resident records and did not adhere to its policy for documenting changes in resident conditions. On August 4, 2024, a resident experienced a change in condition and was admitted to the hospital. However, the resident's electronic health record (EHR) lacked documentation regarding the change in condition, physician notification, and the time of hospital transfer. Additionally, the facility did not ensure that the electronic Medication Administration Record (eMAR) and electronic Treatment Administration Record (eTAR) for two residents were completed according to facility policies. These records contained numerous blanks without explanations for the omissions. The sample size for the survey was 28, with a total census of 156 residents.
Failure to Complete Physician-Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that treatments for pressure ulcers were completed as ordered by the physician for three residents. Nursing staff documented that the treatments were completed, although they were not. The facility identified 15 residents with pressure ulcers, and upon sampling four residents, deficiencies were found in the care of three residents. The facility had a census of 164 at the time of the survey.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, as evidenced by an 8.0% error rate observed during a survey. This was based on 25 opportunities for errors, of which two errors occurred. The deficiency was noted in the care of a resident, contributing to the overall error rate. The facility's census at the time was 164 residents. This deficiency remains uncorrected, as indicated by a previous Statement of Deficiencies.
Documentation Failures in Pressure Ulcer and Pain Management
Penalty
Summary
The facility failed to ensure accurate documentation on the treatment administration record (TAR) for pressure ulcer treatments for three residents. These treatments were not completed as ordered, indicating a lapse in following prescribed care protocols. Additionally, a resident requested and received pain medication, but staff did not document the administration of the medication, including the location and intensity of the resident's pain. This lack of documentation highlights a failure in maintaining accurate medical records in accordance with accepted professional standards.
Failure to Complete Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered by the physician for three residents. The nursing staff documented that treatments were completed, although they were not. This deficiency was identified during a review of the facility's treatment records and through interviews and observations. The facility had 15 residents with pressure ulcers, and issues were found with three of the four sampled residents. Resident #19, who had diagnoses including paraplegia and schizophrenia, had multiple stage 4 pressure ulcers. The resident's treatment orders included specific wound care instructions for the right heel, sacrum, and left ischium. However, observations revealed that the dressings on these wounds were not changed as ordered on 7/11/24, despite being documented as completed. The facility's wound nurse admitted to asking floor nurses to complete the treatments, which were not done. Resident #21, with paraplegia and diabetes, had a stage 4 pressure ulcer on the sacrum. The treatment was supposed to be done every shift, but observations showed the dressing was not changed as required. Similarly, Resident #22, with malnutrition and depression, had a stage 4 pressure ulcer on the sacrum, and the dressing was found to be missing, despite documentation indicating the treatment was completed. Interviews with staff revealed a lack of communication and follow-through on treatment responsibilities, contributing to the deficiency.
Failure to Promptly Assess and Treat Wounds
Penalty
Summary
The facility failed to promptly assess and treat wounds for several residents, leading to deficiencies in care. One resident had a right hip wound that was reported by a CNA to an LPN, but it was not assessed or treated until the following day. The resident believed the wound was caused by tight incontinent briefs, which the facility had not replaced with the correct size after a change in ownership. The wound nurse confirmed the presence of the wound and noted it was trauma-related, not pressure-related. The facility's wound management policy requires immediate assessment and treatment, which was not followed in this case. Another resident reported soreness on their bottom to staff, but it took two days for the wound to be assessed. The resident also complained about the size of the incontinent briefs, which were too small and caused discomfort. The wound nurse identified an open area on the resident's buttock, which was also attributed to the tight briefs. The facility's failure to provide appropriately sized briefs and timely wound care contributed to the resident's skin breakdown. Additionally, a resident with a laceration on their right palm did not receive timely treatment. The resident reported the injury caused by a broken wheelchair armrest to staff, but assistance was delayed for several hours. The resident expressed concern about the lack of nursing attention and the potential for more serious issues if immediate care was not available. The facility's documentation and response to the incident did not align with their policies, as the laceration was not properly assessed or documented, and a CMT, rather than a nurse, provided initial wound care.
Failure to Provide Adequate Tracheostomy Care and Assessment
Penalty
Summary
The facility failed to provide appropriate nursing assessments and care for residents with tracheostomies, specifically for two residents who were diagnosed with respiratory infections and vomiting. The facility's policies required that tracheostomy care be performed as ordered by the attending physician, with any unusual observations reported immediately and documented in the medical record. However, the facility did not adhere to these policies, as evidenced by the lack of documentation and failure to notify physicians of significant changes in the residents' conditions. Resident #6, who had a tracheostomy and was diagnosed with respiratory failure, experienced a series of respiratory issues, including thick secretions and changes in oxygen saturation levels. Despite these symptoms, there was a lack of consistent documentation and communication with the physician regarding the resident's condition. The resident's condition deteriorated, leading to hospitalization with diagnoses of sepsis, pneumonia, and other complications. The facility's failure to document and report changes in the resident's condition contributed to the delay in appropriate medical intervention. Similarly, Resident #44, who also had a tracheostomy and was dependent on tube feeding, experienced vomiting and respiratory issues. The facility's staff did not perform adequate assessments or document the resident's condition as required by the facility's policies. The lack of proper documentation and communication with the physician regarding the resident's vomiting and potential aspiration risk further exemplified the facility's failure to provide appropriate care. These deficiencies highlight the facility's non-compliance with its own policies and the resulting negative impact on resident care.
Insufficient Nursing Staff Leads to Care Deficiencies
Penalty
Summary
The facility failed to ensure a sufficient number of skilled licensed nurses were on duty each shift to provide nursing care to all residents in accordance with resident care plans and per the facility assessment. Specifically, the facility did not have a licensed nurse on duty for the night shift in the rehab building, which resulted in four residents not receiving necessary medical care. This included the failure to administer tube feedings and medications as ordered, as well as the lack of tracheostomy care for three residents. Resident #16, who had severe cognitive impairment and was dependent on staff for all activities of daily living, did not receive tube feedings or tracheostomy care as required. The resident's care plan indicated the need for enteral nutrition and tracheostomy care due to conditions such as respiratory failure and quadriplegia. However, the electronic Medication Administration Record (eMAR) and electronic Treatment Record (eTAR) showed multiple instances where required care and medication administration were not documented, indicating that these were not provided. Similarly, Resident #44, who also had severe cognitive impairment and required tube feeding and tracheostomy care, did not receive the necessary care. The resident's eMAR and eTAR showed blank entries for required interventions, such as enteral feeding and medication administration. Resident #6, with similar care needs, also did not receive the necessary tube feeding and tracheostomy care, as evidenced by blank entries in their eMAR and eTAR. These deficiencies highlight the facility's failure to meet the staffing requirements necessary to provide adequate care to its residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 16.28% error rate. This was identified during a medication pass observation where seven errors occurred out of 43 opportunities. The errors involved five residents, all of whom had issues with their medication administration. The facility's policies on medication administration and error handling were not adhered to, leading to these deficiencies. Resident #11, who had chronic bronchitis and COPD, did not receive their prescribed fluticasone propionate nasal suspension and Symbicort inhaler during a medication administration observation. Despite this, the medication administration record (MAR) inaccurately showed that these medications had been administered. Similarly, Resident #3, who was cognitively intact, did not receive their fluticasone propionate inhaler as prescribed, yet the MAR indicated it had been given. Resident #8 received a multivitamin instead of the prescribed multivitamin with minerals, and the MAR incorrectly documented the administration of the correct medication. Further issues were observed with Resident #10, who did not receive their prescribed Pyridoxine HCI and Lactinex due to unavailability in the medication cart and stock room. Resident #9 also did not receive their normal saline eye drops because they were not available in the medication cart or stock room. Interviews with the Certified Medication Technicians (CMTs) and the Interim Director of Nurses revealed lapses in medication ordering and stock management, contributing to the medication errors.
Medication Administration and Documentation Failures
Penalty
Summary
The facility failed to ensure accurate documentation of medication administration for several residents, leading to discrepancies in the medication administration records (MAR). During a medication administration observation, it was noted that Certified Medication Technician (CMT) B did not administer prescribed medications to Residents #11 and #3 due to the medications being out of stock. Despite this, the MAR indicated that the medications had been administered. Additionally, CMT B administered a multivitamin to Resident #8 but failed to provide the multivitamin with minerals as prescribed, yet documented it as given. Further observations revealed that CMT A also failed to administer medications as ordered. For Resident #9, CMT A could not find the normal saline eye drops or gabapentin and did not notify the physician or resident representative about the missing medications. The MAR inaccurately showed that these medications were administered. Similarly, for Resident #10, CMT A was unable to provide Lactinex and pyridoxine HCL due to unavailability but documented them as administered on the MAR. Interviews with the CMTs and the Interim Director of Nursing (DON) highlighted a lack of adherence to facility policies regarding medication administration and documentation. The Interim DON confirmed that staff should document reasons for not administering medications and notify relevant parties, which was not done in these cases. The failure to follow these procedures resulted in inaccurate MARs and a lack of communication about medication availability issues.
Misappropriation of Resident's Debit Card by CNA
Penalty
Summary
The facility failed to protect a resident from misappropriation of property when a Certified Nurse Aide (CNA) took the resident's debit card and used it without permission. The resident, who was alert and oriented, had been admitted to the facility and was unaware of the card's whereabouts. The resident's family member discovered the unauthorized charges amounting to $3,051.32 after reviewing financial records and reported the incident to the facility. The facility's investigation revealed that the CNA, identified as CNA F, had used the resident's debit card at various stores, including Walmart, Ross, Wing Stop, and a gas station, as well as vending machines within the facility. The misuse of the card began shortly after the resident's admission and continued for several weeks. The facility's Director of Nursing (DON) and Human Resources Manager were able to identify CNA F from video surveillance footage provided by the police, which showed the CNA using the card at multiple locations. The facility's Theft/Loss Prevention policy outlines procedures for safeguarding residents' property and mandates reporting and investigating any suspected misappropriation. Despite these policies, the CNA was able to exploit the resident's trust and access the debit card, leading to significant unauthorized expenditures. The facility's failure to prevent this incident highlights a lapse in the protection of residents' personal property, as the CNA was able to misuse the card over an extended period before being identified and terminated.
Failure to Apply Compression Suit and Provide Glucose Monitoring Device
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice in two instances. In the first instance, a resident with a diagnosis of high blood pressure and moderately impaired cognition was supposed to wear a compression suit on the lower extremities every night for one hour to reduce edema. Despite the physician's order and documentation in the Treatment Administration Record (TAR) indicating the compression suit was applied, the resident reported never receiving assistance to wear it. Interviews with staff revealed a lack of awareness and misunderstanding of the order, with one LPN incorrectly documenting the application of the suit without actually performing the task. In the second instance, a resident with diagnoses including diabetes and respiratory failure was supposed to receive a continuous glucose monitoring device as ordered. The order was entered into the electronic medical record but was rejected, and the nurse did not follow up with the pharmacy. Consequently, the pharmacy did not receive the order, and the resident did not receive the device. The Director of Nursing (DON) later confirmed that the nurse should have contacted the pharmacy to ensure the order was processed. These deficiencies highlight a failure in communication and adherence to physician orders, resulting in residents not receiving necessary medical interventions. The lack of proper documentation and follow-up by nursing staff contributed to these issues, as evidenced by the discrepancies between recorded actions and actual care provided.
Medication Errors Due to Staffing Issues
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as staff did not administer necessary medications to several residents. Specifically, seizure medications were not given to three residents, antibiotics were not administered to one resident, and an anticoagulant was not provided to another resident. Additionally, the facility staff did not notify the physician or resident representatives about these medication errors, which could lead to unreported significant medication errors. The report highlights that the facility's staffing issues contributed to these medication errors. On a particular night, there was no nurse available in the rehab building to administer medications through g-tubes, as required. The staffing coordinator was aware of the absence of a nurse but failed to ensure that a nurse was present to administer the necessary medications. As a result, residents with g-tubes did not receive their medications, and the facility's documentation did not reflect any notifications to physicians or resident representatives about the missed doses. Interviews with staff revealed that the staffing coordinator attempted to address the issue by sending a group text to nurses in the LTC building, but no nurse was available to cover the rehab building. The Director of Nursing (DON) expected the staffing coordinator to confirm coverage and notify the on-call nurse, but this did not occur. Consequently, the residents did not receive their prescribed medications, and the facility failed to document the medication errors or notify the appropriate parties.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 937 citations issued within 25 miles in the last 12 months — including the 17 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 Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sherbrooke Village | 1.7 mi | ★★★★★ | 6 | 0 |
| Nazareth Living Center | 2.6 mi | ★★★★★ | 4 | 0 |
| Lemay Nursing | 3.3 mi | ★★★★★ | 0 | 0 |
| Fountain Care At Sunset Hills | 3.5 mi | ★★★★★ | 3 | 0 |
| Mary, Queen And Mother Center | 3.7 mi | ★★★★★ | 3 | 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.