Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brooke Haven Healthcare during CMS and state inspections, most recent first.
Dignity During Mealtimes: Staff were observed standing while assisting residents with meals, feeding two residents at once, and leaving meals untouched in front of residents without assistance available. CNAs stated this was normal practice, while the Administrator, DON, and ADON said staff were expected to sit while assisting residents and to assist one resident at a time.
Resident trust funds were not handled within required timeframes for several residents. Three residents who expired still had balances in their accounts long after death, and one resident who discharged to another facility did not receive a final accounting of personal funds within 30 days. The Administrator stated she was responsible for the resident trust fund and that balances were expected to be provided within 30 days after discharge, but the funds were overlooked.
A facility failed to have PASARR documentation in the record for two residents, including one with stroke, schizoaffective disorder, aphasia, depression, anxiety, cognitive impairment, and vascular dementia with behavioral disturbance, and another with schizoaffective disorder and MDD. The Administrator said PASARR screening should be part of the record, while the SS Director said he/she usually only handled PASARR for community admissions; no level II PASARR screenings were on file for any residents, and the facility had no PASRR policy.
A resident with severe cognitive impairment, ESRD, type 1 DM, and total dependence for care had a sacral pressure injury that was documented as stage 1 on weekly skin checks, but the facility missed multiple weekly skin assessments and did not record the wound type, stage, measurements, or characteristics. Staff applied a bordered foam dressing to the sacrum without a physician order, did not notify the physician, and later observed the dressing covering an open area with fecal contamination before incontinent care was completed.
The facility failed to provide safe respiratory care by not keeping nasal cannulas properly stored when not in use and by not following oxygen orders for two residents. Observations found cannulas on the floor, under bedding, or hanging from a wheelchair brake without a sealed bag, one resident’s cannula was only in one nostril, another resident’s concentrator was off with oxygen not being delivered as ordered, and a third resident lacked portable oxygen supplies despite orders for oxygen when out of the room. Staff interviews confirmed that oxygen should be on as ordered, cannulas should be aligned in the nose, and portable tubing should be stored in a bag when not in use.
Medication error rate exceeded 5% after an LPN made 2 insulin pen administration errors, resulting in an 8% error rate. Two residents received insulin aspart by pen, but the LPN failed to prime the pens per manufacturer instructions before giving the ordered doses. The facility policy required insulin pens to be used correctly and in accordance with prescriber orders, and the DON and ADON stated staff were expected to prime pens with 2 units before administration.
Infection control practices were not followed during wound care and incontinent care for multiple residents. Staff entered rooms without hand hygiene, failed to wear gowns for EBP, did not change gloves between dirty and clean tasks, reused the same area of wipes during pericare, placed supplies and soiled items on beds or the floor, and continued care without sanitizing equipment between residents. The facility also had incomplete TB screening documentation for several residents, including missing read dates and a missing test result.
A resident with severe cognitive impairment and poor safety awareness received a second-degree burn from spilled hot coffee after a CNA handed them a cup without a lid, contrary to their care plan. The incident was not promptly communicated to the wound physician, delaying appropriate medical intervention. The facility failed to conduct daily follow-up skin assessments, and a prescribed treatment was unavailable due to an allergy, contributing to inadequate wound care.
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, risking cross-contamination and food-borne illness for all 69 residents. Observations showed unlabeled food bins, carbon build-up on equipment, and debris on floors. The walk-in freezer and refrigerator had significant build-up and debris, and the dry storage room contained undated and improperly stored food items. Staff interviews confirmed the absence of cleaning schedules and logs, and the dishwasher had been out of service for over a month.
The facility did not maintain a surety bond at the required level for residents' personal funds. The bond was $100,000, but the average monthly balance required a bond of at least $103,500. Both the Business Office Manager and the Administrator acknowledged the regulatory requirement, and the facility lacked a policy for the surety bond.
A facility failed to administer the correct insulin dosage to a diabetic resident due to a misreading of blood sugar levels by an RN, resulting in the administration of 14 units instead of the required 18 units. Additionally, the facility did not follow an RD's recommendation to reduce the enteral feed rate for a resident with cerebral palsy, leading to continued weight gain.
The facility failed to complete comprehensive discharge summaries for two residents who were discharged home. Both residents' closed medical records lacked documentation of a recapitulation or completed discharge summary. The Administrator and DON indicated that the discharging nurse was responsible for completing these summaries prior to discharge, but the facility did not provide a policy regarding this process.
A resident's urinary catheter drainage bag was improperly positioned, lying on the floor or touching a wheelchair wheel, contrary to facility policy. Staff interviews confirmed the bag should be hung below the bladder and off the floor, highlighting a lapse in catheter care adherence.
The facility failed to follow physician's orders for oxygen therapy for two residents and did not ensure proper tracheostomy care for a resident with a tracheostomy. A resident with COPD received oxygen at 4 liters per minute instead of the prescribed 2 liters. Another resident performed self-tracheostomy care without following aseptic techniques, using tap water instead of sterile water, and not inserting the inner cannula. The facility lacked a specific oxygen policy and did not document the resident's competency for tracheostomy cleaning.
A facility failed to provide trauma-informed care for a resident with PTSD, as their care plan did not address PTSD or include goals and interventions for mental health support. The resident, diagnosed with PTSD, depression, and anxiety, expressed experiencing symptoms and triggers, but the facility lacked a PTSD policy and did not document past trauma or triggers in the care plan.
The facility failed to post the required daily nurse staffing information for three consecutive days, affecting the transparency of staffing levels for residents and visitors. The Staff Posting Sheet was outdated, and the facility lacked a policy on posting nurse staffing information. The Administrator and DON acknowledged the requirement for daily postings.
The facility failed to ensure accurate narcotic reconciliations for two residents, leading to discrepancies in narcotic counts. The narcotic medications were not documented accurately by staff, resulting in mismatches between recorded and actual counts. Interviews revealed that a nurse administered medication without signing it out in the narcotic book, and the CMT was unsure about another discrepancy. The DON and Administrator emphasized the importance of documenting narcotic administration properly.
The facility failed to limit PRN orders for psychotropic medications to 14 days, did not attempt gradual dose reductions for antipsychotic medications, and lacked appropriate diagnoses for the use of Seroquel in two residents. Interviews revealed a lack of responsibility for auditing chart orders, relying instead on a consultant pharmacist for reviews.
The facility failed to properly label and store medications, with opened insulin pens found undated and medication carts left unlocked and unattended. A resident was left with medication unattended in their room, contrary to facility policy. Staff interviews confirmed the need for proper labeling and secure storage, but these practices were not followed.
The facility failed to maintain the dumpster properly, as observed on multiple occasions with its lids left open, potentially affecting all 69 residents. Despite staff training to keep the dumpster closed when not in use, interviews with the Administrator and Assistant Maintenance Director confirmed that the lids were not consistently closed.
The facility failed to maintain proper infection control practices during wound, incontinence, and catheter care for several residents. Staff did not change gloves or perform hand hygiene as required, and glucometers were not properly disinfected between uses. Additionally, Enhanced Barrier Precautions were not followed during high-contact care activities.
The facility did not maintain an effective antibiotic stewardship program as required by its policy. Despite having a program in place, there was no documentation of antibiotic stewardship tracking. The Infection Preventionist reviewed antibiotic orders and ensured they met criteria, but the information was only discussed in monthly QAPI meetings without proper documentation. This deficiency had the potential to affect all residents, with one resident currently receiving antibiotics.
The facility failed to follow professional standards of practice for a resident with severe infections, leading to a deficiency in care. The resident was admitted without timely treatment orders for a wound, and several doses of prescribed antibiotics were missed without documentation. Interviews with staff revealed that the facility did not adhere to its policies on admission assessment, wound care, and medication administration.
Dignity During Mealtimes
Penalty
Summary
The facility failed to assure staff treated five sampled residents with dignity during mealtimes by standing while assisting with feeding, assisting multiple residents at the same time, and leaving meals untouched in front of residents without assistance available. The report states that the facility census was 57 and that the resident rights policy required employees to treat all residents with kindness, respect, and dignity and to support residents in exercising their rights. The facility did not provide a policy on dining assistance. During observations, CNA D, CNA E, and CNA I were seen standing while assisting residents with meals, including standing over residents seated in wheelchairs or at dining tables. One CNA assisted two residents at the same time, and meals for other residents sat untouched for 15 to 20 minutes while staff assisted others. In several instances, staff did not cut up noodles before feeding, did not cover plates, did not rewarm food, and did not verbalize departure when leaving a resident without assistance. Interviews with CNAs showed that standing while feeding and assisting two residents at once was described as normal practice, while the Administrator, DON, and ADON stated staff were expected to sit while assisting residents and to assist one resident at a time.
Resident trust funds not refunded or finalized within required timeframes
Penalty
Summary
The facility failed to refund resident trust funds within 30 days after death for three residents and failed to complete a final accounting of resident personal funds within 30 days of discharge for one resident. Review of the facility policy titled Resident Trust Fund showed that resident trust fund accounts were to be closed out when a resident left the facility with no plans to return, and that funds were to be handled according to the resident’s status, including transfer to another facility, return to SSA, or other appropriate disposition. The facility census was 57. Review of closed records showed that Resident #69 expired with $864.90 still held in the resident trust fund account, and the balance was documented 806 days late. Resident #71 expired with $705.47 still held in the account, documented 660 days late, and Resident #72 expired with $378.87 still held in the account, documented 469 days late. Resident #70 discharged to another facility with $1,291.00 still held in the resident trust fund account, and the final accounting was documented 29 days late. During interview, the Administrator stated she was responsible for the resident trust fund and expected residents to receive a final accounting and the balance of their funds within 30 days after discharge per facility policy, but Resident #70’s funds deposited after discharge and the other residents’ balances were overlooked.
Missing PASARR Screening Documentation
Penalty
Summary
The facility failed to provide a PASARR screening for one sampled resident and one additional resident outside the sample. Resident #8 was admitted with diagnoses including stroke, schizoaffective disorder, aphasia, depression, anxiety, cognitive communication deficit, mild cognitive impairment, and vascular dementia with behavioral disturbance, but there was no documentation of completed level I or level II PASARR screening in the record. Resident #52 was admitted with schizoaffective disorder and major depressive disorder, and although a determination letter dated 06/26/17 showed the resident had been referred for a level II screening and met the federal definition of serious mental illness and intellectual disability related condition but did not require specialized services, there was no documentation of completed level I or level II PASARR screening in the record. During interviews, the Administrator stated she expected the level I PASARR screening and, if required, the level II screening to be part of the resident record. The Social Services Director stated he/she normally did not expect to work on level I or level II PASARR screenings unless a resident admitted from the community. The report also states there were no level II PASARR screenings currently on file for any residents in the facility, and the facility failed to provide a policy regarding PASRR.
Failure to Document and Treat a Sacral Pressure Injury
Penalty
Summary
The facility failed to document the type, stage, measurements, and characteristics of a facility-acquired pressure ulcer and failed to notify the physician or obtain an order for treatment for one resident with a sacral pressure injury. The resident had multiple diagnoses including end stage renal disease, type 1 diabetes mellitus, spinal stenosis, dystonia, pain, major depressive disorder, anxiety disorder, and GERD. The resident was dependent for all ADLs and mobility, was always incontinent of bowel and bladder, and had severe cognitive impairment. The Braden Scale score was 12, indicating high risk for skin breakdown. The resident’s record showed a stage 1 sacral pressure injury documented on weekly skin checks, but the facility did not complete weekly skin assessments for four of eight opportunities. The care plan addressed pressure injuries present upon admission and included monitoring wound healing weekly, pressure relieving devices, turning and repositioning, and treatment to the buttocks as ordered, but it did not address the resident’s stage 1 sacral pressure ulcer. The physician order sheet and TAR contained orders for Triad Paste to the buttocks and turning every two hours, but there were no orders for weekly skin assessments, no dressing order for the sacrum, and no pressure ulcer treatment order. The TAR also lacked documentation of skin or wound assessments and pressure ulcer treatments, and there was no documentation of the wound’s type, stage, measurements, or characteristics from 02/22/26 through 02/27/26. During care, staff placed a bordered foam dressing on the resident’s sacrum without a physician order and without documenting the dressing or notifying the physician. On observation, the sacral dressing was brown on the outside and partially unattached; when it was lifted, it covered a nickel-sized open area with a white substance on the wound. The resident was found with fecal matter in the brief, and the soiled dressing was put back in place over the wound before incontinent care was completed. Staff interviews confirmed the dressing had been applied for protection, that the wound had not been assessed after the dressing was placed, and that the physician, DON, or ADON had not been notified. The ADON later stated the wound appeared at least stage 2, while the physician stated staff should report skin issues and that a dressing should have a physician order.
Improper Oxygen Use and Cannula Storage
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not ensuring proper storage of nasal cannulas when not in use and by not following oxygen orders for two residents. The facility policy titled Oxygen Administration addressed verifying oxygen orders, assembling equipment, placing the oxygen device on the resident, and checking equipment, but it did not address proper storage of nasal cannulas. During observations, nasal cannulas were found on the floor, under a sheet, wrapped around a forehead, or hanging from a wheelchair brake without a sealed container or bag. One resident with COPD and systolic CHF had an order for continuous oxygen at 2 to 4 L/min via nasal cannula to maintain oxygen saturation above 90 percent. Observations showed the resident’s nasal cannula lying on the floor with the prongs touching the floor, under the resident’s sheet, and hanging from the wheelchair brake without a sealed container. At one observation, the resident’s oxygen saturation was 89 percent without oxygen. Later, the resident was observed with the nasal cannula in place, but the portable oxygen cannula still hung from the wheelchair brake without a sealed container. A second resident with acute and chronic respiratory failure with hypoxia had an order for continuous oxygen to maintain oxygen saturation above 90 percent. Observations showed the nasal cannula sideways on the resident’s face and inserted in only one nostril, the portable cannula lying on the floor without a sealed container, and later the oxygen concentrator turned off with the resident not receiving oxygen as ordered. A third resident with COPD and systolic CHF had orders for oxygen as needed, daily oxygen saturation checks, titration to keep saturation above 90 percent, and portable oxygen when out of the room, but observations showed the nasal cannula hanging coiled outside a container, no portable oxygen supplies available, and the resident outside the room without the portable equipment. Staff interviews stated the cannula should be aligned in the nose, oxygen should be on as ordered, and portable tubing should be stored in a bag when not in use.
Medication Error Rate Exceeded Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, with 2 errors out of 25 medication administration opportunities, resulting in an 8% error rate for 2 residents. The deficiency involved insulin aspart pen administration for two sampled residents. The facility policy required medications to be administered according to prescriber orders and required insulin pens to be clearly labeled for single resident use, with the nurse verifying the correct pen before administration. The manufacturer’s instructions for the insulin aspart Flex Pen required the pen to be primed by selecting 2 units, holding the pen with the needle pointing up, tapping the cartridge holder, pushing the dose knob until zero appeared, and confirming insulin at the needle tip before giving the dose. For one resident, the order was for insulin aspart pen 6 units plus sliding scale before meals, and the resident’s blood sugar was 140 at the time of administration. For the second resident, the order was for insulin aspart pen 12 units before meals. In both observed administrations, the LPN gave the ordered insulin subcutaneously using the resident’s insulin aspart pen but failed to prime the pen according to the manufacturer’s instructions before administering the insulin. During interview, the LPN stated that in the previous state he/she worked in, insulin pens were not primed. The ADON and DON stated that staff were expected to prime insulin pens with two units before administering the full dose, and the Administrator stated staff were expected to follow policy and procedure regarding insulin administration.
Infection Control Breakdowns During Wound Care, Incontinent Care, and TB Screening
Penalty
Summary
The facility failed to implement infection prevention and control practices during wound care and incontinent care for multiple residents, including residents with open wounds and residents on enhanced barrier precautions (EBP). During incontinent care for one resident, two CNAs entered the room without performing hand hygiene, did not use a gown, and one CNA used the same area of a disposable wipe multiple times while cleaning fecal material. The same CNA touched multiple surfaces and items in the room, including a closet handle, clean clothing, a drawer handle, and clothing inside the drawer, without changing gloves or performing hand hygiene. During the same care episode, the resident was transferred using a soiled incontinent pad, and the resident was later assisted with transfer while staff again did not perform hand hygiene or use a gown. During wound care for residents with open wounds, an LPN failed to follow EBP and hand hygiene practices. For one resident with a right heel wound, the nurse entered the room without hand hygiene, did not wear a gown, placed supplies on the dresser without a clean barrier, and cleaned the wound and surrounding skin without changing gloves or performing hand hygiene between tasks. For another resident with wounds to both lower legs, the nurse placed supplies on the resident’s bed and later on the floor, did not perform hand hygiene, did not change gloves between dirty and clean tasks, and used scissors and wound care supplies without sanitizing them between residents. For a third resident with wounds to the hips and sacrum, the nurse placed soiled scissors on the bedside table, did not perform hand hygiene, and continued wound care without changing gloves between wound sites. Additional incontinent care observations showed repeated breaks in infection control. For one resident, a CNA cleaned the groin and buttocks using the same area of a wipe multiple times, did not change gloves or perform hand hygiene between dirty and clean tasks, and used the incontinent pad to turn the resident. For another resident, a CNA performed hand hygiene and donned gown and gloves, but then continued care without changing gloves or performing hand hygiene while cleaning different groin and buttock areas, used the incontinent pad to reposition the resident, and a nurse later exposed a sacral dressing with fecal material in the brief and returned the same soiled dressing over an open wound. The facility also failed to correctly screen three residents for TB as required by state regulation; the records showed incomplete or missing TB skin test documentation, including missing read dates and one missing result.
Resident Burned Due to Inadequate Supervision and Care Plan Adherence
Penalty
Summary
The facility failed to provide a safe environment for a resident with severe cognitive impairment, resulting in the resident receiving a second-degree burn from spilled hot coffee. The resident, who had diagnoses of non-traumatic brain injury, dementia, and anxiety, was dependent on staff for all activities of daily living and had poor safety awareness. Despite being care planned to use a spill-proof cup with a lid and straw, a CNA unfamiliar with the resident handed them a regular coffee cup without a lid, leading to the spill and subsequent burn. The incident report indicated that the CNAs and nurse immediately changed the resident and assessed the site, initially finding no redness or open areas. However, a large blister developed later, which was not promptly communicated to the wound physician. The physician was not informed of the burn until a week later, which delayed appropriate medical assessment and intervention. The facility's documentation lacked follow-up skin assessments after the initial incident, which should have been conducted daily to monitor the injury's progression. The facility's Director of Nursing acknowledged that the prescribed silvadene cream was not available due to the resident's sulfa allergy, and the pharmacy did not fill the prescription. This oversight contributed to the delay in appropriate wound care. The wound physician expressed concern over the delayed notification and the potential complications due to the resident's fragile state. The incident highlights a breakdown in communication and adherence to care plans, resulting in inadequate supervision and response to the resident's needs.
Sanitation Deficiencies in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas, which increased the risk of cross-contamination and food-borne illness for all 69 residents. Observations revealed multiple issues, including the absence of cleaning logs, unlabeled food bins, and significant carbon build-up on kitchen equipment. The kitchen's metal backsplash, can opener, and various cooking surfaces were found with oily films and carbon deposits. Additionally, the air conditioning diffuser and the floor beneath kitchen appliances were covered in dust, grime, and debris. The walk-in freezer had a significant frost build-up, and the walk-in refrigerator contained liquid and food debris on the floor, along with grime on the walls and ventilation louvers. In the dry food storage room, numerous food items were undated and unlabeled, and some were stored in containers with expired dates. Disposable bowls and paper towels were improperly stored on the floor, and food debris was scattered along the walls. Interviews with dietary staff and the administrator confirmed the lack of cleaning schedules and logs, and acknowledged the need for improvements in food labeling and storage practices. The dishwasher had been out of service for over a month, contributing to the unsanitary conditions, and a repair was delayed due to a part being specially made.
Failure to Maintain Adequate Surety Bond for Residents' Personal Funds
Penalty
Summary
The facility failed to maintain a surety bond for the security of residents' personal funds at the required level. The bond amount was supposed to be at least one and one-half times the average monthly balance of the residents' personal funds over the last twelve months. The facility's current bond was $100,000, while the average monthly balance of the residents' personal funds was $68,621.10, necessitating a bond of at least $103,500. During interviews, both the Business Office Manager and the Administrator acknowledged that the surety bond should be one and one-half times the residents' trust balance to meet regulatory requirements. Additionally, the facility did not provide a policy for the surety bond.
Insulin Administration Error and RD Recommendations Not Followed
Penalty
Summary
The facility failed to administer the correct amount of insulin to a resident diagnosed with diabetes mellitus. The resident's Physician Order Sheet specified a sliding scale for insulin administration based on blood sugar levels. On a specific date, a Registered Nurse (RN) documented the resident's blood sugar as 425, which required 18 units of insulin according to the sliding scale. However, the RN mistakenly administered only 14 units of insulin, believing the blood sugar level was 373. This error occurred because the RN misread the documented blood sugar level on a piece of paper and did not verify it in the electronic record. Additionally, the facility did not follow the Registered Dietician's (RD) recommendations for another resident diagnosed with cerebral palsy. The RD suggested reducing the resident's enteral feed rate to stabilize weight gain, as the resident had gained 20 pounds over six months. Despite this recommendation, the facility continued the existing feeding regimen without making the suggested adjustments. The facility's failure to implement the RD's recommendations contributed to the resident's continued weight gain.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to complete a comprehensive discharge summary for two residents who were discharged home. Resident #58 was discharged on 11/25/24, and Resident #66 was discharged on 09/19/24. In both cases, there was no documentation of a recapitulation or a completed discharge summary in their closed medical records. During an interview, the Administrator and Director of Nursing stated that the discharging nurse was responsible for completing the discharge summary, which should have been completed prior to the discharge of the residents. The facility did not provide a policy regarding a discharge summary or recapitulation.
Improper Catheter Care Observed
Penalty
Summary
The facility failed to ensure proper care for a resident with a urinary catheter, as the catheter drainage bag and tubing were observed to be improperly positioned. The drainage bag was found lying on the floor between the bed frame and a wheelchair, contrary to the facility's policy which mandates that the catheter tubing and drainage bag be kept off the floor. This was observed on multiple occasions, with the drainage bag either lying on the floor or touching the wheel of a wheelchair, despite having a privacy cover in place. Interviews with staff, including CNAs and the Director of Nursing, confirmed that the catheter drainage bag should be hung below the bladder and off the floor, ideally on a non-moving part of the bed frame. The staff acknowledged that the drainage bag and tubing should not be in contact with the floor or any movable objects like wheelchair wheels. The deficiency was identified through observations and interviews, highlighting a lapse in adherence to the facility's catheter care policy.
Failure to Follow Physician's Orders and Ensure Proper Tracheostomy Care
Penalty
Summary
The facility failed to adhere to physician's orders for supplemental oxygen therapy for two residents and did not ensure proper tracheostomy care for one resident. Resident #39, diagnosed with malignant neoplasm of the supraglottis and having a tracheostomy, was observed performing self-care of the tracheostomy without following aseptic techniques. The resident used tap water instead of sterile water for cleaning, did not change gloves or perform hand hygiene during the procedure, and did not insert the inner cannula of the tracheostomy. The resident expressed difficulty breathing with the inner cannula in place, which was corroborated by an LPN who noted the resident sometimes removed it for comfort. Resident #62, diagnosed with chronic obstructive pulmonary disease, had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, the resident was observed receiving oxygen at 4 liters per minute, which was not in accordance with the physician's order. The DON confirmed that the oxygen order should have been followed as prescribed. The facility lacked a specific oxygen policy and did not document Resident #39's competency for tracheostomy cleaning. The DON stated that competency checks for tracheostomy care were conducted twice a year, but the resident's self-care did not align with the facility's tracheostomy care policy, which required sterile techniques and proper documentation of the procedure and the resident's response.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to identify, assess, and provide supportive interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). The resident's medical record indicated a diagnosis of PTSD, depression, and anxiety disorder, with a Trauma Informed Care Assessment showing the resident was triggered for PTSD. Despite this, the comprehensive care plan did not address PTSD, lacked goals for maintaining the resident's psychosocial and mental health, and did not document the resident's past trauma or any triggers that could cause trauma. Additionally, there were no interventions outlined for addressing behaviors if they occurred or for providing support to the resident. During an observation and interview, the resident expressed experiencing PTSD symptoms, including replaying traumatic images and being triggered by a train whistle. The resident was tearful and spoke with a quivering voice about past trauma. The facility's administrator acknowledged that PTSD should be addressed in the care plan, and the Social Service Designee noted that the resident had recently started discussing their PTSD. However, the facility did not have a PTSD policy in place, contributing to the deficiency in care for the resident.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to post the required daily nurse staffing information, which includes the total number of staff and the actual hours worked by both licensed and unlicensed nursing staff directly responsible for resident care. This deficiency was observed for three out of four days, with the facility census being 69. Observations on specific dates revealed that the Staff Posting Sheet was outdated, showing a date of 12/02/24, and the required information was not posted for 12/04/24, 12/05/24, and 12/06/24. During an interview, the Administrator and Director of Nursing acknowledged that nurse staffing should be posted daily on the Nurse Staffing board. Additionally, the facility did not provide a policy regarding the posting of nurse staffing information.
Inaccurate Narcotic Reconciliation for Two Residents
Penalty
Summary
The facility failed to ensure accurate narcotic reconciliations for two residents, leading to discrepancies in narcotic counts. Specifically, the narcotic medications for two residents were not documented accurately by the on-coming and off-going staff. For one resident, the hydrocodone count was recorded as 22 tablets, but only 20 tablets were found in the medication cart. For another resident, the eszopichlone count was recorded as seven tablets, but only six tablets were found in the medication cart. The staff did not document the administration of these medications on the Controlled Drug Receipt-Record Disposition forms. Interviews revealed that the night nurse administered the eszopichlone but failed to sign it out in the narcotic book, although it was signed on the resident's MAR. The Certified Medication Technician (CMT) was unsure about the discrepancy in the hydrocodone count but mentioned that they counted the narcotics at the start and end of their shift, even if it was with themselves. The Director of Nursing and the Administrator stated that staff should always make time to perform narcotic counts during shift changes and document the administration of narcotic medications on both the MAR and the narcotic book.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to adhere to regulations regarding the use of psychotropic medications for several residents. For one resident, the facility did not limit the use of a PRN order for clonazepam to 14 days, as required. This resident had a diagnosis of dementia and was prescribed clonazepam for agitation without a stop date. Additionally, the facility did not attempt a gradual dose reduction (GDR) for another resident who was prescribed Rexulti, an antipsychotic medication, despite the manufacturer's warning about increased mortality in elderly patients with dementia-related psychosis. This resident had diagnoses of unspecified dementia and major depressive disorder. Furthermore, the facility failed to ensure appropriate diagnoses for the use of Seroquel, an antipsychotic medication, for two residents. One resident was prescribed Seroquel for a cognitive communication deficit, and another for dementia, without documentation of an appropriate diagnosis. The manufacturer's safety information for Seroquel indicates it is not approved for elderly patients with dementia-related psychosis. Interviews with facility staff revealed that there was no designated responsibility for auditing chart orders for appropriate diagnoses, and the facility relied on a consultant pharmacist for monthly medication reviews.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to label and store medications properly, as evidenced by the presence of opened insulin pens that were not dated in the medication cart. This included Lantus, Fiasp, and lispro insulin pens, which should have been discarded 28 days after opening according to the manufacturer's recommendations. Additionally, the medication cart was observed to be unlocked and unattended on multiple occasions, with staff and residents passing by, creating a potential risk for unauthorized access to medications. In one instance, a resident was left with medication unattended in their room. The resident had a physician's order for diltiazem ER and gabapentin, which were left on the bedside table in a medication cup. The resident reported not having water to take the medication, which was later confirmed by a housekeeper who found the medication still on the table. The Certified Medication Technician responsible for administering the medication admitted to leaving it with the resident, contrary to the facility's policy that requires staff to watch residents take their medication. Interviews with staff, including LPNs and the Director of Nursing, confirmed that insulin pens should be dated when opened and that medication carts should be locked when unattended. The facility's policies on medication storage and administration were not adhered to, as evidenced by the unlocked medication carts and the failure to date insulin pens. The facility did not provide a policy regarding the storage of medications in a resident's room, further highlighting the lack of adherence to safe medication practices.
Improper Dumpster Maintenance
Penalty
Summary
The facility failed to maintain the dumpster in a manner that would prevent pests and ensure garbage containment, potentially affecting all 69 residents. Observations on three separate occasions revealed that the dumpster, located near the kitchen entrance, had its two plastic lids completely open. Interviews with the Administrator and the Assistant Maintenance Director confirmed that the dumpster should be closed when not in use, and staff had been trained to do so. However, it was noted that the lids were not consistently closed, indicating a lapse in adherence to the expected protocol.
Infection Control Deficiencies in Wound, Incontinence, and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices during wound care, incontinence care, and Foley catheter care for several residents. Specifically, during wound care for Resident #21, the RN did not change gloves or perform hand hygiene after removing the old dressing and before applying a new dressing. Additionally, the Xeroform dressing was placed on a non-sterile towel before being applied to the wound, which was against the semi-sterile procedure expected for such care. Similarly, during wound care for Resident #36, the LPN did not wear a gown as required under Enhanced Barrier Precautions (EBP). Incontinence care for Residents #9 and #60 was also performed without proper hand hygiene and glove changes. CNAs involved in the care did not change gloves or perform hand hygiene after cleaning soiled areas and before touching clean items or the resident's environment. This lack of adherence to hand hygiene protocols was further observed during catheter care for Resident #32, where gloves were not changed after cleaning the peri area and before touching other items. The facility also failed to properly disinfect glucometers between uses for Residents #62, #118, and #119. The RN used an alcohol pad instead of the manufacturer-recommended Sani wipes to disinfect the glucometer, which was insufficient for proper disinfection. Interviews with staff, including the Administrator and DON, revealed a lack of understanding and adherence to the facility's infection control policies, particularly regarding the use of EBP and proper hand hygiene practices.
Failure in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program (IPCP) that included an effective antibiotic stewardship program. The facility's policy, revised in December 2016, required antibiotics to be prescribed and administered under the guidance of the Antibiotic Stewardship Program, which aimed to monitor antibiotic use among residents. However, a review of the program on December 6, 2024, revealed no documentation of antibiotic stewardship tracking. The October 2024 Quality Assurance Performance Improvement (QAPI) meeting minutes for Infection Control included data on infections and antibiotic prescriptions, but there was no evidence of tracking compliance with the stewardship program. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) indicated that while the IP reviewed antibiotic orders and ensured they met criteria, the information was only discussed in monthly QAPI meetings without proper documentation or tracking. This deficiency had the potential to affect all 69 residents in the facility, with one resident currently receiving antibiotics at the time of the review.
Failure to Follow Professional Standards of Practice
Penalty
Summary
The facility failed to follow professional standards of practice for one resident, leading to a deficiency in care. The resident was admitted with severe infections, including cellulitis and necrotizing fasciitis, but the facility did not obtain treatment orders for the wound in a timely manner. The initial assessment did not include a skin assessment, and the physician was not contacted immediately for wound care orders. It took three days for the staff to identify the lack of treatment orders, and the resident was only referred to a wound clinic after this delay. Additionally, the facility failed to administer prescribed antibiotics on multiple occasions without documenting the reasons for the missed doses. The facility's policies on admission assessment, wound care, and medication administration were not followed. The admission assessment should have included a skin assessment, and the attending physician should have been contacted immediately to obtain necessary treatment orders. The wound care policy required a physician's order for wound care, which was not obtained promptly. The medication administration policy required medications to be administered as prescribed, but the resident missed several doses of antibiotics without any documentation or notification to the supervisor. Interviews with the staff, including an LPN, the Assistant Director of Nurses (ADON), and the Director of Nurses (DON), revealed that the facility did not adhere to its policies and professional standards. The DON acknowledged that the admitting nurse should have performed a skin assessment and obtained treatment orders as needed. The ADON and the LPN confirmed that wound care and medication administration should be done per physician's orders and documented accordingly. The facility's failure to follow these procedures resulted in inadequate care for the resident, who was later hospitalized for a gastrointestinal bleed.
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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 West Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Healthcare, West Plains | 0.9 mi | ★★★★★ | 0 | 0 |
| West Vue Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 3 | 0 |
| Willow Care Nursing Home | 17.8 mi | ★★★★★ | 8 | 0 |
| Mountain View Healthcare | 20.8 mi | ★★★★★ | 0 | 0 |
| Shady Oaks Healthcare Center | 23.7 mi | ★★★★★ | 4 | 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.