Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookhaven Nursing & Rehab during CMS and state inspections, most recent first.
A resident with cellulitis, gangrene, and a necrotic left great toe did not receive wound care fully consistent with the wound care FNP’s documented plan of care. The FNP repeatedly ordered daily cleansing with hypochlorous acid, Betadine application, and calcium alginate dressings cut to fit inside the wound, with changes daily and as needed. However, nursing staff entered physician orders that reduced treatment to every other day and omitted or altered the calcium alginate directions, and these discrepancies persisted over multiple weeks. Interviews with LPNs, an RN, the FNP, the physician, the DON, and the Administrator showed that all expected the electronic orders to match the FNP’s recommendations, but they were unaware that the entered orders did not reflect the specialist’s specified frequency and application method, resulting in a failure to provide care per standards of practice and the certified wound care plan.
A resident with dementia and schizophrenia requested pain medication and, after being told to wait, became agitated and struck the medication cart. The CMT responded in a raised voice with a statement perceived as threatening by multiple staff, such as warning it would be the last time the resident hit the cart. Staff interviews and documentation confirmed the CMT's conduct was disrespectful and violated the resident's right to dignity and respect.
A resident with multiple chronic conditions did not receive scheduled medications at the prescribed times, with morning medications administered over two hours late. Staff interviews confirmed that medication administration was frequently delayed due to high workloads, and residents had complained about late medications. The facility lacked an effective system to ensure medications were given within the required time frames.
A resident with complex psychiatric and medical needs did not receive proper pharmaceutical services after returning from the hospital due to staff failing to accurately transcribe, clarify, and administer new medication orders. Several prescribed medications were omitted or incorrectly entered into the EHR, and staff did not consistently document medication administration or reasons for omissions, resulting in the resident not receiving all ordered medications.
The facility failed to enforce its smoking policy, allowing residents to keep smoking materials in their rooms and on their person, contrary to the policy that requires these items to be stored at the nurses' station. Residents with various health conditions, including COPD, were found smoking unsupervised, and staff interviews revealed a lack of adherence to the policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of oversight.
The facility failed to serve food at the required temperature, with residents reporting cold and unappetizing meals. Observations confirmed that food temperatures were below the required 120 degrees Fahrenheit, and staff acknowledged resident dissatisfaction with meal quality.
The facility failed to follow proper food safety protocols by stacking wet dishes, which could lead to contamination. Observations showed numerous dishes stacked upside down with trapped water droplets, contrary to the facility's policy and FDA guidelines. Interviews with dietary staff confirmed the expectation for dishes to be air-dried before stacking, highlighting a deficiency in practice.
The facility failed to maintain an effective infection control program, with deficiencies in TB screening for new hires, improper catheter maintenance, and inadequate hand hygiene and medication administration practices. Staff did not consistently follow protocols for sanitizing shared medical equipment, such as glucometers, increasing the risk of cross-contamination.
A facility failed to complete the required PASARR for a resident with paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident's care plan addressed delusions, but the absence of a PASARR indicates a failure to ensure appropriate care and services. The Business Office Manager could not locate the PASARR documentation, and the Social Services Director stated they try to complete these forms within 48 hours of admission.
A resident with a history of cerebral infarction and Parkinson's disease had inconsistencies in their code status documentation. While the resident's face sheet and care plan indicated a DNR status, the physician's order sheet listed them as a full code. Staff interviews confirmed that the code status should be consistent across all records, but discrepancies were found, highlighting a failure in maintaining accurate documentation.
A resident with a history of osteomyelitis and MRSA experienced a deficiency in care due to the facility's failure to document and treat a worsening elbow wound. Despite the resident's complaints and the presence of drainage, staff did not maintain current treatment orders or consistently document assessments. Interviews revealed communication issues among healthcare providers, contributing to the deficiency.
A facility failed to document regular wound assessments for a resident with a pressure ulcer on the right hip. Despite having a care plan and physician orders, the facility did not consistently record assessments or measurements, leading to a deficiency in care. Interviews revealed that wound assessments were not regularly performed unless by a visiting clinic, and documentation was acknowledged as an issue by the ADON.
Two residents in the facility did not receive their prescribed medications due to unavailability. One resident, with a vitamin B12 deficiency, missed numerous doses of B Complex-Vitamin B12 tablets, while another resident, with constipation and pain, missed doses of Senna Plus and acetaminophen. Staff interviews revealed a lack of communication and follow-up regarding medication availability, and the facility's policy on medication administration was not adhered to, resulting in a deficiency in pharmacy services.
The facility experienced a 12.5% medication error rate due to incorrect Vitamin D3 dosing and unavailability of acetaminophen and Senna Plus for two residents. Additionally, fast-acting insulin was administered without ensuring a meal within the recommended time frame. Staff interviews revealed procedural lapses in medication administration and communication about unavailable medications.
A resident with diabetes was administered rapid-acting insulin but was not provided a meal or snack within the recommended time frame. Observations showed a delay of 54 minutes before a meal was served, contrary to staff interviews indicating meals should be provided within 30 minutes. The facility's policy lacked specific guidance on insulin administration timing.
Failure to Align Wound Care Orders With Wound Specialist’s Plan of Care
Penalty
Summary
The deficiency involves the facility’s failure to provide wound care in accordance with the wound care specialist’s recommendations and to correctly enter and follow wound treatment orders for a resident with cellulitis and gangrene. The resident was cognitively intact, required moderate assistance for transfers, and had impaired skin integrity with bilateral lower leg cellulitis and a necrotic left great toe with dry gangrene. The facility’s wound care policy required specific treatment orders and care plans that reflected the current wound status and appropriate goals and approaches. The care plan and physician orders were supposed to be based on the wound care FNP’s weekly assessments and written recommendations. The wound care FNP documented multiple progress notes specifying that the left great toe wound should be cleansed with hypochlorous acid without rinsing, painted with Betadine, and covered with a calcium alginate dressing cut to fit inside the wound edges, with dressing changes to occur daily and as needed. These recommendations were documented on several dates, including 12/12/25, 12/19/25, and 01/02/26, and the FNP indicated that all orders would remain in effect until discontinued, revised, or replaced. Despite this, the facility’s Physician Order Sheets did not consistently reflect these directions. On 12/15/25, the order for the left big toe was entered as cleansing with hypochlorous acid and painting with Betadine with treatment once every other day, and it did not include the calcium alginate dressing as ordered by the FNP. On 12/19/25, the order was updated to include calcium alginate but specified application to the crevice between the toe and foot once every other day, rather than daily and cut to fit inside the wound as directed by the FNP. The January 2026 Physician Order Sheet still did not reflect the correct daily frequency or the instruction to cut the calcium alginate to fit inside the wound, even after the FNP’s 01/02/26 note again ordered daily dressing changes with calcium alginate cut to fit in the wound base. Nursing staff interviews showed that LPNs believed they were to follow the wound care FNP’s recommendations and that a nurse would enter those recommendations into the computer for the physician to sign, but they were unaware that the treatment frequency had been decreased to every other day and that this change did not match the FNP’s recommendations. The FNP stated that he/she expected staff to follow his/her and the physician’s wound care orders, did not order a decrease in treatment frequency, and was unaware that the facility had reduced the frequency. The physician and DON both stated they expected nurses to enter and follow orders that matched the FNP’s recommendations, but they did not know the entered orders differed from those recommendations. This series of incorrect order entries and failure to align the POS with the wound care specialist’s documented plan of care led to the facility not providing wound care per standards of practice and per the wound care specialist’s certified plan of care for the resident’s left great toe wound. The resident’s care plan updates reflected some of the FNP’s clarifications, such as painting the big toe with Betadine and placing calcium alginate around the toe in the crevice between the toe and healthy tissue, and noted that wound care to the left leg should be done every other day and as needed. However, these care plan entries still did not fully match the FNP’s written orders for daily dressing changes and for calcium alginate to be cut to fit inside the wound edges. Staff interviews confirmed that the process relied on nurses to transcribe the FNP’s recommendations into physician orders, and that the DON and Administrator expected those orders to match the FNP’s notes. The discrepancy between the FNP’s documented orders and the actual physician orders entered and followed by staff, particularly regarding the frequency of treatment and the method of applying calcium alginate, constituted the failure to provide care according to standards of practice and the wound care specialist’s recommendations for this resident. The deficiency is further supported by the fact that multiple staff members, including LPNs, an RN, the FNP, the physician, the DON, and the Administrator, acknowledged that the facility’s practice was to follow the wound care FNP’s recommendations and that the orders in the computer should match those recommendations. Nonetheless, the POS entries did not reflect the FNP’s specified daily dressing changes and detailed application instructions for calcium alginate. The FNP also noted that increased drainage from the toe was related to the resident’s increased activity and did not warrant a decrease in treatment frequency, yet the facility’s orders reduced the frequency to every other day without a corresponding recommendation from the FNP. These documented inconsistencies between the wound care specialist’s certified plan of care and the orders actually entered and followed by the facility staff form the basis of the cited deficiency.
Resident Rights Violated by Disrespectful and Threatening Staff Conduct
Penalty
Summary
A deficiency occurred when a Certified Medication Tech (CMT) spoke to a resident in a disrespectful and threatening manner during a medication pass. The resident, who had diagnoses including unspecified dementia and schizophrenia, approached the medication cart to request pain medication, reporting significant pain at the time. The CMT told the resident to wait, which led to the resident becoming agitated, striking the medication cart, and using derogatory language toward the CMT. In response, the CMT raised their voice and made a statement interpreted by multiple witnesses as threatening, such as, "if you hit my cart again, that will be the last time you hit it," or similar variations. Multiple staff members, including CNAs, nurses, and supervisors, either overheard or were present during the incident and described the CMT's tone as raised, disrespectful, and threatening. Written and verbal statements from staff corroborated that the CMT's response was inappropriate and not in line with resident rights or facility policy, which requires residents to be treated with dignity and respect. The resident expressed feeling uncomfortable and not wanting to be around the CMT due to the interaction. The facility's own policy emphasizes the right of residents to be treated with consideration and respect, and staff interviews confirmed that threatening language toward residents is unacceptable. The Director of Nursing and Administrator both acknowledged that the CMT's statements were disrespectful and should not have been made. The incident was reported and documented by several staff, and the situation was de-escalated after intervention by other staff members.
Failure to Administer Medications Timely According to Policy and Standards
Penalty
Summary
The facility failed to ensure that medications were administered to a resident in accordance with professional standards of quality and facility policy. Observation, interview, and record review revealed that a resident with multiple diagnoses, including bipolar disorder, anxiety disorder, heart failure, and hypertension, did not receive scheduled medications at the prescribed time. The resident's Medication Administration Record (MAR) indicated several medications were scheduled for administration at 8:00 A.M., but on the observed date, these medications were not administered until 10:15 A.M., which was two hours and fifteen minutes after the scheduled time. The resident also reported that medications were frequently not given at the scheduled times, including evening doses being administered late. Interviews with staff, including Certified Medication Technicians (CMTs), Registered Nurses (RNs), Certified Nurse Aides (CNAs), and the Director of Nursing (DON), confirmed that there were ongoing issues with timely medication administration. Staff consistently stated that medications should be administered within one hour before or after the scheduled time, and that administration outside this window is considered late and a medication error. Staff attributed the delays to high medication loads, with one CMT responsible for administering medications to up to 58 residents across multiple halls, making it difficult to adhere to scheduled times. Additional interviews with CNAs revealed that they had received complaints from residents about late medication administration, particularly in the afternoons. The DON and Administrator acknowledged the staffing assignments and the expectation that medications be administered as ordered, but were not aware of the extent of the delays until brought to their attention during the survey. The facility did not have an effective system in place to ensure timely medication administration, resulting in repeated late administration of medications to residents.
Failure to Accurately Transcribe and Administer Medications After Hospital Discharge
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of a resident following discharge from the hospital. Upon the resident's return, staff did not properly transcribe or clarify new medication orders, resulting in discrepancies between the hospital discharge instructions and the medications entered into the facility's electronic health record (EHR). Several medications ordered at discharge, including fluphenazine, Seroquel, ketoconazole, clotrimazole, and Miralax, were not added to the physician's order sheet, and there were inconsistencies in the dosages and administration instructions for other medications such as gabapentin and oxybutynin. Additionally, staff failed to document administration or reasons for omission of multiple medications on the Medication Administration Record (MAR) for the day of the resident's return. The resident involved had a complex psychiatric and medical history, including schizoaffective disorder, bipolar type, PTSD, depression, and a history of suicidal ideation. The care plan required close monitoring, administration of psychotropic medications as ordered, and assessment for side effects. Despite these needs, the facility did not ensure that the resident's medication regimen was accurately reconciled or administered as prescribed after the hospital stay. Interviews with staff revealed confusion about the process for entering and verifying new medication orders, with several staff members unsure of their responsibilities or the accuracy of the orders entered into the EHR. Further, the nurse practitioner and other staff reported that the medication list in the EHR did not match the hospital discharge orders, and it took several days to identify and attempt to correct the discrepancies. During this period, the resident was not receiving all prescribed medications, and staff did not consistently document or clarify missing or incorrect orders. The lack of timely and accurate medication reconciliation and administration directly contravened facility policy and resulted in the resident not receiving necessary pharmaceutical care as ordered.
Failure to Enforce Smoking Policy in LTC Facility
Penalty
Summary
The facility failed to ensure an environment as free of accident hazards as possible by not adhering to its smoking policy. The policy mandates that all smoking materials be kept at the nurses' stations and that residents should not retain smoking materials or lighters in their rooms. However, several residents were found to have smoking supplies on their person and in their rooms, contrary to the facility's policy. This was observed during interviews and inspections, where residents were seen with cigarettes and lighters in their possession and in their rooms. Resident #27, who was diagnosed with chronic obstructive pulmonary disease (COPD) and other health issues, was found to have cigarettes and lighters in his/her room and on his/her person. Despite being assessed as a safe smoker, the resident was not following the facility's policy of keeping smoking materials at the nurses' station. Similarly, Resident #268, who had a history of COPD and other conditions, was not care planned for smoking, and there was no documentation of a smoking assessment. This resident also kept smoking supplies in his/her room and smoked unsupervised. Other residents, such as Resident #49 and Resident #67, were also found to have smoking materials in their rooms and on their person, despite being care planned to store these items at the nurses' station. Interviews with staff, including a CNA and an RN, revealed that residents often carried their own smoking supplies and smoked unsupervised, which was against the facility's policy. The Director of Nursing and the Administrator were unaware of these practices, indicating a lack of enforcement and oversight of the smoking policy.
Deficiency in Food Temperature and Quality
Penalty
Summary
The facility failed to ensure that food prepared and served to residents was palatable and at a safe and appetizing temperature. The facility's policy, as outlined in the Nutrition and Dining Services Manual, requires hot foods to be served at a minimum of 120 degrees Fahrenheit. However, multiple residents reported that their meals were often cold, with specific complaints about cold eggs and low-quality meat. During a resident council meeting, several residents expressed dissatisfaction with the temperature and quality of their meals, indicating that the food was often barely warm or cold. Observations of meal trays confirmed these complaints, with recorded temperatures for various food items falling below the required 120 degrees Fahrenheit. For instance, scrambled eggs were measured at 97.1 degrees Fahrenheit, and a sausage patty at 85.9 degrees Fahrenheit. Additionally, the food was described as bland and unappetizing. Interviews with staff revealed that while tray audits were conducted when complaints were made, the issues with food temperature and quality persisted. The Dietary Manager acknowledged that residents were not satisfied with certain meals, and the Administrator expected staff to adhere to the facility's food service policy.
Improper Dish Drying Practices Lead to Potential Contamination
Penalty
Summary
The facility failed to adhere to proper food safety protocols by not allowing dishes to air dry before stacking them, which could lead to potential contamination or bacterial growth. Observations on multiple occasions revealed that a significant number of plastic bowls, dessert cups, ceramic plates, serving trays, plate covers, and metal steam table pans were stacked upside down while still wet, trapping water droplets and preventing adequate air flow. This practice was contrary to the facility's policy and the 1999 Food Code issued by the FDA, which mandates that equipment and utensils must be air-dried before being stacked or stored. Interviews with dietary staff, including a Dietary Aide, a staff member identified as [NAME] T, and the Dietary Manager, confirmed that dishes should be air-dried before being put away. The Dietary Manager specifically noted that dishes should not be stacked wet due to the risk of bacterial growth. The facility's Administrator also expressed an expectation that staff follow the food service policy, which includes allowing dishes to air dry before stacking. Despite these expectations and policies, the facility's practices did not align with the required standards, leading to the identified deficiency.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection control program, as evidenced by multiple deficiencies observed during the survey. The facility did not adhere to its own policy and standards of practice regarding tuberculosis (TB) screening for new hires. Three staff members, including a CNA, an LPN, and a Dietary Aide, did not receive the two-step tuberculin skin test within the required timeframe. The initial TB tests for these staff members were either delayed or not read within the 48 to 72-hour window, and the second step was not administered according to the recommended schedule. Additionally, the facility failed to maintain catheters in a manner that prevents bacterial contamination. Observations revealed that a resident's catheter bag and tubing were repeatedly found on the ground, potentially introducing bacteria into the system. Staff interviews confirmed that catheter bags and tubing should not be dragging on the floor, yet this practice was not consistently followed. The facility also demonstrated lapses in medication administration and hand hygiene practices. Staff were observed touching medications and the inside of medication cups with bare hands, potentially contaminating the medications. Hand hygiene was not consistently performed during incontinent care or wound care, increasing the risk of cross-contamination. Furthermore, shared medical equipment, such as glucometers, was not properly sanitized between uses, contrary to the facility's policy and manufacturer recommendations.
Failure to Complete PASARR for Resident with Mental Health Diagnoses
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASARR) for a resident with diagnoses of paranoid schizophrenia and major depressive disorder prior to or upon admission. The resident was admitted with a diagnosis that necessitated a PASARR, but the facility did not have documentation of a completed PASARR in the resident's medical record. The Business Office Manager was unable to locate the level one PASARR documentation, and the Social Services Director indicated that they attempt to complete these forms within 48 hours of admission. The resident's care plan included interventions for managing delusions, such as redirecting the resident and administering medication as per physician orders. However, the absence of a PASARR indicates a failure to ensure the resident received appropriate care and services tailored to their mental health needs. The Administrator mentioned that the PASARR was done in 2007 before electronic records, and staff should verify the presence of a DA 124 form upon admission if required by the resident's diagnosis.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status across their medical records, leading to a deficiency. The resident, who had a history of cerebral infarction, Parkinson's disease, cognitive communication deficit, and Type 2 diabetes mellitus, had chosen a Do Not Resuscitate (DNR) status. However, discrepancies were found in the documentation: the resident's face sheet and care plan indicated a DNR status, while the physician's order sheet listed the resident as a full code. This inconsistency was observed despite the resident having signed an Outside the Hospital Do Not Resuscitate (OHDNR) form, which was also signed by the physician. Interviews with various staff members, including CNAs, CMTs, LPNs, and the Director of Nursing, revealed that the code status should be consistent across all documentation, including the resident's door, care plan, and electronic medical records. However, the inconsistency persisted, as evidenced by the red dot on the resident's door indicating a DNR status, while the physician's order contradicted this. The staff, including the Assistant Director of Nursing and the Administrator, acknowledged that the code status should be uniform throughout the resident's chart, highlighting a failure in maintaining accurate and consistent documentation of the resident's wishes.
Failure to Document and Treat Resident's Elbow Wound
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the management of a wound on the resident's left elbow. The resident, who had a history of osteomyelitis and MRSA, experienced an elbow wound that was not consistently documented or treated according to physician orders. The facility's staff did not maintain current lists of orders in the resident's clinical record, leading to confusion and errors in treatment. Additionally, there was a lack of documentation regarding the notification of the physician and assessments of the wound. The resident's medical records showed multiple instances where staff failed to document the assessment or treatment of the elbow wound. Despite the resident's complaints of pain and the presence of drainage, there were no documented orders for treatment of the wound from early November through mid-December. The visiting wound clinic's notes indicated that the wound had worsened over time, with increased drainage and the presence of bone fragments. However, the facility staff did not consistently document these findings or follow up with appropriate treatment orders. Interviews with facility staff revealed a lack of communication and coordination among the various healthcare providers involved in the resident's care. The Assistant Director of Nursing (ADON) and other staff members acknowledged the documentation issues and the challenges posed by the involvement of multiple physicians. Despite the resident's requests for a wound culture and concerns about the worsening condition, the facility did not adequately address these issues, leading to a deficiency in the standard of care provided to the resident.
Inadequate Documentation of Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that a resident with a pressure ulcer received care consistent with professional standards of practice. The resident, who was admitted with an unspecified open wound on the right hip, had a care plan indicating the presence of a pressure ulcer. However, the facility did not document regular full wound assessments as required. The resident's medical records showed gaps in documentation, with no assessments or measurements recorded for extended periods, despite the presence of a wound management log and physician orders for treatment. Interviews with staff revealed inconsistencies in the wound assessment and documentation process. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) indicated that wound assessments and measurements were not consistently performed or documented unless conducted by a visiting wound clinic. The ADON acknowledged that documentation was an issue, and the Director of Nursing (DON) stated that wound monitoring should be completed weekly and documented in the nurses' notes. The resident expressed that staff did not assess the wound on a weekly basis, and the facility's policy required documentation of skin assessments, including any abnormalities. Despite the policy and the resident's care plan, the facility did not maintain consistent documentation of the wound's condition, leading to a deficiency in providing appropriate pressure ulcer care and preventing new ulcers from developing.
Medication Unavailability for Residents
Penalty
Summary
The facility failed to provide pharmacy services to meet the needs of each resident, as evidenced by the unavailability of ordered medications for two residents. Resident #49, who was admitted with a diagnosis of vitamin B12 deficiency, did not receive the prescribed B Complex-Vitamin B12 tablets for a significant portion of November and all of December. The Medication Administration Record (MAR) indicated that the medication was unavailable for 18 out of 30 doses in November and all 13 doses in December. The resident confirmed during an interview that there were times when medications were not available, and the Assistant Director of Nursing (ADON) was unaware of the issue until it was brought to her attention. Resident #13, who was admitted with diagnoses including constipation and pain, also experienced medication unavailability. The resident's MAR showed that Senna Plus, a laxative, was not administered for several days in December due to unavailability. Additionally, acetaminophen, prescribed for pain management, was not administered for multiple doses. Interviews with staff, including Certified Medication Technicians (CMTs) and Licensed Practical Nurses (LPNs), revealed that there was a lack of communication and follow-up regarding the unavailability of medications, and the staff did not consistently notify the appropriate personnel to address the issue. The facility's policy on medication administration requires that medications be given as ordered by the physician. However, the report highlights a breakdown in the process, as staff failed to ensure that medications were available and administered as prescribed. Interviews with the Director of Nursing (DON) and the Administrator confirmed that staff should follow procedures for medication administration and notify the appropriate personnel if medications are unavailable. Despite these expectations, the residents went without their prescribed medications for extended periods, indicating a deficiency in the facility's pharmacy services.
Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5 percent, resulting in a 12.5 percent error rate. This was due to four medication errors out of 32 opportunities, affecting two residents. For one resident, the Certified Medication Tech (CMT) administered incorrect doses of Vitamin D3 and failed to provide acetaminophen and Senna Plus due to unavailability. The CMT acknowledged the absence of these medications and had informed the Assistant Director of Nursing (ADON) about the supply issue. Interviews with staff revealed a lack of adherence to procedures for checking emergency kits and notifying physicians when medications were unavailable. Another deficiency involved the administration of insulin to a resident. The Licensed Practical Nurse (LPN) administered fast-acting insulin without ensuring the resident received a meal within the recommended time frame. The resident did not receive a meal until 54 minutes after insulin administration, contrary to best practices that suggest a meal or snack should be provided within 30 minutes. Interviews with staff, including the ADON and Director of Nursing (DON), confirmed the expectation that meals should be provided promptly after insulin administration. The facility's policy on medication administration lacked specific guidance on insulin administration timing, contributing to the deficiency. Staff interviews highlighted inconsistencies in following procedures for medication administration and communication regarding unavailable medications. The Director of Nursing and Administrator emphasized the importance of adhering to physician orders and ensuring residents do not go without necessary medications.
Failure to Provide Timely Meal After Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of rapid-acting insulin. Resident #42, who has diagnoses including chronic kidney disease, high blood pressure, diabetes, and weakness, was administered six units of insulin aspart subcutaneously at 11:21 A.M. However, the resident was not provided with a meal or snack within the recommended time frame after insulin administration. Observations showed that the resident had not received a lunch tray 54 minutes after the insulin was given, and there were no snacks visible in the resident's room. Interviews with staff, including LPNs, CMTs, the ADON, and the DON, revealed inconsistencies in the understanding and implementation of insulin administration protocols. While some staff members indicated that a meal or snack should be provided within 30 minutes of insulin administration, others suggested that waiting up to an hour might be acceptable, though not best practice. The facility's policy on medication administration did not provide specific guidance on the timing of meals or snacks in relation to insulin administration, contributing to the deficiency observed.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 138 citations issued within 25 miles in the last 12 months — including the 1 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 Springfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilson's Creek Nursing & Rehab | 0.1 mi | ★★★★★ | 4 | 0 |
| Springfield Skilled Care Center | 1 mi | ★★★★★ | 7 | 0 |
| Manor At Elfindale, The | 2.3 mi | ★★★★★ | 10 | 0 |
| Magnolia Square Nursing And Rehab | 3.3 mi | ★★★★★ | 1 | 0 |
| Springfield Rehabilitation & Health Care Center | 3.5 mi | ★★★★★ | 0 | 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.