Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chariton Park Health Care Center during CMS and state inspections, most recent first.
A resident with a history of elopement, polysubstance abuse, and high elopement risk was not consistently monitored as ordered, with multiple missed 15-min face checks and repeated unsupervised access outside the unit. The resident previously left through a plexiglass window and later climbed onto the roof and over a fence from the courtyard, then got into an SUV waiting in the parking lot. The resident reported leaving to buy drugs for other residents and selling meth inside the facility. Staff also left a chemical storage room on a secured unit unlocked and open, with residents passing by and hazardous cleaning chemicals inside.
A resident with cognitive intactness, severe mental health diagnoses, and dependence on staff for toileting and transfers was not given a dignified toileting option. After a hoyer transfer, the resident asked to use the bathroom, but staff did not provide a toilet or commode option and the resident later refused the bedpan and had a BM in bed. The resident said staff told him/her to soil himself/herself, which caused embarrassment and feelings of being dirty and undignified; staff and leadership acknowledged that residents should be offered available toileting options and should not be told to soil themselves.
Failure to Protect Residents from Physical Abuse and Verbal Threats A resident with serious mental health diagnoses was involved in a peer altercation that escalated from a money dispute to physical violence, and another resident hit him/her multiple times in the head. The resident was later sent to the hospital with a head hematoma, blurred vision, shoulder pain, and neck strain. The facility’s investigation did not identify the event as abuse. The facility also failed to protect another resident from verbal abuse and intimidation when three residents entered the resident’s room and threatened to beat him/her if he/she reported them for bringing drugs into the facility. Staff reported the residents were yelling and arguing, but the threatened resident’s record did not document the incident.
A resident with schizoaffective disorder, bipolar disorder, and psychosis repeatedly exposed his/her genitals, made sexual comments, and rubbed or humped other residents on a secured unit, while staff and leadership knew about the behavior but did not document active monitoring or update the care plan with interventions. The facility also did not investigate a separate incident in which three residents entered another resident’s room, argued, and verbally threatened to beat him/her up; staff separated them and obtained PRN antipsychotic medication, but no root cause review was completed.
Food items were found undated, uncovered, or improperly sealed in kitchen storage and refrigeration, including pitchers of tea and lemonade, bowls of pudding and brownies, and open bags of flour and sugar in an uncovered tub. Both dining room ice/water dispensers had visible debris on the spouts, dietary staff were observed plating food with beard restraints that did not fully cover facial hair, and the floor by the ice machine was soiled with dirt and dried food crumbs.
The facility failed to maintain complete Legionella water management policies and did not monitor cold water temperatures or maintain a water flow map. Staff also failed to follow infection control practices during resident care, including missing hand hygiene during blood glucose checks and medication passes, not cleaning insulin pen hubs before needle attachment, placing soiled linens on the floor, and not using EBP PPE or proper hand hygiene and gloves during resident care activities.
Call lights were not kept within reach for multiple residents despite care plan directions and facility policy. Surveyors observed call lights left on a recliner, on the floor under or beside the bed, clipped to a light fixture, or placed behind a wheelchair, and residents or staff confirmed the lights could not be reached for use.
Unsafe and Unhomelike Environment in Resident Areas: Surveyors observed multiple areas of disrepair throughout the facility, including dust, urine odor, missing toilet paper holder, damaged sink and door surfaces, broken privacy curtains, patched and unpainted drywall, mismatched paint, and boards covering windows in occupied resident rooms. Shower rooms had rusted heaters, peeling paint, black or mold-like buildup, hair on the floors, and damaged fixtures, while the dining room had torn, sagging curtains and a boarded window. Staff reported repairs were entered into an app, but several issues had remained unresolved for extended periods.
Failure to Report Resident-to-Resident Altercation: Staff failed to immediately report a physical altercation between two cognitively intact residents to the Administrator, despite the facility abuse policy requiring immediate reporting of suspected abuse. One resident reported being punched in the arm and chest, the other admitted punching the resident multiple times, and a CMT witnessed the incident and separated them. The interim DON said she did not recognize it as a physical altercation, and the Administrator stated she was not informed.
MDS coding was inaccurate for three residents. One resident with repeated falls and a stage II pressure ulcer had MDSs that did not reflect the falls or unhealed pressure ulcer during the look-back period. A second resident with blindness and low vision was coded with adequate vision, higher care needs, and incontinence that did not match observations and the resident’s statements. A third resident was coded with schizophrenia on the MDS even though the record showed schizoaffective disorder and no documentation of schizophrenia.
A facility failed to maintain comprehensive, person-centered care plans for four residents when current needs were not reflected in the plans. One resident had chronic pain with frequent PRN opioid use and ongoing pain complaints, but the care plan did not address pain or narcotic use. Another resident’s smoking assessment identified tobacco use and multiple safety concerns, yet the care plan had no smoking interventions. A third resident had a newly placed urinary catheter after hospitalization, but the care plan did not include the catheter. A fourth resident had a new stage II pressure ulcer with wound care orders, but the care plan was not updated to include the wound.
Care plans were not kept current for multiple residents. One resident’s plan listed full code, communication risk, regular diet, and total ADL dependence even though the MDS, POS, and resident interview showed DNR status, intact cognition, and less assistance needed. Other residents had plans that did not match DNR orders, diet changes, guardian status, repeated falls and fall interventions, or current transfer needs such as hoyer lift use and two-person assistance. Staff and the administrator acknowledged that care plans should reflect the most current level of care, but several plans remained inaccurate.
Trauma-informed care assessments and care plans were incomplete for three residents with PTSD and other mental health diagnoses. The facility documented no trauma history, symptoms, or triggers on assessments and did not include individualized trigger-specific interventions in the care plans, despite residents reporting multiple traumas and specific triggers such as loud noises, yelling, dishonesty, opposite-sex conflict, and perceived threats. Staff interviews showed limited awareness of resident-specific triggers, and one resident reported being triggered by a fire alarm test without advance warning.
Nurse aides were not completed with CNA training within the required 4-month timeframe. Records showed multiple employees hired as NAs had no documentation of finishing training, while interviews and observations showed they were assigned to direct care and performing hands-on tasks such as peri-care, transfers, dressing, and Hoyer lift assistance. HR and the DON/Administrator said NAs were expected to complete certification within 120 days, but the facility still had staff working in NA roles without completed training.
Discontinued and completed meds were left stored in the Station One med room beyond the facility’s required destruction timeframe. Multiple residents had leftover meds, including atorvastatin, haloperidol, hydroxyzine, ibuprofen, and lactulose, still in an upper cabinet even though staff said meds were usually destroyed weekly or at least monthly by the Staffing Mentor/Educator, ADON, and Administrator.
Staff failed to follow the ravioli bake recipe and did not prepare enough food for the lunch meal. The menu called for ravioli bake, cauliflower, breadstick, and an apple orchard bar, but the kitchen ran out of ravioli bake and rolls during service. Most residents on one hall were given a ham and cheese sandwich and biscuits instead of the planned entrée and rolls. The recipe also required cottage cheese and mozzarella cheese, but the cook did not add them because he/she thought they were already inside the ravioli.
Food Served Cold and Poor Quality in LTC Dining Service A facility failed to serve food items at proper temperatures and to preserve flavor and appearance. Multiple residents reported meals were often cold, bland, rubbery, greasy, undercooked, overcooked, or mushy, and said condiments were not provided with meals. Surveyors observed lunch items served below acceptable temperatures, including a missing entrée after the facility ran out, cold vegetables, and hot items such as chicken teriyaki and a vegetable medley served at temperatures the Dietary Mgr said were below the minimum.
A resident with a documented fish and seafood allergy was served fish, and afterward nursing notes documented itching, a rash, and Benadryl use after the fish contaminated the resident’s food. In separate incidents, one resident did not receive requested milk with lunch, and another resident received a cheese sandwich made with bread heels instead of the ham and cheese sandwich shown on the menu and preferred by the resident.
Nurse aides employed by the facility were required to sign agreements to repay the $700 CNA course cost through paycheck deductions, with any remaining balance taken from the final paycheck if employment ended early. HR stated she was instructed to collect repayment from each paycheck and was unaware of the regulation prohibiting charges to employed nurse aides for CNA training. The Administrator confirmed the facility paid for CNA classes and then required repayment from the aides.
Call lights were not audible outside the Station One nursing station, and staff had to rely on seeing lights above resident doors to know when a call light was activated. Observations showed call lights remained on for several minutes without staff reaching the end of the hall, and staff interviews confirmed they could only hear the signal inside the nursing station. An LPN, CNAs, and an NA all reported that some hallway lights were not visible from key areas, and the Administrator stated the call lights were expected to be audible outside the nursing station.
Insufficient Dining Room Seating: The Station One dining area did not have enough standard-height chairs for all residents who wanted to dine there. During meal service, residents were observed eating while standing, using wheeled walker seats as tables, sitting on the floor, or taking trays back to their rooms because no chairs were available. Residents and an LPN reported the dining area was often too full, and the Administrator stated there should be enough chairs for all residents who wanted to sit in the dining room.
Failure to Protect Residents After Physical Altercation: Two residents were involved in a physical altercation after a verbal exchange, but staff did not call a Code Green, did not ensure timely injury checks or monitoring, and did not keep the residents separated during the incident. One resident punched the other multiple times, threats were exchanged, and staff later described the event as more of an argument rather than a physical altercation. The DON said the incident was not processed as a physical altercation, and the Administrator said she was not notified that day.
A resident with schizoaffective disorder, substance abuse history, suicidal ideations, and prior elopements was identified as an elopement risk and placed on intensive monitoring with q15‑minute face checks. Despite this, staff did not consistently or timely perform and document the required checks, often only opening the door to see if the resident was present and acknowledging being behind due to a busy shift. During this time, the resident used a metal watch band to remove a window security block, opened the window, pushed out the screen, exited into a fenced courtyard, moved a picnic table to climb onto the roof, then jumped down outside the fenced area and walked several blocks away before being noticed by an off‑duty employee and contacted by police.
A resident with schizoaffective disorder, PTSD, substance use history, and prior suicidal ideation had care-planned coping mechanisms that included watching calming TV programs and gaming. After staff removed items with cords, including the TV and gaming system, the resident was placed on 1:1 observation but was not provided access to the TV despite repeatedly requesting it as a coping tool. The assigned staff member had no prior 1:1 experience and focused only on physical supervision, while other team members were unaware of the resident’s escalating distress and requests. The resident became increasingly agitated, overturned carts, broke a window, and used a glass shard to cut the forearm, requiring ED and psychiatric care. Following the resident’s return, staff failed to thoroughly remove remaining glass shards from the room, allowing the resident to find and reuse shards on multiple occasions to cut the same forearm while alone. Although the care plan was updated to reflect high suicide risk and called for a written safety plan and specific self-harm interventions, the record showed no evidence that a written safety plan was developed with the resident, demonstrating a failure to implement person-centered behavioral health services and maintain a safe environment.
A resident with a history of aggressive behaviors was sent to a hospital for psychiatric evaluation after multiple assaults on staff. The facility issued an immediate discharge notice while the resident was hospitalized, but failed to specify an appropriate discharge location as required, instead listing the psychiatric hospital. The discharge notice was not amended to correct this, resulting in a deficiency.
A resident with a history of aggressive behavior and mental illness was not provided with the required level of supervision, resulting in an unprovoked physical assault on another resident in a vending room. The assaulted resident sustained facial lacerations requiring sutures. The facility's existing interventions and monitoring failed to prevent this incident, despite documented risks and care plan requirements.
Residents on the secured unit were routinely provided only plastic forks and spoons, with no knives, making it difficult to eat certain foods and leading some to use their hands. Staff and residents reported that plastic utensils were used to avoid delays in smoke breaks caused by the need to account for metal silverware, rather than based on resident preference or safety needs. This practice did not align with the facility's policy to promote dignity and consider resident preferences.
A resident with a history of substance abuse was admitted without staff completing the required search and inventory of personal belongings, allowing the resident to bring in and share illegal drugs and prescription medication with others. Multiple residents subsequently tested positive for methamphetamines and THC. Staff interviews confirmed the search was not done due to competing priorities, and leadership was unaware the protocol had not been followed.
Staff failed to document the clinical rationale for administering PRN antipsychotic and antianxiety medications to a resident with multiple psychiatric diagnoses. Despite facility policy requiring assessment and documentation of behaviors or symptoms justifying PRN use, staff administered these medications without recording the necessary behavioral evidence in the progress notes, as confirmed by MAR reviews and staff interviews.
Facility staff did not notify a resident's physician, NP, or guardian about significant changes in the resident's condition, including refusal of diagnostic procedures, ongoing weight loss, and low blood pressure readings, despite facility policy requiring such notifications. The resident had severe cognitive impairment and a guardian, but documentation and interviews confirmed that notifications were not consistently made regarding these critical health events.
The facility did not follow physician orders to provide double portions or double entrees at meals for several residents, as observed during meal service and confirmed by resident interviews. Despite documented orders and care plans indicating the need for increased food portions, dietary staff did not serve the prescribed amounts, citing budget cuts. Key staff members, including the DON, Administrator, and Dietitian, were unaware of the change and stated that physician orders should be followed.
A facility failed to provide adequate supervision after an altercation between two residents, leading to a second incident involving another resident. Despite being on one-on-one supervision, a resident approached others in the dining room, resulting in a physical altercation. Staff interviews revealed a lack of effective intervention and communication, contributing to the deficiency.
A resident with a history of aggression physically assaulted another resident after a verbal altercation. The facility staff failed to separate the residents or monitor the aggressive resident adequately, leading to the incident. The aggressive resident's care plan lacked necessary interventions, and staff were unaware of the incident's severity.
A facility failed to report a resident-to-resident abuse incident to the state agency. The incident involved a verbal and physical altercation between two residents, resulting in physical harm. The facility's policy requires immediate reporting, but the incident was not documented, and the resident's legal guardian, physician, or medical director were not notified. Staff interviews revealed a lack of awareness and communication about the incident.
A resident reported being verbally and physically attacked by another resident, but the facility failed to investigate the incident. The activity director intervened during the altercation, but the administrator and DON were unaware of the physical attack and no investigation was conducted. This resulted in a deficiency in handling abuse allegations.
A resident with mental health disorders engaged in inappropriate text communication with an LPN, who responded to the resident's requests for a sexual relationship via social media. The resident was cognitively intact but had hallucinations and delusions. The facility's policies prohibit such interactions, and the incident was discovered during an unrelated investigation.
The facility did not assess the ability of three residents to consent to sexual relations, resulting in a failure to protect one resident from sexual abuse. One resident, with mood disorders and mild mental retardation, reported being forced into oral sex by another resident with oppositional defiant disorder and moderate intellectual disabilities. The facility's policies on assessing consent capacity and preventing non-consensual sexual activities were not effectively implemented. Staff awareness of sexual activities and lack of intervention, along with concerns from legal guardians, highlighted deficiencies in supervision and adherence to guidelines.
The facility failed to store, prepare, and serve food in accordance with professional standards, leading to multiple deficiencies in food safety and sanitation. Observations revealed improperly sealed food items, unsanitary storage conditions, uncovered trash cans, dirty ice and water dispensing machines, and poor hygienic practices by staff.
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents of staff being rude, dismissive, and using inappropriate language towards residents. Residents reported fear of retaliation for filing grievances, and specific staff members were identified as frequently mistreating residents. Observations and interviews confirmed these issues.
The facility failed to protect residents' rights to retain and use personal possessions, specifically instant coffee, by keeping it locked up and controlling access times. This affected eight residents, including those with guardians and those who were cognitively intact. Residents expressed frustration over the policy, and there was no documented reason in their medical records to justify the restriction.
The facility failed to provide reasonable accommodation for a resident who required assistance to get out of bed and had a broken wheelchair. Additionally, the facility did not provide adequate seating in the Station 2 dining area, forcing residents to eat with trays on their laps due to insufficient chairs and table space.
The facility failed to promptly address residents' concerns voiced in resident council meetings and did not hold monthly meetings as required. Various issues, including missing clothing and dietary requests, were not documented or resolved. Interviews revealed a lack of clarity and consistency in the process for addressing concerns, with lapses occurring during a transition period.
The facility failed to maintain a clean, sanitary, and orderly environment, with multiple deficiencies observed in resident rooms and common areas, including torn drywall, missing paint, water stains, and damaged furniture. A resident reported issues with a non-functional cold-water faucet and the removal of their TV, which had not been replaced despite requests. Staff interviews revealed a lack of clarity regarding cleaning responsibilities and insufficient maintenance efforts.
The facility failed to ensure residents knew how to file grievances, where forms were located, or how to complete them. Multiple residents expressed fear of retaliation and reported unresolved issues, such as missing clothing. The Social Services Director was unaware of her role in the grievance process, and no grievances had been filed since she assumed the role.
The facility failed to complete required pre-employment screenings for four of eight sampled employees, including criminal background checks, Employee Disqualification List checks, and Nurse Aide Registry checks, as mandated by facility policy. These checks were either not completed or were conducted after the employees had already started working.
The facility failed to ensure proper medication administration and monitoring, including preparation and administration by the same staff, obtaining physician orders for self-administration, completing accuchecks, and documenting narcotic counts.
The facility failed to provide an ongoing program of meaningful activities to meet the interests and well-being of residents. Several residents were observed with no staff interaction or activities, and there was a lack of documented participation in activities for extended periods. The Activity Director confirmed the lack of scheduled activities on weekends and evenings and acknowledged the need for more one-on-one programming for certain residents.
The facility failed to ensure the safety of a resident with suicidal ideations by not removing plastic bags from their room and not documenting increased monitoring. Additionally, the facility did not use wheelchair foot pedals for another resident, and failed to prevent a third resident from being transported unsafely in a rollator walker by another resident.
The facility failed to offer sufficient fluids to maintain proper hydration and health for three residents. Observations showed that residents did not have water pitchers or glasses of fluids in their rooms, despite the facility's policy. Staff interviews confirmed that water pitchers were either broken or not replaced, and fluids were not consistently offered as required.
The facility failed to ensure that two nurse aides completed a CNA training program within four months of their employment. The Administrator admitted awareness of the timeline but stated that the aides had 'slipped through the cracks.' The facility did not have a specific policy on CNA training programs.
Inadequate supervision allowed repeated elopement and unsecured chemicals
Penalty
Summary
The facility failed to provide adequate supervision for a resident who was under guardianship, lived on a locked behavior unit, and had a documented history of elopement and polysubstance abuse. The resident was identified as high risk for elopement in the care plan and elopement risk evaluation, with instructions that the resident be monitored closely, remain in view when outside, not go into the courtyard without staff supervision, and receive face checks or intensive monitoring per facility protocol. The facility policy stated that residents at risk for elopement were to receive adequate supervision and that alarms were not a replacement for necessary supervision. The record showed repeated gaps in the required monitoring. Documentation of 15-minute face checks contained multiple intervals far longer than 15 minutes, including gaps of more than an hour and several gaps of multiple hours. On one day, the resident had face checks documented in the early morning and then no further documentation until mid-afternoon. Nursing notes also documented the resident as being on 15-minute checks, but the monitoring record did not consistently reflect that level of observation. The resident had already left the facility previously by going out through a plexiglass window, hopping a fence, and getting into a car in the parking lot. After that event, the resident was placed on one-on-one supervision and then on 15-minute face checks. Later, while in the locked behavioral unit courtyard, the resident climbed onto the roof and over a fence without being seen by staff. Staff outside the courtyard observed the resident leave in an SUV that was waiting for the resident. The resident told staff and police that he/she left to buy drugs for other residents and reported selling methamphetamine inside the facility. Another resident reported purchasing illegal drugs from the resident, and the resident stated he/she had left the facility multiple times before to obtain drugs for others. The facility also failed to secure hazardous chemicals in a storage room on the secured behavioral health unit. During observation, the chemical storage room door was open and later was found not latched and able to be opened freely, while residents walked past and no staff were present on the hall. The room contained multiple bottles and buckets of cleaning chemicals, including acid bowl cleaner, restroom disinfectant, degreaser, peroxy products, delimer, and dish detergents. The MSDS sheets for several of these products identified them as hazardous, corrosive, harmful if swallowed, or requiring locked storage.
Failure to Preserve Resident Dignity During Toileting
Penalty
Summary
The facility failed to treat one resident with dignity and respect when staff did not provide a reasonable toileting accommodation and told the resident to urinate and defecate in the bed. Resident #79 was cognitively intact, had diagnoses including generalized anxiety disorder, major depressive disorder, borderline personality disorder, PTSD, agoraphobia with panic disorder, need for assistance with personal care, and a closed displaced intertrochanteric fracture of the right femur. The resident’s care plan and MDS showed dependence on staff for toileting hygiene, personal hygiene, and toilet transfers, and that the resident was frequently incontinent of bowel and bladder. During observation, staff transferred the resident from a wheelchair to the bed with a hoyer lift. After the transfer, the resident said he/she wanted to use the bathroom. NA S asked whether staff should remove the resident’s pants so he/she could go and then be cleaned afterward. The resident appeared uncomfortable with the number of staff present and the state agency staff left the room. Later that day, the resident refused the bedpan and had a bowel movement in the bed, after which staff provided perineal care. The resident stated that the bedpan had previously left an indentation when staff left him/her on it for a long period of time, and since then he/she feared being forgotten when using it. The resident said staff never offered a way to transfer him/her to a toilet or commode, did not like being told to soil himself/herself, and felt embarrassed, dirty, and undignified. NA S said the resident sometimes refused the bedpan and that he/she did not believe the facility had a hoyer lift pad with an opening for commode use. An LPN and the interim DON stated it was not acceptable to have a resident soil themselves and that staff should offer every available option, while the Administrator stated staff should offer the toilet or commode first and that the facility had a hoyer lift pad with a hole for transfer to the toilet or commode.
Failure to Protect Residents from Physical Abuse and Verbal Threats
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse when another resident struck him/her multiple times in the head during a resident-to-resident altercation. The resident who was struck had diagnoses including bipolar disorder, mood disorder, anxiety disorder, oppositional defiant disorder, and schizophrenia, with documented emotional dysregulation, aggression, impaired impulse control, limited insight and judgment, and difficulty interacting appropriately with others. The incident began after a dispute involving money and video games, with the resident reporting that another resident had given money for video games and later accused him/her of taking the money and not returning with the games. According to the resident’s account, the confrontation escalated in the dining room after verbal exchanges with another resident and comments from a third resident. The resident stated that another resident pushed him/her to the floor, pinned his/her arms down, and hit him/her on the side of the head and face while he/she was on the floor. The resident was later sent to the hospital with a hematoma on the left temple, head pain, blurred vision, and left shoulder pain, and hospital records documented an unspecified head injury, left shoulder pain, and neck strain. The facility’s investigation described the event as physical aggression not involving the head and stated it was not abuse or neglect. The facility also failed to ensure a second resident was free from verbal abuse and intimidation when three residents entered the resident’s room and threatened harm if the resident reported them for bringing drugs into the facility. One of the involved residents stated that he/she told the resident it would not be wise to snitch and that they would beat him/her up if he/she did not stop talking. Another involved resident confirmed that the group went to the room because the resident had accused them of bringing and using drugs in the facility and admitted making a threatening statement. Staff reported that all of the residents were yelling and arguing in the room, and the incident was not documented in the threatened resident’s record.
Failure to address sexually inappropriate behavior and resident-to-resident threats
Penalty
Summary
The facility failed to develop and implement meaningful interventions, including non-pharmacological interventions and alternate strategies, for a resident with serious mental illness and a history of behavioral problems who displayed sexually inappropriate behaviors toward other residents on a secured locked unit. The resident had diagnoses including schizoaffective disorder, bipolar disorder with psychotic features, and unspecified psychosis, and the PASRR described limited insight, poor judgment, behavioral difficulties requiring 24-hour monitoring, and a need for a structured environment. The resident’s care plan identified a history of behavioral challenges, impaired social interaction, and a need to intervene to protect the rights and safety of others, but the record showed the resident’s sexual behaviors were not actively monitored on the psychiatric problem list and the care plan was not updated after staff documented sexual comments, genital exposure, and other sexually inappropriate conduct. Staff and residents reported repeated incidents in which the resident exposed his/her genitals, made sexual comments, and rubbed or humped other residents while exposed. One progress note documented the resident exposing his/her genitals, cursing, and making inappropriate sexual comments, and the resident stated, “I’m trying to get laid.” The Activity Director said the resident’s sexual behaviors had been reported to management and nursing staff and nothing had been done about it. Multiple residents stated the behavior happened regularly, made them uncomfortable, and caused them to avoid the resident. A CNA said the resident exposed his/her genitals all the time, sometimes became aggressive with other residents, and staff were supposed to separate the resident from others when this occurred. The Administrator acknowledged awareness of the sexual behaviors but said she did not know what to do about them and expected the care plan to reflect interventions. The facility also failed to investigate and address the root cause of an incident involving three residents who intimidated and verbally threatened another resident. On the day of the incident, staff documented that the residents were verbally abusive with peers and received PRN antipsychotic medication, but the record did not document that they were in another resident’s room threatening him/her or that interventions from their care plans were used. Interviews showed the three residents went into the other resident’s room after an accusation about drugs in the facility, argued with the resident, and told him/her not to keep “running his/her mouth,” with one resident stating they were going to beat him/her up. Staff separated the residents and obtained PRN medication, but the Administrator later stated she did not know about the incident, no root cause investigation was completed, and residents threatened each other all the time.
Improper Food Storage, Unsanitary Ice Machines, and Inadequate Beard Restraints
Penalty
Summary
Food items were found improperly stored and labeled in the kitchen and dry storage areas. A refrigerator contained six pitchers of lemonade, including one dated 4-25, and eight pitchers of tea that were undated. The same refrigerator also contained ten uncovered bowls of pudding and brownies that were undated. During interview, Dietary Staff Y said older pitchers were placed in front and newer pitchers in back, and that the bowls of pudding and brownies were going to be thrown away but had not been. In the dry storage room, a large white plastic tub on wheels held open 25-pound bags of all-purpose flour and granulated sugar, and the tub lid was missing. The Dietary Manager stated staff should label, date, and properly cover food items, date each beverage pitcher, and close or seal the flour and sugar bags. The ice/water dispensing machines in both dining rooms had buildup on the dispensing spouts. Observations showed white crusty debris, dark-colored debris, and rusty-colored debris on the Station One machine at 8:29 A.M. and on the Station Two machine at 11:16 A.M. The Maintenance Supervisor said the vendor came quarterly and maintenance staff were instructed not to touch the units because it would void the warranty. The Dietary Manager said the vendor maintained the machines but she was unsure how often deep cleaning and sanitizing occurred, and dietary staff only wiped the exterior and cleaned the spout if debris was noticed. In addition, Dietary Staff O and Dietary Staff M were observed with facial hair that was not fully covered by beard restraints while plating food on the tray line and over steam table pans. The Dietary Manager stated beard restraints should cover all facial hair, including anything more than light stubble. An area of tiled floor by the ice machine was also observed soiled with dirt and dried food crumbs, and the Dietary Manager said dietary aides cleaned the floors daily on each shift.
Infection Control and Water Management Failures
Penalty
Summary
The facility failed to develop complete policies and procedures for monitoring its water system and for implementing Legionella surveillance. The policy did not identify who was responsible for the water management program, the members of the water management team, the specific items to be monitored with measurable parameters, or the acceptable ranges and actions to take when values were outside those ranges. The facility also did not have a water flow map showing the hot water heaters or how water flowed through the building, and its temperature logs for February, March, and April 2026 documented only hot water temperatures and did not include cold water temperatures. During observation, the cold water in the tub in the 100 hall shower room measured 82.2 degrees F and the hot water measured 106.5 degrees F. At an occupied resident room sink, hot water measured 74.8 degrees F after two minutes and 112 degrees F after five minutes. At another occupied resident room sink, hot water measured 105.2 degrees F after five minutes, and at a third occupied resident room sink, hot water measured 106.1 degrees F. The interim DON said she did not know about a water management team. The Maintenance Director said staff checked hot water temperatures, did not check cold water temperatures, did not know the proper hot water range, and did not have a water flow map. He also said the facility tested for Legionella when a vendor told them to and that there was no water management team. The facility also failed to follow infection control practices during resident care and medication administration. A CMT performing a blood glucose check for one resident did not perform hand hygiene before putting on gloves or after removing them. Another CMT administered medications to three residents without washing or sanitizing hands between residents, and during one medication pass a pill fell to the floor and was picked up and later placed in a sharps container without hand hygiene. An LPN failed to clean the hubs of insulin pens with alcohol before attaching needles for insulin administration to four residents. Additional observations showed soiled linens from one resident were placed directly on the floor during incontinent care, enhanced barrier precautions were not followed for a resident with an indwelling urinary catheter when linens were changed without a gown, and another LPN failed to perform hand hygiene and glove use appropriately during tube feeding, medication administration, and blood sugar monitoring for two residents.
Call lights left out of residents’ reach
Penalty
Summary
The facility failed to ensure call lights were within reach for five residents, contrary to the residents’ care plans and the facility policy requiring call lights to be accessible at the bedside, toilet, and bathing area. The policy stated staff would ensure the call light was within reach and secured as needed, and that the call system would be accessible while residents were in bed or other sleeping accommodations. During observation, interview, and record review, surveyors found call lights placed out of reach for residents who were in bed, asleep, or seated in wheelchairs, including lights left on a recliner, on the floor under the bed, clipped to a light fixture, or positioned behind the resident’s wheelchair. Resident #48 was cognitively intact, able to make needs known, and independent for transfers, but had a recent fall with a left humeral head fracture and was identified in the care plan as at risk for falls with instructions to keep the call light within reach. Staff notes showed the resident needed stand-by assistance for ADLs, toileting, and walking. On observation, the resident was in bed while the call light was on a recliner out of reach and later covered by a blanket on the recliner, and the resident stated he/she could not reach it and needed more help after the recent fall. CNA C stated the resident could use the call light if he/she could reach it. Resident #12 had no spoken words, was cognitively intact, and required maximum assistance for bed mobility and transfers. The care plan directed staff to encourage use of the bell and ensure the call light was in reach. Surveyors observed the resident sitting on the ground beside the bed after staff found the resident there, and the call light was coiled around the footboard at the end of the bed and not within reach. Resident #71, who had moderate cognitive impairment and was independent for mobility, had a care plan directing that the call light be within reach and that requests for assistance receive prompt response; surveyors observed the call light on the ground under the bed on two occasions. Resident #11, who was dependent on staff for all transfers and required a mechanical lift, had a care plan directing that the call light and personal items be kept within reach after transfer; surveyors observed the call light clipped to a light fixture and out of reach. Resident #79, seated in a wheelchair next to the bed, had the call light attached at the head of the bed behind the wheelchair, and the resident stated there was no way to reach it and that staff often placed it there even though he/she could not use it to call for help.
Unsafe and Unhomelike Environment in Resident Areas
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment in multiple resident care areas, including occupied resident rooms, bathrooms, shower rooms, the dining room, and privacy curtains. Surveyors observed large amounts of dust on an exhaust fan, a strong urine odor in a shared bathroom, no toilet paper holder with the toilet paper placed on a handrail, a missing piece of porcelain from a sink exposing the black underlayer, and scraped areas on a bathroom door exposing wood. A resident stated it would be nice to have a place for the toilet paper because it frequently fell on the floor. In another occupied room, the privacy curtain between two beds was broken and would not completely close around the beds, and a CNA stated the curtain could not be pulled because it was broken. Additional occupied rooms had multiple patched drywall areas that were not painted or sanded, mismatched paint, and a board covering a window. Residents stated the walls had been in that condition for months to years and that it would be nice to have a nice-looking room. One resident reported the board had covered the window since August 2025. Surveyors also observed environmental disrepair in the Station Two shower rooms and dining room, including rusted baseboard heaters, peeling paint on window frames, floors, walls, and shower enclosures, black or mold-like substances near floors and walls, missing paint, dull and damaged mirrors, clumps of hair on the shower floor, and a poorly fitting plastic cover behind a toilet. In the dining room, a board covered a large window and the curtains were torn, sagging, and not attached in several areas. Staff stated repairs were reported through an app, maintenance patched holes quickly but had not had time to sand and paint them all, shower room floors were an ongoing issue, and boards on windows had been ordered but had remained unresolved for over six months.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to timely report a resident-to-resident altercation to the Administrator, despite its abuse policy requiring all allegations of abuse to be reported immediately. During the incident, Resident #23 struck Resident #88 in the arm and chest multiple times during a smoke break after a verbal exchange involving a staff member’s child. Staff separated the residents, and the interim DON later stated she was notified that morning but did not realize the event was a physical altercation and therefore did not notify the Administrator. The Administrator stated she was not informed that Resident #23 struck Resident #88 or that a verbal exchange occurred, and she expected resident-to-resident altercations to be reported immediately after the residents were separated and safe. Resident #88’s MDS showed the resident was cognitively intact with no hallucinations, delusions, or behaviors, and diagnoses included schizophrenia, schizoaffective bipolar type, personality disorder, and anxiety. Resident #23’s quarterly MDS showed the resident was cognitively intact with no hallucinations, delusions, or behaviors, and diagnoses included traumatic brain injury, anxiety disorder, depression, bipolar disorder, schizophrenia, PTSD, impulse disorder, and dysthymic disorder. Interviews with both residents and another resident confirmed the altercation, with Resident #88 reporting being punched and Resident #23 admitting to punching Resident #88 four to five times. A CMT also witnessed the incident and stated that staff separated the residents and notified the interim DON, but the Administrator was not notified of the physical altercation.
MDS Coding Was Inaccurate for Falls, Wounds, Vision, Function, and Diagnosis
Penalty
Summary
The facility failed to accurately code the MDS for three residents according to the RAI manual. The report states that the MDS process must accurately reflect the resident’s status and include direct observation and communication with the resident and direct care staff. During interview, the MDS coordinator said she had just taken over the facility’s MDSs, had not been to the facility, and did not complete the MDSs for the residents identified in the citation. The Administrator said she expected the MDS to be accurate and coded according to the RAI manual. For one resident with diagnoses including muscle weakness, unsteadiness on feet, gait and mobility abnormalities, lack of coordination, and repeated falls, the record showed multiple falls and a pressure ulcer during the look-back periods. Progress notes documented falls on the floor, out of a wheelchair, and onto a fall mat, as well as a new stage II pressure ulcer on the intergluteal cleft with ongoing wound care. However, the quarterly MDS and significant change MDS did not reflect falls since the prior assessment and did not identify unhealed pressure ulcers. For a second resident with blindness in one eye and low vision in the other, the quarterly MDS coded vision as adequate, indicated assistance levels that did not match observed function, and recorded frequent urinary incontinence and occasional bowel incontinence. Observations showed the resident independently ate after tray delivery, self-propelled the wheelchair short distances, transferred independently between bed and wheelchair, had independent bathroom privileges, had no period of incontinence, and only needed staff to turn on the water and bring towels for bathing. The resident also stated he or she could only see shadows, was independent with eating, transfers, toileting, wheeling short distances, and hygiene, and rarely had urine or bowel accidents. For a third resident, the annual MDS coded schizophrenia even though the medical record showed schizoaffective disorder, bipolar type, and no documentation supported a diagnosis of schizophrenia.
Incomplete Care Plans for Pain, Smoking, Catheter, and Pressure Ulcer
Penalty
Summary
The facility failed to develop and maintain comprehensive, person-centered care plans for four residents when the care plans did not address identified needs related to pain, a pressure ulcer, smoking, and a urinary catheter. The facility policy required comprehensive care plans with measurable objectives, time frames, and interventions based on the resident’s comprehensive assessment, and the interdisciplinary team was responsible for preparing and revising those plans after assessments. In a review of 30 sampled residents, surveyors found that the care plans for the affected residents did not reflect current conditions or ordered care. For one resident with diagnoses including chest pain, cervical radiculopathy, left hand joint pain, low back pain, and other chronic pain, the record showed frequent use of PRN pain medications, including Norco, Tylenol, and Biofreeze, along with physician orders to assess pain every shift and consult pain management. The resident reported ongoing pain during interviews, including chest pain and worsening back pain, and requested pain medication while observed walking in the hallway. Despite this, the current care plan contained no documentation that the resident had pain, used narcotic pain medications, or had interventions to address pain. A second resident had a smoking assessment showing tobacco use, limited or no ROM in the arms or hands, insufficient fine motor skills to hold smoking items safely, and safety concerns related to lighting, holding, and extinguishing tobacco products. The resident also stated that he or she smoked occasionally and had neuropathy in the hands. The care plan, however, did not document smoking, smoking interventions, or the safety concerns identified in the smoking assessment. A third resident had a newly placed urinary catheter after hospitalization for urinary retention, with a urology note documenting the catheter in place, possible diabetic cystopathy, hydronephrosis, and an order for monthly catheter changes. The resident confirmed the catheter remained in place during interview. The care plan did not document the urinary catheter. A fourth resident had a new in-house acquired stage II pressure ulcer in the intergluteal cleft, with wound care orders for daily cleansing and gauze application, but the care plan was not updated to include the pressure ulcer. The Administrator stated the IDT was responsible for completing and updating care plans at risk management meetings, and the MDS Coordinator stated she was responsible for completing new admission and annual care plans but did not know whether a corporate care plan coordinator existed.
Care Plans Not Updated to Reflect Current Resident Needs
Penalty
Summary
The facility failed to update and revise comprehensive care plans so they accurately reflected residents’ current care needs, code status, diet orders, decision-making status, fall risk, and transfer status. In a review of 30 sampled residents, five residents had care plans that did not match current assessments, physician orders, observations, or resident interviews. The facility policy stated that comprehensive care plans were to be developed within 7 days of the comprehensive assessment and reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. For one resident, the care plan listed the resident as full code, at risk for impaired communication, on a regular diet with large portions, and totally dependent for dressing, personal hygiene, and oral care. However, the MDS showed the resident was cognitively intact, could make self understood and understand others, required only partial/moderate assistance for dressing and bathing, and supervision or touch assistance for oral care. The physician order sheet and an emergency cart list showed the resident was DNR, and the resident stated he/she could communicate needs, needed only one staff for some assistance, and did not want CPR. Another resident’s care plan listed a regular diet and full code status, but the physician orders and emergency cart documentation showed DNR status and a mechanical soft diet with ground meat texture and condiments to moisten food. A third resident’s care plan identified a guardian and full code status, while the face sheet and interview showed the resident was his/her own responsible party, had no guardian, and was DNR. The remaining residents also had care plans that did not reflect current conditions. One resident with diagnoses including weakness, unsteadiness, gait abnormality, coordination problems, and repeated falls had a fall care plan marked resolved even though progress notes documented multiple falls, including falls from bed, wheelchair, and while on a fall mat. Staff interviews described the resident as a fall risk with a low bed, fall mat, call light in reach, 15-minute face checks, and frequent reminders to use the call light, but these interventions were not reflected in the active care plan. Another resident’s care plan listed assistance from one staff for toileting and transfers, but progress notes, therapy information, and staff interviews showed the resident required two staff and a hoyer lift for transfers and ADLs, with therapy noting the resident remained a hoyer lift for non-therapy staff. The administrator stated the interdisciplinary team was responsible for updating care plans at risk management meetings, that the care plan should reflect the most current level of care, and that a corporate staff member had been updating care plans but was no longer helping.
Trauma-Informed Care Assessments and Care Plans Were Incomplete
Penalty
Summary
The facility failed to accurately complete trauma-informed care assessments and to develop individualized care plans with interventions to identify trauma history, symptoms related to trauma, and triggers that could cause re-traumatization for three residents. The facility policy stated that trauma-informed care should account for experiences and preferences, identify trauma history and triggers through multiple sources including resident interview, and incorporate individualized interventions to avoid re-traumatization. However, for the sampled residents, the assessments and care plans did not consistently include the specific trauma experiences or the triggers reported by the residents during interview. For one resident with diagnoses including PTSD, nightmare disorder, bipolar disorder with psychotic features, major depressive disorder, TBI, dissociative disorder, mild intellectual disability, borderline personality disorder, and personality disorder, the care plan listed PTSD and general interventions such as medication administration, anxiety assessment, and encouraging expression of emotions, but did not include the type of trauma or specific triggers. The resident’s record showed no Trauma Informed Care Assessment completed between admission and the later assessment date, and the assessment documented that the resident did not experience trauma in the last quarter. During interview, the resident described multiple traumas including a bike wreck with head injury, family abuse, a grandparent’s death, and an IED explosion during military service, and identified loud noises such as the fire alarm, doors slamming, arguing, yelling, and the tornado siren as triggers. The resident stated the fire alarm tested that day triggered fear and that staff did not warn him/her about loud noises. For another resident with diagnoses including bipolar disorder, schizoaffective disorder, PTSD, antisocial personality disorder, psychosis, and substance abuse, repeated Trauma Informed Care assessments documented that the resident had not experienced listed trauma events and did not identify symptoms, triggers, or interventions. The care plan addressed behavioral challenges and one-on-one interventions but did not address PTSD or specific triggers to prevent re-traumatization. During interview, the resident described traumatic experiences including witnessing a family member die of a drug overdose, being bullied and spit on, and being triggered when others were manipulative, dishonest, or moved the goal posts. The resident also described feeling calmer and more grounded when given structured goals, work, and church services. For a third resident with PTSD, bipolar disorder, generalized anxiety disorder, opioid dependence, schizoaffective disorder, and ADHD, the care plan described PTSD and general calming interventions, but did not list triggers or directions to prevent triggering or re-traumatization. The resident’s assessments again documented no trauma history and no triggers or interventions. During interview, the resident reported severe PTSD, identified opposite-sex individuals as triggers, and stated yelling or fighting by the opposite sex caused distress. The resident also described a prior incident of breaking a window after being triggered by a perceived threat, and staff interviews showed they were not aware of specific PTSD triggers for residents and relied on the care plan for that information.
Nurse aides not trained or certified within required timeframe
Penalty
Summary
The facility failed to ensure four nurse aides completed a nurse aide training program within four months of hire. The facility policy stated that it maintained a nurse aide in-service training program to ensure continuing competence, and that the DON oversaw coordination and/or provision of nurse aide education. The facility also had an undated Hospitality Aide Duties document stating hospitality aides were not to provide direct patient care, bathing, dressing, grooming, turning and repositioning, feeding, peri-care, catheter care, intake and output measuring/documenting, or other hands-on resident care. Review of records showed one nurse aide had a hire date of 02/10/25 and no documentation of completing a nurse aide training program within four months of hire. On 04/29/26, that employee was documented as a hospitality aide assigned to the direct care nursing department. During interview, the employee said he/she had been working as an NA for about a year, had been in classes since December 2025, and would start testing on 05/09/26. The employee also stated he/she had been providing daily care for residents since working at the facility. Observation on 04/26/26 showed the employee assisting two other nurse aides to transfer a resident with a Hoyer lift. Three additional nurse aides also had no documentation of completing training within four months of hire. One employee hired on 08/01/25 said he/she had started CNA classes a couple of months earlier and performed peri-care, catheter care, gait belt transfers, and Hoyer lift transfers. Another employee hired on 08/05/25 was observed assisting with peri-care, turning a resident, removing soiled clothing and linens, dressing the resident, and using a gait belt to assist the resident to stand; that employee said he/she had started nurse aide classes one to two months after hire but had not completed the course. Human Resources said all NA employees were considered NAs from their hire date, tracked their progression on a whiteboard and in staffing development, and would not expect an NA to remain in the nursing department more than four months without certification. The Administrator stated an NA was to complete CNA certification within four months of hire and, if not, should be transferred or terminated.
Discontinued Medications Not Destroyed Timely
Penalty
Summary
Drugs and biologicals were not stored and destroyed in accordance with facility policy in the Station One medication storage room. The facility policy stated medications that could not be returned to the dispensing pharmacy were to be destroyed weekly if possible, but at minimum monthly, and the DON was responsible for ensuring no-longer-needed medications were kept securely and destroyed properly. During observation and record review, discontinued or completed medications for multiple residents were still stored in an upper cabinet in the medication storage room well beyond the required time frame. For one resident, orders showed atorvastatin calcium and haloperidol were discontinued on 03/02/26, and ibuprofen was completed on 03/26/26, yet on 04/28/26 the resident still had 24 atorvastatin tablets, 20 haloperidol tablets, and 6 ibuprofen tablets stored in the cabinet. For another resident, hydroxyzine pamoate was discontinued on 12/04/25, but 21 capsules remained stored on 04/29/26. For a third resident, hydroxyzine HCL completed on 12/22/25 and lactulose completed on 02/27/26, yet 9 hydroxyzine tablets and approximately 328 mL of lactulose remained stored on 04/29/26. For a fourth resident, hydroxyzine HCL completed on 02/13/26, but 11 tablets were still stored on 04/29/26. Staff interviews confirmed medications were usually destroyed by the Staffing Mentor/Educator and ADON, but the medications had not been destroyed within 30 days as required by policy.
Failure to Follow Recipe and Prepare Enough Lunch Entrées
Penalty
Summary
The facility failed to provide a nourishing and well-balanced lunch meal when staff did not follow the recipe for ravioli bake and did not prepare enough food to serve all residents the items listed on the lunch menu. The census was 116. The lunch menu called for ravioli bake, cauliflower, breadstick, and an apple orchard bar, but during meal service Dietary Staff M served ravioli bake, cauliflower, rolls, and canned fruit. By 12:46 P.M., the kitchen had run out of ravioli bake and rolls, and staff served only three residents on the 500 Hall the entree. The remaining approximately 15 residents on the 500 Hall were given a ham and cheese sandwich instead of ravioli bake and biscuits instead of rolls. The Dietary Manager stated the cook should have prepared four pans of ravioli instead of three and directed staff to serve the alternate meal items. Review of the recipe showed ravioli bake was supposed to include spaghetti sauce, cheese ravioli, cottage cheese, mozzarella cheese, and parmesan cheese, but Dietary Staff N did not add the cottage cheese and mozzarella cheese because he/she believed those ingredients were already inside the ravioli. The Dietary Manager stated the staff member was newer, young, and needed more training, and the Consultant Dietitian said the facility may have run out of food because portions were too large or the item was not prepared properly.
Food Served at Improper Temperatures and Poor Quality
Penalty
Summary
The facility failed to prepare and serve food items to conserve nutritive value, flavor, appearance, and temperature. The facility policy on food temperatures required hot foods to be served above 140 degrees Fahrenheit, with acceptable serving temperatures listed for multiple food categories, and required menu substitution and discarding of foods that could not be corrected in time for meal service. During interviews, multiple residents reported that meals were often cold, bland, rubbery, greasy, undercooked, overcooked, or mushy, and several stated that condiments such as ketchup, mustard, and mayo were not provided with meals. One resident also reported burnt pizza and powdered eggs, and another said the food was usually served at room temperature. Survey observations during lunch service showed that the facility ran out of ravioli bake during the meal service, and the sample tray taken after service showed the cauliflower at 90.3 degrees Fahrenheit and the creamed corn at 109.7 degrees Fahrenheit, both tasting cold. On the following day, the sample tray showed chicken teriyaki at 108.6 degrees Fahrenheit and a vegetable medley at 100 degrees Fahrenheit, both cold to taste. The Dietary Manager stated hot food items should be served at at least 120 degrees Fahrenheit, and the Consultant Dietitian stated the same and was unaware residents had complained of cold food.
Failure to Honor Food Allergies, Beverage Requests, and Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated a resident’s allergy when staff served fish to a resident with a documented allergy to fish and seafood. The resident’s face sheet, allergy report, physician orders, baseline care plan, and pink dietary order slip all identified the fish and seafood allergy, and the lunch menu for that day included oven fried fish. After the meal, nursing staff administered Benadryl for itching, and notes documented a rash on the resident’s abdomen. The resident later stated that fish had been served, that the fish contaminated the noodles, and that hives developed and required Benadryl twice. The facility also failed to provide milk to a resident who requested it with lunch. The resident stated that staff told him/her that only tea or lemonade could be provided. During observation, the resident was served a meal tray without milk, and the resident again stated that milk had been requested but not provided. A CNA stated that dietary staff were supposed to place milk on trays for residents with orders for milk, but there was never milk in the unit refrigerator and staff would have to go to the kitchen to get it, which could delay service. The facility further failed to provide a resident with the preferred food item listed on the menu. A resident received a cheese sandwich made with one slice of bread, one heel of bread, and one slice of cheese instead of the ham and cheese sandwich shown on the menu. The resident stated a desire for the ham and cheese sandwich and said he/she liked deli ham. The Dietary Manager stated the resident only liked a specific cut of deli ham that was not available, and staff should have prepared a sandwich with two slices of bread, deli meat, and cheese rather than using the heel of the bread.
Nurse Aides Charged for CNA Training Costs
Penalty
Summary
The facility failed to ensure compliance with the Federal requirement for nurse aide training by charging nurse aides employed by the facility for the cost of the CNA training program. Review of 42 CFR 483.152 showed that no nurse aide who is employed by, or has received an offer of employment from, a facility on the date the aide begins a nurse aide training and competency evaluation program may be charged for any portion of the program, including textbooks or other required materials. The facility census was 116. Review of the facility policy, Agreement Between the facility corporation and Employee Regarding Payment for CNA Courses, showed that the employer would cover the $700 CNA course cost, but the employee agreed to repay the amount through paycheck deductions over 12 months, with any remaining balance withheld from the final paycheck if employment ended early. Multiple nurse aides and HR signed these agreements, and interviews confirmed that the facility paid for the CNA course and then deducted money from each paycheck or required repayment from the final paycheck. The HR Manager stated she was instructed to have nurse aides sign the contract so a portion of each paycheck could be taken until the course was repaid, and she was unaware of the regulation against requiring nurse aides to pay for CNA courses. The Administrator stated the facility paid for CNA classes and the nurse aides signed a contract to repay the facility through paycheck deductions.
Call system not audible outside nursing station
Penalty
Summary
The facility failed to ensure that the call system was audible in resident bathroom and bathing areas and throughout Station One hallways. The facility policy required call lights at each resident bedside, toilet, and bathing facility, with call lights relaying directly to staff or a centralized location so staff could respond appropriately. The policy also stated that staff who saw or heard an activated call light were responsible for responding, and that problems with the call system were to be reported immediately with an alternative solution used until the issue was corrected. Observations showed the call light monitor and audible signal were located inside the locked Station One nursing station behind plexiglass windows. The lights above resident room doors turned on when call lights were activated, but the audible signal could not be heard outside the nursing station or at the entrances to the 100, 200, and 300 hallways. During multiple observations, call lights for a resident room remained on for several minutes while no staff were seen walking to the end of the hall, and the light above the room door was not visible from the front of the hall near the nurses' station. There was no audible sound near the nurses' station to indicate the call light was on. Staff interviews confirmed the problem. A CNA said call lights could be heard only when inside the nursing station and were difficult to hear outside it. An LPN stated staff could only hear Station One call lights inside the nursing station and had to rely on seeing the lights above resident doors; staff could not see some hallway lights from the dining room or from the nursing station, including the last four rooms on the 200 hall and the 300 hall lights. Another CNA and an NA said the call lights were not audible unless they went into the nursing station, which they did not do often, and that residents sometimes became upset because staff did not come quickly when the call light was on. The Administrator stated the call lights used to be very loud and expected them to be audible outside the nursing station.
Insufficient Dining Room Seating
Penalty
Summary
The facility failed to provide sufficient seating in the Station One dining area to accommodate all residents for dining. Fifty-eight residents from the 100, 200, and 300 halls shared the dining area, but observation showed only 12 standard-height dining chairs, 10 tall chairs along the back wall with no tables in front of them, and 3 tall chairs placed between shorter tables where the chairs were higher than the tables. During lunch service, residents were observed eating in ways that reflected the lack of available seating, including one resident using a wheeled walker seat as a tray table, another eating while standing at the counter, and another standing at a table before taking the tray back to the room. One resident entered looking for a chair, found none, and left saying there was no place to sit. Additional observations showed the same pattern on later dates, including residents using walker seats as tables, multiple residents taking trays to their rooms to eat, one resident sitting on the floor while eating, and another eating while standing. At one meal, all standard dining chairs were occupied and a resident and visitor stood because no open chairs were available. Residents interviewed said there were not enough chairs to sit at the dining room tables and that they often ate in their rooms or had to leave the dining room because seating was unavailable. An LPN said the dining room got full at meal service time, and the Administrator stated there should be enough chairs for all residents who wanted to sit in the dining room.
Failure to Protect Residents After Physical Altercation
Penalty
Summary
The facility failed to follow its abuse and neglect policy when two residents were involved in a resident-to-resident physical altercation and staff did not remove them from contact with one another, evaluate the accused resident’s condition, or monitor both residents for further incidents. The policy stated that residents who allegedly mistreat another resident are to be removed from contact during the investigation, and the accused resident’s condition is to be immediately evaluated to determine appropriate therapy, care approaches, and placement. The facility census was 116. Resident #88’s MDS described the resident as cognitively intact with no hallucinations, delusions, or behaviors, and diagnoses including schizophrenia, schizoaffective bipolar type, personality disorder, and anxiety. During interview, Resident #88 stated that Resident #23 punched him/her in the arm and chest after a comment about a child, that staff were present but did not call a Code Green, and that staff did not check for injuries or monitor him/her after the altercation. Resident #23’s MDS showed the resident was cognitively intact with no hallucinations, delusions, or behaviors, and diagnoses including traumatic brain injury, anxiety disorder, depression, bipolar disorder, schizophrenia, PTSD, impulse disorder, and dysthymic disorder. Resident #23 stated that he/she punched Resident #88 four to five times, that Resident #88 threatened to kill him/her or put him/her in the hospital, and that staff did not call a Code Green or monitor him/her after the altercation. A witness resident reported seeing the incident and stated that Resident #88 punched Resident #23 multiple times, then called Resident #23 names and made threats. A CMT said the residents were separated after the altercation and that staff usually provided one-on-one monitoring after such incidents, but the residents were not on one-on-one supervision. The CMT also said staff did not call a Code Green. The interim DON stated she did not realize or process that the event was a physical altercation and thought it was more of an argument, while the Administrator stated she was not notified of the altercation that day and expected staff to report such incidents immediately so an investigation could begin and protective measures could be put in place.
Failure to Perform 15‑Minute Safety Checks Allows Elopement Through Window and Roof
Penalty
Summary
The deficiency involves the facility’s failure to provide protective oversight and complete ordered 15‑minute safety checks for a known elopement‑risk resident, resulting in an undetected elopement through the resident’s room window. The resident had multiple psychiatric and behavioral diagnoses, including schizoaffective disorder, psychoactive substance abuse, suicidal ideations, mood disorder, ADHD, opioid abuse, anxiety disorder, and insomnia due to another mental disorder. The resident’s PASRR and care plan documented a long history of mental health issues, substance use, homelessness, prior overdoses, abuse history, and a need for ongoing psychiatric care, low‑stimulation environment, consistent routines, and environmental supports to prevent elopement. Facility assessments, including elopement risk evaluations, identified the resident as at risk for elopement, with a documented history of elopement from prior secured facilities and from home, as well as prior elopement from this facility shortly after admission. The facility’s own elopement and intensive monitoring policies required systematic identification and monitoring of residents at risk for elopement, including intensive monitoring and 15‑minute checks for residents with poor impulse control or elopement ideation. The resident’s elopement risk evaluation showed an increasing risk score over time, and nursing notes documented the resident’s agitation, drug‑seeking behavior, difficulty with redirection, and multiple attempts to get out the door. Staff documented that the resident was on intensive monitoring with every 15‑minute face checks, and the care plan called for completion of elopement risk assessments and face checks/intensive monitoring. On the day of the incident, staff recognized that the resident was “spiraling,” irritated, and had verbalized intent to run away and had attempted to open a door earlier in the day. Despite this, the 15‑minute checks were not consistently or timely completed as ordered, and staff responsible for the checks acknowledged being behind on face checks due to a busy day and documenting checks when they had time rather than at the required intervals. During the period when the resident was supposed to be under 15‑minute face checks, the resident used a metal watch band to loosen and remove the screws from a rubber security block in the windowsill, slid open the side window, pushed out the screen, and exited into a fenced courtyard. The resident reported that it took about an hour to remove the block and open the window and that he closed the curtain when staff entered the room so they would not notice his actions. Staff performing checks reported that they completed face checks by opening the door and seeing if the resident was in the room, without observing what the resident was doing. After exiting into the courtyard, the resident moved a picnic table next to the building, stood on it, climbed onto the roof, crossed the roof, jumped down into an open area outside the fenced courtyard, and walked several blocks down city streets. Facility staff were unaware the resident had eloped until an off‑duty employee saw the resident walking in pajamas and a coat and notified the facility, and a police officer subsequently made contact with the resident, who admitted leaving the facility through the window and walking away.
Removal Plan
- Transferred Resident #1 to the hospital by ambulance per the resident's request after the elopement event
- Placed Resident #1 on one-on-one observation for safety upon return to the facility
- Notified the resident's guardian and physician of the elopement
- Arranged psychiatric services evaluation for Resident #1
- Implemented additional interventions to ensure the security of Resident #1's window as well as all windows in the facility
- Secured the courtyard picnic table to the concrete patio
- Educated all staff regarding the resident elopement policy, residents at risk for elopement, and intensive monitoring procedures
- Educated staff on documentation requirements for face checks and window security
Failure to Implement Behavioral Health Care Plan and Maintain Safe Environment for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate behavioral health treatment and services to a resident with serious mental illness, a history of trauma, and known coping mechanisms, resulting in multiple self-harm incidents. The resident had diagnoses including schizoaffective disorder, mood disorder, ADHD, PTSD, opioid abuse, anxiety disorder, and insomnia, with a documented history of severe bullying, sibling suicide, homelessness, substance abuse, and the death of a child. The PASRR and care plan identified the need for a low-stimulation environment, consistent routines, psychotherapy, ongoing psychiatric care, and person-centered, trauma-informed interventions. The care plan also directed staff to monitor for anxiety, avoid power struggles, provide opportunities for healthy energy release, and use non-invasive coping mechanisms before behavioral outbursts. Staff were aware that the resident’s coping mechanisms included watching calming television programs (especially Animal Planet), gaming, music, and writing in notebooks. On one occasion, the resident’s guardian reported that the resident had voiced self-harm ideations, after which the resident was placed on one-on-one supervision and staff were instructed to search the room and remove harmful objects. Items with cords, including the television, gaming system, power cords, shoelaces, and hoodies with strings, were removed from the room. Two days later, while on one-on-one observation, the resident repeatedly requested the return of the television to watch Animal Planet, a known coping mechanism, and repeatedly asked to see the Environmental Services Supervisor to help get the television back. The one-on-one staff member assigned that day had never previously provided one-on-one observation and understood their role as only to prevent the resident from hurting self or others. The staff member did not provide additional interventions or access to the television, and the Social Services Designee later stated there was no reason to keep the television and personal items from the resident while on one-on-one observation and was not aware of the resident’s repeated requests or escalating distress. As the resident’s requests for the television went unmet and the Environmental Services Supervisor was unavailable, the resident became increasingly agitated, knocked over linen carts, threw items in the hallway, and then went to the room and broke the inside pane of the double-pane window. The resident sat on the bed surrounded by glass, picked up a shard, and cut the left forearm from elbow to wrist, requiring emergency transport for medical and psychiatric evaluation. After the resident’s return from the hospital, staff failed to ensure the room was free of remaining glass shards. The resident later found glass in the windowsill and under the bed on separate occasions, cutting the same forearm multiple times while alone in the room. Staff documentation and interviews confirmed that shards remained in the windowsill and curtain area and that the room had not been thoroughly cleared of glass before the resident’s return. Although the care plan was updated to include high suicide risk and the need for a written safety plan and specific self-harm interventions, the record showed no evidence that staff collaborated with the resident to develop the written safety plan as directed. These actions and inactions demonstrate the facility’s failure to implement care-planned, person-centered behavioral health interventions, to maintain a safe environment free of known hazards, and to provide necessary services to support the resident’s highest practicable mental and psychosocial well-being. The deficiency is further supported by staff and resident interviews describing the mismatch between the resident’s identified needs and the care actually provided. Staff acknowledged that the resident’s coping mechanisms included watching calming animal shows and gaming, and that removal of personal items, including the television, increased the resident’s agitation. The resident reported feeling that staff had taken away all coping mechanisms, leaving nothing to do while on one-on-one observation, and stated that close proximity and talkative staff increased anxiety. The resident described breaking the window with a metal cup, cutting the left forearm to obtain transfer to the hospital, and later intentionally searching the windowsill and under the bed for glass shards to cut the arm again. The Social Services Designee confirmed that glass shards from the initial incident remained in the room and that staff did not thoroughly clean the room before the resident’s return. Additionally, although the care plan called for development of a written safety plan and teaching alternative coping skills, the record contained no documentation that such a written safety plan was created with the resident, indicating a failure to implement the care-planned intervention for managing self-directed violence risk.
Failure to Properly Identify Discharge Location During Immediate Discharge
Penalty
Summary
The facility failed to follow proper immediate discharge procedures for a resident who exhibited increased aggressive behaviors, including multiple physical assaults on staff. After a series of incidents involving physical aggression, law enforcement intervention, and psychiatric evaluation, the resident was sent to a hospital. The facility then determined it could not meet the resident's needs and issued an immediate discharge notice while the resident was at the hospital. However, the discharge notice identified the psychiatric hospital as the discharge location, which did not meet regulatory requirements for specifying an appropriate discharge location. The facility's policy required that, in cases of emergency transfer and subsequent discharge, the discharge location must be properly identified and the resident's status must be evaluated based on their condition at the time of transfer. Despite this, the facility did not amend the immediate discharge notice to reflect an appropriate discharge location after being informed of the error. The discharge letter was also improperly dated, and there was no documentation explaining why the resident was taken into custody on one of the dates in question. The resident, who had a guardian, remained in the hospital pending a hearing after the discharge was appealed. The facility had attempted to find an alternative placement for the resident for several months but was unsuccessful due to the resident's aggressive behaviors. The failure to properly identify a discharge location and to amend the discharge notice as required constituted the deficiency cited in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A resident with a documented history of serious mental illness, including schizophrenia, bipolar disorder, and intermittent explosive disorder, was admitted to the facility with known aggressive and assaultive behaviors. The resident's PASRR and care plan indicated a need for 24-hour protective oversight and specific environmental and supervision interventions to prevent harm to self or others. Despite these documented needs, the resident was on 15-minute face checks rather than continuous supervision at the time of the incident. On the day of the event, the resident entered a vending room where two other residents were present. Without provocation, the resident forcefully slammed another resident's head against a vending machine and struck the resident multiple times in the face with a closed fist. The assaulted resident sustained lacerations to the right eyebrow and upper lip, both requiring sutures. Multiple witness statements and progress notes confirmed the unprovoked nature of the attack and the injuries sustained. The facility's abuse and neglect policy required assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as sufficient staff deployment and supervision to prevent abuse. However, the interventions in place at the time did not prevent the resident with a known history of violence from attacking another resident, resulting in physical harm that met the facility's definition of abuse.
Failure to Provide Appropriate Utensils Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain resident dignity on the secured unit by providing only plastic forks and spoons for meal service, with no knives available for residents to use. Observations showed that residents were served meals such as meatballs and pork chops, which could not be easily cut with the provided utensils, resulting in residents having to use their hands to eat meat. Multiple residents expressed dissatisfaction with the use of plastic utensils, stating it was difficult to eat certain foods and that they did not like using plastic silverware. Staff interviews confirmed that plastic utensils were routinely used for safety reasons and to avoid delays in residents' smoke breaks, which occurred if metal silverware was unaccounted for after meals. Although butter knives were reportedly available upon request, staff did not routinely provide them, and residents were not always aware they could request them. The facility's policy on promoting and maintaining dignity emphasized treating residents with respect and considering their preferences and former lifestyles. However, the practice of serving meals without appropriate utensils, particularly knives, did not align with this policy. Staff and residents indicated that the use of plastic utensils was primarily to prevent issues with accounting for metal silverware and to avoid delaying smoke breaks, rather than based on individual resident needs or preferences. The deficiency affected all 57 residents on the secured unit, as observed and confirmed through interviews and record review.
Failure to Search Resident Belongings Allows Illegal Substances in Facility
Penalty
Summary
Staff failed to follow facility policy regarding the search and inventory of a resident's personal belongings upon admission, resulting in the resident bringing prohibited and illegal substances into the facility. The policy required the admission coordinator or designee to complete an initial inventory and ensure no contraband entered the facility, with floor staff under the charge nurse responsible for addressing and removing any items not allowed. On the night of admission, staff did not complete the required search due to being occupied with other incidents, including a resident attempting to elope and multiple admissions, and subsequently did not want to disturb the new resident who had fallen asleep. The resident, who had a documented history of polysubstance abuse, later reported bringing a dab pen containing cannabis concentrate, 20 tablets of Adderall, and bath salts (an illegal synthetic stimulant) into the facility. The resident stated that none of the staff searched their belongings, which were kept in a duffle bag. The resident admitted to consuming some of the substances and sharing them with other residents. Drug testing confirmed that multiple residents tested positive for methamphetamines and THC, and the resident did not have a physician's order for Adderall. Interviews with staff revealed that the required inventory and search process was not completed at the time of admission, and the Director of Nursing and Administrator were unaware that the search had not occurred. Staff acknowledged that belongings should have been kept at the nurse's station until a search could be completed, but this protocol was not followed. As a result, illegal and controlled substances were introduced and distributed within the facility, directly violating facility policy and federal regulations.
Failure to Document Rationale for PRN Psychotropic Medication Administration
Penalty
Summary
Facility staff failed to document the rationale for administering as needed (PRN) antipsychotic medications to a resident, as required by facility policy. The policy mandates that staff must assess and document the clinical rationale, including the resident's behaviors or symptoms that justify the use of PRN psychotropic medications, and record the effectiveness of the intervention. However, multiple reviews of the resident's Medication Administration Record (MAR) and progress notes revealed that staff consistently administered PRN antipsychotic and antianxiety medications without documenting the specific behaviors or evidence of anxiety that warranted their use. The resident involved had a complex psychiatric history, including diagnoses of schizophrenia, bipolar disorder, schizoaffective disorder, intermittent explosive disorder, and generalized anxiety disorder. The care plan and physician orders indicated the use of several scheduled and PRN psychotropic medications to manage behavioral symptoms such as aggression, agitation, and anxiety. Despite these directives, staff did not provide the required documentation in the progress notes to support the administration of PRN medications, even though the MAR indicated the medications were given and noted as effective. Interviews with staff, including an LPN, the DON, the Administrator, and the psychiatric provider, confirmed that documentation practices did not align with facility policy. Staff acknowledged that PRN medications were sometimes given based on the resident's request or non-verbal cues, but the necessary behavioral documentation was missing. The psychiatric provider also expected staff to document the resident's behaviors when PRN medications were administered to inform ongoing treatment decisions, but this was not consistently done.
Failure to Notify Physician and Guardian of Resident's Significant Condition Changes
Penalty
Summary
Facility staff failed to notify a resident's physician, nurse practitioner (NP), and guardian of significant changes in the resident's condition, including refusal of ordered diagnostic procedures, ongoing weight loss, and low blood pressure readings. The facility's policies required prompt notification of the resident, physician, and representative when there were changes in condition or treatment, but documentation and interviews revealed that these notifications did not consistently occur. Specifically, there was no evidence that the guardian, NP, or physician were informed when the resident refused a CT/Urogram, experienced notable weight loss over several months, or had low blood pressure readings while on antihypertensive medications. The resident involved had a history of severe cognitive impairment, bipolar disorder, and benign prostatic hypertrophy, and was under the care of a guardian due to impaired decision-making capacity. The resident's care plan and assessments indicated the need for involvement of the guardian in care decisions and highlighted the importance of notifying the physician and NP of changes in health status. Despite this, the medical record lacked documentation of notifications to the guardian or providers regarding the resident's refusal of diagnostic tests, significant and ongoing weight loss, and episodes of low blood pressure. The Registered Dietitian's notes also did not prompt documented communication with the NP or guardian regarding the resident's nutritional decline. Interviews with staff, the NP, and the resident's guardian confirmed that required notifications were not made. The NP stated he was not informed of the resident's refusal of an abdominal X-ray or of the low blood pressure readings, and the guardian reported not being notified of the resident's weight loss, low blood pressure, or refusal of procedures. Staff interviews revealed uncertainty or lack of recall regarding whether notifications were made, and the administrator acknowledged that staff should have communicated these changes to the NP and guardian. The deficiency centers on the facility's failure to follow its own policies for timely and appropriate notification of significant changes in a resident's condition.
Failure to Provide Double Portions as Ordered by Physician
Penalty
Summary
The facility failed to follow physician orders to provide double portions or double entrees at meals for five residents who had documented orders for such diets. Observations during meal service showed that dietary staff did not serve double portions or entrees to these residents, despite their orders being clearly listed on the Diet Type Report and physician order sheets. Interviews with the affected residents revealed that they were not receiving the prescribed amounts of food, with some reporting ongoing hunger and concerns about weight stabilization. Care plans for these residents also indicated the need for double portions, particularly in cases of past significant weight loss. The Dietary Manager stated that the practice of serving double portions had been discontinued due to budget cuts, under the belief that it was a matter of resident preference rather than a medical necessity. However, the Director of Nursing, Administrator, and Consultant Dietitian all indicated that they were unaware of this change and affirmed that staff should follow physician orders for diet. The failure to provide double portions as ordered was observed consistently during the lunch meal service, and staff interviews confirmed the deviation from prescribed dietary plans.
Inadequate Supervision Leads to Resident Altercations
Penalty
Summary
The facility failed to provide adequate supervision and oversight following an altercation between two residents, leading to a second altercation involving another resident. Initially, Residents #1 and #3 were placed on one-on-one supervision after an altercation where Resident #1 was pushed down by Resident #3. Despite this measure, staff did not effectively separate the residents or intervene to prevent further incidents. Resident #1, who had moderately impaired cognition and a history of mental health issues, was involved in a subsequent altercation with Resident #2, who was cognitively intact but had a history of hallucinations and delusions. The facility's Behavioral Emergency Policy outlines that staff should recognize when a resident poses a danger and utilize de-escalation techniques as a first resort. However, during the incident, staff failed to adequately monitor and redirect the residents involved. Resident #1, while under one-on-one supervision, approached Resident #3 and Resident #2 in the dining room, leading to Resident #2 striking Resident #1. The staff member providing supervision to Resident #1 did not intervene effectively, citing concerns about personal safety and the speed of the incident. Interviews with staff, including the Director of Nursing and the Interim Administrator, revealed expectations for immediate response to de-escalate situations and protect residents from harm. However, the staff's actions did not align with these expectations, as they failed to prevent the second altercation. The report highlights a lack of effective communication and intervention strategies among staff, contributing to the deficiency in resident supervision and safety.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident with a known history of aggressive behaviors. The incident involved a resident who was verbally assaulted by another resident in the hallway, which escalated to a physical altercation in the dining area. The staff did not adequately separate the residents or monitor the aggressive resident after the initial verbal assault, allowing the situation to escalate to physical violence. The aggressive resident had a documented history of aggression and required 24-hour supervision due to safety concerns. Despite this, the resident's care plan did not include interventions or recommendations to address these behaviors. The staff's failure to implement a 1:1 monitoring system or to separate the residents after the initial verbal altercation contributed to the physical assault, resulting in the victim sustaining scratches and hair loss. Interviews with staff and administration revealed a lack of awareness and communication regarding the incident and the aggressive resident's history. The director of nurses and the administrator acknowledged that the residents should have been separated and that closer monitoring could have prevented the physical assault. The facility's policies on abuse and neglect were not effectively followed, leading to the deficiency.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an allegation of resident-to-resident abuse involving two residents to the state agency as required. The incident involved a verbal and physical altercation between two residents, where one resident became frustrated with the other for using the phone for an extended period. This led to a confrontation where the resident on the phone became aggressive, resulting in physical harm to the other resident, including a scratch on the neck and hair being pulled out. The facility's policy mandates immediate reporting of such incidents to the administrator and appropriate agencies, but this was not followed. The incident was not documented in the medical records, and the resident's legal guardian, physician, or medical director were not notified. Interviews with staff revealed a lack of awareness and communication about the incident, with some staff members not recalling the event or their involvement in it. The director of nurses and the administrator were unaware of the physical altercation and the need for reporting. The administrator acknowledged awareness of a verbal altercation but not the physical attack. The failure to report and document the incident as per the facility's policy resulted in a deficiency in handling and reporting abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate an allegation of verbal and physical resident-to-resident abuse involving two residents. Resident #1, who was cognitively intact, reported that Resident #3 became angry after being asked to get off the phone, leading to a verbal altercation. Resident #3 then physically attacked Resident #1 by shoving, scratching, and pulling out a clump of hair. The activity director and another staff member intervened, but no investigation was initiated following the incident. The activity director witnessed the altercation and attempted to separate the residents, calling a code green for additional staff assistance. Despite the administrator being present in the facility at the time, there was no follow-up investigation or documentation of the incident. The activity director believed that witness statements were collected, but the Director of Nurses and the administrator were unaware of any such documentation. The administrator acknowledged awareness of a verbal altercation but was not informed of the physical attack until later. The Director of Nurses stated that she would have initiated an investigation had she been informed. The lack of communication and failure to investigate the incident resulted in a deficiency in the facility's handling of resident-to-resident abuse allegations.
Inappropriate Communication by LPN with Resident
Penalty
Summary
The facility failed to protect a resident from abuse when an LPN engaged in inappropriate text communication of a sexual nature with the resident. The resident, who had diagnoses of physical and mental health disorders, resided on a secured unit for residents with behavioral issues and was under guardianship. The incident involved the LPN responding to the resident's requests for a sexual relationship through social media, which is against the facility's policies. The resident was cognitively intact but had hallucinations and delusions, as noted in their quarterly Minimum Data Set. The inappropriate communication was discovered when the Director of Nursing (DON) reviewed the resident's phone messages with permission. The messages included sexual content initiated by the resident and responded to by the LPN, which violated the facility's abuse and social media policies. The facility's policies clearly state that staff should not engage in social media contact with residents or suggest any form of sexual relationship. The DON and interim administrator confirmed that such behavior is against the facility's policies and should not occur at any time. The incident was uncovered during an investigation into a different matter, highlighting a breach in the facility's protocol for protecting residents from abuse.
Failure to Assess Consent Capacity Leads to Sexual Abuse Incidents
Penalty
Summary
The facility failed to assess three residents (#19, #47, and #115) for the ability to consent prior to engaging in sexual relations, leading to a failure to protect Resident #47 from sexual abuse by Resident #115. Resident #47, with a history of mood disorders, impulse control disorder, bipolar disorder, and mild mental retardation, reported feeling worthless, experiencing flashbacks, and fearing contracting STDs after being forced into oral sex by Resident #115. Despite Resident #47's limited intellectual capacity and the presence of a guardian, there was no assessment for consent to sexual activity in the medical records. Resident #115, diagnosed with oppositional defiant disorder, ADHD, bipolar disorder, and moderate intellectual disabilities, engaged in sexual activities with Resident #19 without the capacity to understand the purpose, risks, and consequences of such actions. The facility's failure to assess and monitor residents' abilities to consent to sexual activity resulted in abusive situations and violations of residents' rights. The facility's policies regarding sexual activity and abuse were not effectively implemented in the cases of Residents #47 and #115. Despite clear guidelines on assessing residents' capacity to consent to sexual activity, documenting such assessments, and prohibiting non-consensual sexual activities, the facility did not conduct proper evaluations for Residents #47 and #115. Resident #47's care plan indicated the need for structured plans to address inappropriate behaviors and mood stabilization, highlighting the importance of monitoring and intervention in cases of vulnerability. Similarly, Resident #115's care plan identified behavioral challenges and the need for supervision to prevent harm to self and others, indicating the necessity for strict adherence to facility guidelines. The failure to follow established protocols and assess residents' abilities to consent led to instances of sexual abuse and inappropriate behavior within the facility. The lack of oversight and monitoring by facility staff, as evidenced by Resident #115's unauthorized presence on another hall and the failure to intervene in inappropriate behaviors, contributed to the deficiencies in protecting residents from abuse. Staff members, such as CNA E, were aware of residents engaging in sexual activities but did not take appropriate actions to prevent or address such incidents. Additionally, the residents' legal guardians expressed concerns about their wards' capacity to engage in relationships and the potential risks of harm or suicidal ideations following relationship issues. The facility's failure to enforce guardian directives and ensure residents' safety highlights systemic issues in supervision, monitoring, and adherence to established guidelines, ultimately resulting in instances of sexual abuse and misconduct among vulnerable residents.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety and sanitation. Observations revealed that opened food items in the walk-in freezer and dry storage room were not sealed properly, and dented cans were not segregated from active use. Additionally, resident food items in a unit refrigerator were stored under unsanitary conditions, with visible residues and splatters. Trash cans in the kitchen were left uncovered when not in use, and ice and water dispensing machines were found to be dirty and lacking proper air gaps to prevent potential backflow of liquids. Food preparation surfaces were not appropriately cleaned and sanitized, and staff were not knowledgeable about sanitization procedures or the use of the dishwashing machine. Utensils and food containers were found to be in poor condition and not protected from contaminants. Kitchen surfaces and equipment, including floors, ceilings, vents, shelves, drawers, and cooking appliances, were not maintained in a clean state. Staff also failed to practice proper hygienic practices, such as gloving, handwashing, and avoiding the consumption of personal food and beverages while preparing and serving food to residents. The facility census was 116.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents involving staff behavior towards residents. During a group resident council, various residents expressed fear of retaliation if they filed grievances or complaints. They reported that night shift staff had a bad attitude and yelled at residents, with specific mention of a CNA who belittled residents. This was corroborated by individual interviews with residents who described instances of staff being rude, dismissive, and using inappropriate language towards them. One resident with schizoaffective disorder and other mental health diagnoses reported feeling ignored and mistreated by specific staff members, including a CNA who raised their voice when the resident requested extra food. Another resident with a hearing deficit and mental health issues stated that the same CNA yelled at residents who asked for meal alternatives. A third resident with behavioral challenges and mental illness described being yelled at and cursed by the CNA when requesting additional juice. Additional interviews revealed that other residents felt belittled and disrespected by staff, including a resident with multiple sclerosis who reported being cursed at by a nursing aide. Another resident with anxiety and personality disorders felt dismissed by staff when asking questions. A resident with major depressive disorder and schizophrenia reported that staff, particularly on the night shift, were hateful and delayed providing medications while engaging in personal activities. Observations confirmed that a CNA took a chair from a resident without returning it, leaving the resident standing. The DON and administrator acknowledged these issues and stated that they had previously addressed similar complaints with the staff involved.
Facility Fails to Allow Residents to Retain Personal Coffee
Penalty
Summary
The facility failed to protect the residents' right to retain and use personal possessions, specifically instant coffee, by keeping it locked up in the medication room and controlling the times residents could access it. This affected eight residents, including those with guardians and those who were cognitively intact. The facility's policy on Resident's Rights, revised on 07/05/23, states that residents have the right to retain and use personal possessions unless it infringes on the rights or health and safety of others. However, the facility enforced a policy where residents could only access their coffee at 1:00 P.M. and 6:30 P.M., and only in limited quantities, which was signed by the administrator but undated. Observations on multiple occasions showed that the coffee was kept in a large tote in the locked medication room, with each container marked with the resident's name. Interviews with residents revealed that they were unhappy with this arrangement, as they had purchased the coffee with their own money and did not understand why they could not keep it in their rooms. Some residents mentioned that they had no restrictions from their guardians or physicians regarding coffee consumption. They also expressed frustration over having to wait for staff to access their coffee, especially when staff were busy with other duties. The Director of Nursing (DON) and the Administrator acknowledged that residents should have access to their own property but cited issues with coffee being used as currency among residents, leading to trading, stealing, and overuse. The Administrator mentioned that residents had verbally agreed to the limited access policy during activities to make the coffee last longer, but nothing was documented in writing. Despite these explanations, there was no documented reason in the residents' medical records to justify why they could not keep their coffee in their rooms.
Failure to Provide Adequate Seating and Accommodation
Penalty
Summary
The facility failed to provide reasonable accommodation for Resident #81, who required a Hoyer lift and two staff members to get out of bed. Despite the resident's requests to get out of bed more frequently, staff often cited a lack of time or help and did not return to assist. The resident's custom electric wheelchair had been broken for over a month, and although it could still be used manually, staff found it difficult to push. The resident expressed a desire to participate in meals in the cafeteria and go outside but was often left in bed due to the broken wheelchair and lack of alternative seating options that were comfortable for extended periods. Additionally, the facility failed to provide adequate seating in the Station 2 common/dining area, affecting all residents residing in that unit. Observations showed that seven residents had to eat their meals with trays on their laps or on the arms of high-back chairs due to insufficient dining room chairs and table space. Residents expressed dissatisfaction with this arrangement, noting the difficulty and discomfort of balancing meal trays on their laps. Interviews with staff, including CNAs, the Activity Director, the Therapy Director, and the DON, revealed a lack of communication and coordination in addressing the broken wheelchair and seating issues. The Therapy Director was unaware of the resident's discomfort with the alternative wheelchair, and the Maintenance Supervisor was not informed about the shortage of dining room chairs. The facility's failure to ensure appropriate and comfortable seating for Resident #81 and adequate dining arrangements for Station 2 residents led to the identified deficiencies.
Failure to Address Resident Council Concerns and Hold Monthly Meetings
Penalty
Summary
The facility failed to act promptly and follow up with a response to residents' concerns voiced in resident council meetings. Additionally, the facility did not hold monthly resident council meetings as required. The review of the resident council meeting minutes from December 2023 showed various concerns, including missing clothing, dietary requests, and maintenance issues, with no documentation of these concerns being communicated to staff or resolved. The facility did not provide minutes for a January 2024 resident council meeting, and only one meeting was held in February 2024 for station two, with no indication of a meeting for station one. Residents reported that resident council meetings were held sporadically without a specific schedule or agenda, making it difficult to address their concerns effectively. Interviews with the Activity Director (AD), Social Services Director (SSD), Director of Nursing (DON), and the Administrator revealed a lack of clarity and consistency in the process for addressing concerns raised during resident council meetings. The AD, who was new to the position, was unaware of the specific process to follow and admitted that some meetings and minutes fell through the cracks during the transition period. The DON stated that concerns should be emailed to department managers and followed up by the next day, but there was no documentation to support this process. The Administrator acknowledged that the AD was responsible for reporting concerns but admitted that the transition period led to lapses in holding meetings and documenting minutes.
Facility Fails to Maintain Clean and Orderly Environment
Penalty
Summary
The facility failed to provide housekeeping and maintenance services to maintain a clean, sanitary, and orderly environment. Observations revealed multiple deficiencies in various resident rooms and common areas, including torn drywall, missing paint, water stains, and black scuff marks. Additionally, several rooms had issues with missing or damaged furniture, such as bed frames without mattresses, privacy curtains pulled out of the wall, and dresser drawers with missing paint. Bathrooms were found to be in poor condition, with stained floors, peeling ceiling texture, and black discoloration around the base of toilets. In one instance, a resident reported that the cold-water faucet in their sink did not work, and they could only get hot water. This issue had persisted since staff attempted to fix a leak. The resident also mentioned that their TV had been removed by staff, and despite requesting a replacement, they had not received one. The resident expressed frustration over the lack of cold water and the absence of a TV in their room. Interviews with staff members, including housekeepers and the maintenance supervisor, revealed a lack of clarity regarding responsibilities for cleaning certain areas, such as bathroom vents and common areas. The maintenance supervisor admitted that it took a long time to patch and paint walls and that he was running out of paint. He also acknowledged that he had not had time to address all the areas in need of repair, including dining rooms and furniture. The administrator confirmed that maintenance was responsible for ensuring that walls, doors, floors, ceilings, and furniture were in good repair, but the observations indicated that this was not being adequately managed.
Failure to Ensure Residents Knew How to File Grievances
Penalty
Summary
The facility failed to ensure residents knew how to file a grievance, where grievance forms were located, or how to complete a grievance form. During a resident council group interview, multiple residents expressed that they did not know how to file a grievance and feared retaliation from staff if they did. Specific residents reported missing clothing and stated that they had informed staff but had not received any follow-up or resolution. These residents were also unaware of the grievance process or where to find the necessary forms to file a grievance. The facility's policies on resident rights and grievance procedures were reviewed and found to be comprehensive. However, the implementation of these policies was lacking. The Social Services Director (SSD), who was new to the position, was unaware of her role in the grievance process, and no grievances had been filed since she assumed the role. The Director of Nursing (DON) confirmed that grievances were to be filed using a form that residents or visitors had to request from staff, and there was a 24-48 hour turnaround time for resolution. The administrator acknowledged that residents should be able to file grievances without fear of retaliation and that grievance forms should be readily available without needing to ask staff. The SSD's lack of awareness of the grievance process and the residents' fear of retaliation contributed to the deficiency in ensuring residents' rights to voice grievances were upheld.
Failure to Complete Required Pre-Employment Screenings
Penalty
Summary
The facility failed to complete required pre-employment screenings for four of eight sampled employees hired since the previous survey. Specifically, the facility did not request a criminal background check (CBC) for two employees, did not check the Employee Disqualification List (EDL) for three employees, and did not check the Nurse Aide (NA) Registry for three employees prior to hire, as directed by facility policy. The facility's policy mandates that the Human Resources (HR) department conduct pre-employment screenings, including Criminal History, Federal Exclusion Lists, Licensure, Family Care Safety Registry (FCSR), EDL, NA Registry, and I-9 verification, prior to hiring any staff. However, these checks were either not completed or were conducted after the employees had already started working, which is against the facility's policy. The deficiencies were identified through a review of employee files and interviews with HR staff and the Administrator. For instance, the Maintenance Supervisor's file lacked documentation of an NA Registry check, CNA K's file lacked an EDL check, and Hall Monitor L's file showed that the FCSR and NA Registry checks were conducted 19 days after the hire date. Additionally, NA M's file had no documentation of a CBC, EDL, or NA Registry check either before or after the hire date. HR staff confirmed that these checks should be completed before the employee's first paid day, but this was not consistently done. The Administrator also confirmed that he expected all new employees to have these checks completed prior to their first paid day.
Medication Administration and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure staff prepared and safely administered medications to five residents. Certified Medication Technician (CMT) I prepared the medications, but Certified Nurse Aide (CNA)/CMT/Team Lead G administered them without observing the preparation process. This practice was observed during a medication pass, where medications for residents with various diagnoses, including schizoaffective disorder, anxiety, diabetes, and mood disorder, were involved. The facility's policy mandates that the person who prepares the medication must also administer it, which was not followed in these instances. Additionally, the facility failed to obtain a physician order for a resident to self-administer eye drops. During the medication pass, the resident self-administered the eye drops without a proper order, which is against the facility's policy. The facility's Resident's Rights Policy requires an interdisciplinary team to determine if a resident can safely self-administer medications, which was not done in this case. The facility also failed to complete accuchecks as ordered for a resident with diabetes and did not obtain a urinalysis when ordered for another resident. The resident's care plan indicated the need for daily blood glucose monitoring, but there was no documentation of these checks being performed. Similarly, a urinalysis ordered for a resident with urinary issues was not obtained in a timely manner. Furthermore, the facility did not document the narcotic counts being completed by two staff members, as required by their policy, on multiple occasions.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities on a daily basis to meet the interests and the physical, mental, and psychosocial well-being of each resident. This deficiency was observed in five residents out of 34 sampled residents. The facility census was 116. During a resident council meeting, residents reported that there were not many activities on the unit, the activity calendar was not followed, and there were no activities on weekends or after supper. Observations and record reviews confirmed that several residents did not participate in any documented activities for extended periods, and there was a lack of staff interaction and engagement with the residents. Resident #48's care plan indicated a need for cognitive stimulation and social activities, but there was no documentation of activity participation for several months. Observations showed the resident in their room with no staff interaction or activities provided. Similarly, Resident #96, who had dementia and other mental health diagnoses, was observed lying in bed or standing in the hallway with no staff interaction or activities. The resident's activity progress notes indicated minimal participation in activities, and there was no documentation of activity engagement for several months. Resident #110, who had dementia, anxiety, and depression, had no care plan for activities and no documented participation in activities for several months. Observations showed the resident pacing in their room or standing in the hallway with no activities provided. Resident #25, who had a traumatic brain injury and other mental health disorders, was observed sleeping in bed most of the time due to boredom. The resident expressed a desire for more activities but reported that there had not been an activity director for several months. Resident #116, who had schizophrenia and insomnia, participated in a craft activity but expressed a desire for more activities, especially in the evenings. The Activity Director confirmed the lack of scheduled activities on weekends and evenings and acknowledged the need for more one-on-one programming for certain residents.
Failure to Ensure Resident Safety and Proper Monitoring
Penalty
Summary
The facility failed to ensure the safety of Resident #102, who expressed suicidal ideations and threatened self-harm by placing a bag over their head. Despite the resident's high risk for suicide as indicated by the Columbia Suicide Severity Rating Scale, the care plan was inconsistent, and the resident's room contained plastic liner bags in trash cans, which could be used for self-harm. Staff interviews revealed a lack of awareness and documentation regarding the resident's increased monitoring, and the resident continued to express suicidal thoughts without appropriate intervention or documentation of face checks and room safety measures. The facility also failed to ensure the safety of Resident #48 by not placing their feet on wheelchair foot pedals while being propelled by staff. Observations showed the resident's feet were unsupported, which could lead to accidents or injuries. Staff interviews confirmed that wheelchair pedals should be used for resident safety, but this practice was not followed. Additionally, the facility did not implement effective interventions to prevent Resident #21 from being transported in their rollator walker by another resident. Despite staff and resident awareness that this practice was unsafe, it continued to occur. The DON and other staff members acknowledged the issue but failed to implement successful interventions to stop the behavior, putting Resident #21 at risk of injury.
Failure to Provide Sufficient Fluids to Residents
Penalty
Summary
The facility failed to offer sufficient fluids to maintain proper hydration and health for three residents. Observations over several days showed that Residents #48, #96, and #110 did not have water pitchers or glasses of fluids in their rooms. This was despite the facility's policy that fluids should be passed every two hours, with additional fluids provided during meals. Staff interviews confirmed that water pitchers were either broken or not replaced, and fluids were not consistently offered as required by the policy. Resident #48, who has diagnoses including dementia and schizophrenia, was observed without water pitchers or glasses of fluids in their room over multiple days. The resident's care plan emphasized the need to encourage fluids to promote prompted voiding responses. Similarly, Resident #96, who has dementia and bipolar disorder, was also observed without water pitchers or glasses of fluids in their room. The care plan for this resident also highlighted the importance of encouraging fluids to prevent urinary tract infections and skin breakdown due to incontinence. Resident #110, diagnosed with dementia, anxiety, and depression, was observed with dry lips and no water pitcher or glass of fluids in their room. Staff interviews revealed that fluids were not consistently offered, and water pitchers were not available for many residents. The Director of Nursing and the Administrator both confirmed that fresh water should be passed every two hours and that fluids should be offered with meals, but this was not being done consistently.
Failure to Ensure Timely Completion of CNA Training
Penalty
Summary
The facility failed to ensure that two nurse aides, NA BB and NA U, completed a certified nurse aide (CNA) training program within four months of their employment. NA BB was hired on 02/09/23, and NA U was hired on 06/02/23. Review of their employee files showed no documentation of completion of the CNA training program within the required timeframe. During an interview, the Administrator acknowledged responsibility for enrolling NAs in the training program and admitted awareness of the four-month completion timeline. However, the Administrator stated that the NAs had not yet tested and had 'slipped through the cracks.' The facility census was 116, and the Director of Nursing confirmed that the facility did not have a specific policy on Nursing Assistant and Certified Nursing Assistant training programs.
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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 Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Glasgow Gardens | 12.6 mi | ★★★★★ | 0 | 0 |
| Brunswick Health Care Center | 17.6 mi | ★★★★★ | 11 | 0 |
| Aspire Senior Living Moberly | 20.2 mi | ★★★★★ | 3 | 0 |
| North Village Park | 20.4 mi | ★★★★★ | 49 | 3 |
| Valley View Health & Rehabilitation | 21 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 August 2026) and official state health department websites.