Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Four Seasons Living Center during CMS and state inspections, most recent first.
Facility staff failed to provide enough nursing staff to match the facility assessment for the resident census. The assessment required 4 RCCs, 8 LPNs, 24 CNAs, and 9 CMTs per 24 hours, but the staffing schedule showed shortages across the week, including fewer RCCs, LPNs, CNAs, and CMTs than required. The administrator and staffing coordinator said staffing was managed using the facility assessment, and the staffing coordinator reported many employees had recently quit.
Care plans were not updated with new interventions after two residents repeatedly pulled fire alarms. One resident was cognitively intact with other behavioral symptoms noted on MDS, and the other had moderate cognitive impairment; staff observed and documented repeated fire alarm pulling, but multiple nurses and aides said they did not know what interventions were in place. The care plan policy did not give direction for updating plans after new or increased behaviors.
Staff failed to follow abuse reporting requirements when a cognitively intact resident reported being raped in their sleep and requested hospital evaluation for a rape kit. An LPN reported the allegation to the administrator in the early morning hours and believed it had been reported to the state agency. The administrator confirmed receiving the report but chose not to notify the state, stating that an internal investigation completed within two hours concluded the alleged sexual abuse did not occur, contrary to the policy requiring immediate reporting of all such allegations to the state agency within two hours.
Facility staff did not accurately code psychiatric/mood disorder diagnoses on MDS 3.0 assessments for three cognitively intact residents who had documented bipolar disorder or PTSD in their diagnosis reports and care plans. Although the facility’s policy required accurate and timely completion of MDS sections, the MDS assessments omitted these active psychiatric diagnoses while care plans referenced bipolar disorder, schizophrenia, hallucinations, delusions, and PTSD with interventions. During an interview, the MDS Coordinator stated that active diagnoses under treatment should appear on the MDS but admitted not knowing whether these residents had bipolar disorder or PTSD due to the large resident population.
Staff failed to update care plans after new or increased behaviors, including suicidal ideation and physical aggression. One resident involved in a resident-to-resident altercation with religiously themed statements about not needing medication did not have new interventions added to the care plan despite documentation of the incident. Another resident with depression, assessed as low suicide risk, repeatedly expressed self-harm intent and was found with ligatures around the neck on multiple occasions, yet the care plan lacked guidance for staff on responding to suicidal ideation or self-harm attempts. Additional residents who engaged in physical and verbal altercations were assessed as cognitively intact without behavioral symptoms, and their care plans were not revised to include behavior-related interventions. Interviews with an LPN, the administrator, and the MDS coordinator confirmed that care plans should be updated after such events but highlighted that this was not consistently done.
Staff failed to report an allegation of physical abuse to the state survey agency within the required two-hour timeframe after a cognitively intact, ambulatory resident with schizoaffective disorder, bipolar type, ADHD, and an impulse disorder reported that a CNA grabbed the resident by the coat collar and pushed the resident against a wall. The allegation was communicated to the administrator by an LPN, and the administrator began but did not complete an online report to the Department of Health and Senior Services, resulting in no documented submission of the abuse allegation as required by facility policy.
Staff failed to monitor exit doors during a fire drill, resulting in a resident with psychiatric conditions eloping undetected for several hours, while two other residents also left the unit due to lack of supervision. In addition, medications were left unsecured and unattended in areas accessible to residents who wander, with staff confirming lapses in direct observation and medication security.
Staff failed to follow hand hygiene and dietary sanitation practices. A dietary aide handled soiled and clean dishes without washing hands, other staff washed hands for only a few seconds before preparing or serving food, and a staff member touched a phone and trash lid before handwashing. Wet dishes were stored before air drying, wet cleaning cloths were left out instead of in sanitizer, the ice machines used for resident ice did not drain through an air gap, and multiple kitchen surfaces, equipment, floors, walls, vents, steamtable wells, and an ice scoop were observed dirty or contaminated.
Incomplete Water Management Program: Facility staff failed to develop and implement complete water system policies and procedures to address Legionella risk. Surveyors observed a cooling tower, multiple ice machines, and multiple water sources, while record review showed the water management program lacked a facility-specific risk assessment, control measures, corrective actions, and documentation of quarterly testing. In interview, the maintenance director and administrator were unaware of key water sampling procedures, control measures, and documentation requirements.
Staff failed to receive adequate training on behavioral health competencies and resident-specific interventions, resulting in multiple incidents where residents with mental health diagnoses engaged in verbal and physical altercations without timely or appropriate staff intervention. Staff were unsure how to access care plans or when to call behavioral crisis codes, and documentation of incidents was lacking. Residents and staff reported feeling unsafe due to the lack of effective behavioral health management.
Residents were required to line up outside the enclosed nurse's station for med pass and communicate with staff through a small hole in the plexiglass, which residents and staff described as not dignified and prison-like. Residents were also made to stand in line for meal trays in the dining room because there were not enough chairs and no staff serving at the tables, and leadership acknowledged residents should not have to stand in line if they wanted to be served.
Insufficient dining room chairs were observed in several dining areas, including the Tiger Medical Unit, Tiger Lane, and the men's and women's behavioral dining rooms. Residents were seen standing in hallways or at tables with meal trays, moving so others could sit, or taking meals to their rooms because there were not enough chairs. Staff reported that some chairs were broken or missing, that residents sometimes took chairs to their rooms, and that residents were unable to eat together in the dining room when seating was unavailable.
Staff failed to maintain a clean, comfortable, and homelike environment and failed to provide timely laundry support. Surveyors observed dirty resident rooms and common areas with stained floors, damaged walls, broken furniture, missing trim, uncovered vents, leaking or broken toilets, and dirty A/C units. Residents reported broken or missing linens and clothing, long delays in getting laundry returned, and some were wearing dirty clothes or hospital gowns while waiting for clean items. Staff interviews confirmed broken laundry equipment, limited staffing, and inconsistent handling of resident laundry.
Facility staff failed to consistently provide bed hold notices to residents or their representatives when residents were transferred to the hospital, and failed to send required transfer/discharge notices to the LTC Ombudsman for multiple residents. Records for eight sampled residents showed repeated hospital transfers and returns, but no documentation of bed hold notices or Ombudsman notification. Interviews with an LPN, SSD, Administrator, and DON showed confusion about who was responsible for completing and sending the notices.
Failure to Update Care Plans for Changed Resident Needs: The facility did not revise care plans for multiple residents when their needs changed. Residents had documented pressure ulcers, psoriasis, elopement risk, dietary restrictions, suicidal ideation, hospice status, significant weight loss, edema, and other new or changed conditions, but the corresponding care plans were not updated to reflect those needs or interventions. Staff interviews showed confusion about who was responsible for care plan updates and inconsistent communication when changes occurred.
Failure to Provide ADL Care, Hygiene, and Nail Care: Staff did not maintain personal hygiene, grooming, bathing, or nail care for multiple residents with cognitive impairment and ADL dependence. Observations showed residents wearing the same soiled clothing for days, with oily unkempt hair, body odor, and long dirty fingernails; one resident was also observed eating with dirty fingers and nails. Records did not document refusals or offered showers in several cases, and staff interviews confirmed concerns about dirty nails and missed ADL care were not being reported.
Facility staff failed to ensure nine NAs completed CNA training within the required 120-day time frame. Record review showed the aides had hire dates spanning several months, but their files lacked documentation of completed nurse aide training. Interviews with the NA, DON, Administrator, and HR showed the CNA instructor quit, leaving classes unfinished, and the aides continued working as NAs because the facility needed staffing coverage.
Failure to Document Controlled Substance Administration in Narcotic Record: Staff did not document controlled substance administrations in the Control Drug Record book for three residents, even though the MAR showed doses of Tramadol, Clonazepam, and Suboxone were given. During narcotic counts, staff could not locate medication cards for two residents, and one resident's Suboxone count did not reconcile with the record. Interviews confirmed staff were expected to document narcotics in real time and reconcile counts at shift change, but the DON was not aware of the discrepancies.
Loose, unpackaged medications were found in five of seven med carts observed, including crushed pills and multiple tablets and capsules in medical, behavior, and narcotic storage areas. The facility's Medication Storage Policy did not address loose meds in carts, and staff interviews showed uncertainty about the schedule for checking carts, although the DON and Administrator expected frequent checks and no loose meds.
Hot food was served below required temperatures in two dining areas. In one dining room, a dietary aide placed sausage gravy in a steam table at about 90-92 dF and served it without confirming it reached the required temp. In another area, a dietary aide used an open cart instead of the insulated food cart for breakfast trays, and scrambled eggs and hashbrowns measured only 95-100 dF before being served to residents.
Failure to Post Daily Nurse Staffing Information: Facility staff did not post the required daily nurse staffing information in accessible areas on multiple units, including the 200 hall, 300 hall, 100 hall medical and behavioral units, and the Alzheimer's Unit. The required posting was to show the census and the total number and actual hours worked by RN, LPN/LVN, and CNA staff per shift, but staff said the postings were incomplete, sometimes not filled out for months, and did not include hours worked.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Staff did not promptly inform a resident, the resident's doctor, and a family member about important events such as injury, decline, or room changes, as required. This lapse in communication was identified during the survey.
The facility did not complete the care plan within 7 days of the comprehensive assessment, and the care plan was not prepared, reviewed, and revised by a team of health professionals as required.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines. No further details about specific actions, staff, or residents are provided.
Facility staff did not notify a resident's guardian after the resident, who was moderately cognitively impaired, sustained a humeral fracture. Although the facility's policy and staff interviews confirmed the requirement to inform the responsible party of such changes, the guardian was not contacted following the injury.
Staff did not update care plans for two residents after each experienced unwitnessed falls, despite existing policies and staff knowledge that care plans should be revised following such incidents. One resident with cognitive impairment and another considered low risk for falls both had incident reports documenting falls, but no new interventions were added to their care plans. Staff interviews confirmed the expectation to update care plans, but this was not done due to other assignments.
The facility did not ensure that its services met professional standards of quality, as evidenced by practices that did not align with established guidelines.
Facility staff did not consistently provide the number and type of nursing staff required by their own facility assessment, with staffing schedules showing shortfalls in NAs and the absence of an RCC on several days. The Staffing Coordinator was not trained to use the facility assessment for scheduling, and the administrator had not compared staffing schedules to assessment requirements. Staff interviews reflected mixed perceptions of staffing adequacy, with some noting a need for more crisis prevention education.
Staff failed to complete and document wound care treatments as ordered for two residents, with multiple missed entries on the TAR and no documentation of refusals, despite facility policy requiring timely and thorough documentation. Interviews with an LPN, the administrator, and the DON confirmed the expectation for documentation and revealed that audits were not consistently performed.
The facility staff failed to follow proper sanitation procedures, resulting in potential food contamination. Wet dishes were stacked without air drying, and unsanitary conditions were observed in the kitchens, including food debris and lime deposits. Staff interviews revealed a lack of awareness and enforcement of cleaning protocols, contributing to the deficiencies.
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of records and staff interviews. The facility's policies require separate accounting for resident funds, but the Account Receivable Aging report showed residents' funds were held in the facility's operating account. Staff interviews confirmed the lack of written authorization to hold resident funds in the facility account.
The facility failed to refund personal funds to three residents within the required timeframe after discharge. Despite policies mandating refunds within 30 days of a resident's death and five days of discharge, credit balances remained unaddressed. Interviews revealed a lack of awareness and responsibility among staff, with the Business Office Manager and Corporate Account Receivable Manager acknowledging the issue but citing workload delays. The new administrator was unaware of the outstanding balances, highlighting a breakdown in communication and process adherence.
The facility failed to maintain a clean and safe environment, with observations of unclean resident rooms, broken furniture, and inadequate maintenance. Residents reported unsanitary conditions, such as feces in bathrooms and issues with wheelchairs. Insufficient housekeeping staff and poor communication among staff contributed to the deficiency.
The facility failed to provide adequate weekend activities for residents, with only Bingo and church services offered, leading to boredom and disengagement. The activities calendar was inaccurate, listing events like Father's Day in October, causing confusion. Staff shortages on weekends limited the variety of activities, and the Director of Nursing acknowledged the need for scheduled activities and accurate calendars to prevent negative impacts on residents' moods.
The facility failed to serve hot food at safe temperatures, with observations showing food items like chicken paprikash and squash served below the required 135°F. Staff used room temperature plates and ineffective plate covers, leading to cold meals. Residents reported frequent cold food, and staff lacked awareness of proper serving temperatures. The dietary manager acknowledged the issue but did not routinely check food temperatures, and the administrator was unaware of the problem.
The facility failed to conduct required pre-employment screenings for four new employees, violating their policy. The Human Resources department did not complete necessary checks, such as the Family Care Safety Registry (FCSR) and Employee Disqualification List (EDL), before hiring. Interviews revealed that the Human Resources representative and the administrator were unaware of these oversights.
Facility staff failed to document medication and treatment administration for three residents, leading to a deficiency. A resident with a diabetic foot ulcer did not have documented wound treatments and pain assessments, while another with severe cognitive impairment had missing entries for wound treatment and barrier cream application. A third resident with a feeding tube had missing documentation for syringe kit changes and tube flushing. Interviews revealed that missing signatures were not reported, and the facility's tracking system was underutilized.
A resident with a history of inserting foreign objects into their colostomy bag and stoma was repeatedly hospitalized due to the facility's failure to implement and document interventions. Despite being cognitively intact, the resident's care plan lacked strategies to prevent access to potential objects, and staff did not attempt interventions after each incident.
Facility staff failed to update care plans for two residents regarding colostomy bag use and necessary interventions. One resident's care plan lacked directions for colostomy bag use, while another resident, with a history of inserting foreign objects into their colostomy bag, had no new interventions documented despite multiple hospitalizations. The DON and MDS Coordinator acknowledged these oversights.
A resident with a surgical wound and multiple diagnoses was transferred to the hospital from a wound care appointment without notifying the guardian. Facility staff, including an LPN, DON, and Resident Care Coordinator, failed to inform the guardian, despite the facility's policy requiring notification of significant changes or transfers.
The facility staff failed to maintain an infection prevention and control program, leading to potential COVID-19 spread. Staff did not isolate COVID-19 positive residents properly, wore inappropriate PPE, and disposed of contaminated PPE incorrectly. Observations and interviews confirmed these deficiencies.
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. Interviews revealed inconsistencies in understanding and executing the facility's Post Fall Protocol, with confusion about responsibility for ensuring tasks were completed. The DON admitted some staff had trouble using the PCC system, leading to gaps in required documentation.
Insufficient Nursing Staffing Compared to Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by the facility assessment. The facility census was 239.1, and the facility assessment dated 08/01/25 showed an average daily census of 235 occupied beds over the prior six months. The assessment stated that direct care staffing for a 24-hour period should include 4 RCCs, 8 LPNs, 24 CNAs, and 9 CMTs based on the resident population and their needs for care and support. Review of the staffing schedule from 05/10/26 through 05/16/26 showed staffing below the facility assessment requirements on each day reviewed. Examples included 3 RCCs, 6 LPNs, 16 CNAs, and 8 CMTs on Sunday; 3 RCCs, 6 LPNs, 10 CNAs, and 6 CMTs on Monday; 3 RCCs, 4 LPNs, 14 CNAs, and 7 CMTs on Tuesday; and similar shortages throughout the week. During interviews, the administrator said the staffing coordinator was responsible for updating the schedule and worked with the DON to ensure enough staff per the facility assessment. The staffing coordinator said he/she completed the daily staffing schedules, coordinated with the administrator and DON, followed the facility assessment to determine required staffing, and had many employees who recently quit.
Care Plans Not Updated for Repeated Fire Alarm Pulling
Penalty
Summary
The facility failed to complete and maintain comprehensive, person-centered care plans with updated interventions after two residents repeatedly pulled fire alarms. The facility’s comprehensive care plan policy stated that care plans should include measurable objectives and time frames to meet residents’ medical, nursing, mental, and psychosocial needs, but it did not provide direction for updating a resident’s plan of care when a new or increased behavior occurred. Surveyors found that staff did not update the care plans for two residents after the behavior of pulling fire alarms was identified and continued. Resident #1’s quarterly MDS showed the resident was cognitively intact and had other behavioral symptoms one to three days during the lookback period. The resident’s care plan dated 03/31/26 identified pulling fire alarms as a negative behavior, but it did not include new interventions related to that behavior. On 05/26/26, staff were observed turning off the fire alarm, and the resident stated he/she had pulled it. Staff interviews confirmed the resident had a history of pulling fire alarms when upset or when wanting cigarettes, but multiple staff members did not know what interventions were in place. Resident #2’s comprehensive MDS showed moderate cognitive impairment and no behavioral symptoms during the lookback period, yet progress notes documented that the resident pulled the fire alarm on 05/25/26. The care plan dated 05/26/26 noted behaviors related to mental illness, including pulling facility fire alarms, and staff interviews described frequent and repeated fire alarm pulling, but staff again did not know what interventions were in place.
Failure to Timely Report Allegation of Sexual Abuse to State Agency
Penalty
Summary
Facility staff failed to timely report an allegation of sexual abuse to the State Survey Agency (DHSS) within the required two-hour timeframe. The facility’s Abuse and Neglect Policy, dated 06/12/24, requires that all allegations of abuse, including sexual assault, be reported immediately, but no later than two hours after the allegation is made, to the administrator and appropriate agencies in accordance with state and federal regulations. Resident #4, assessed as cognitively intact on a recent quarterly MDS, reported in a progress note dated 04/02/2026 that he/she had been raped in his/her sleep and requested to be sent to the hospital for a rape kit. During interviews, LPN A stated that the resident reported being raped by someone and later indicated it was a family member, and that this allegation was reported to the administrator around 5:00 A.M. LPN A said he/she was told the administrator reported the allegation to DHSS. The administrator reported receiving a call about the allegation of sexual abuse around 5:30 A.M. but acknowledged that he/she did not file a complaint with DHSS. Instead, the administrator stated he/she conducted an investigation and determined within two hours that the alleged sexual abuse did not occur, and therefore did not report the allegation to DHSS as required by policy and regulation.
Failure to Accurately Code Psychiatric Diagnoses on MDS Assessments
Penalty
Summary
Facility staff failed to complete accurate and comprehensive MDS 3.0 assessments for multiple residents with documented psychiatric diagnoses. The facility’s policy dated 11/06/23 required understanding CMS changes and accurate, timely completion of all MDS sections by responsible staff. For one resident, the diagnosis report dated 04/30/23 showed a documented bipolar disorder, and the care plan dated 3/31/26 identified bipolar disorder and schizophrenia with hallucinations and delusions; however, the resident’s quarterly MDS, dated [DATE], did not include the bipolar disorder diagnosis, even though the resident was assessed as cognitively intact. For another resident, a diagnosis report dated 06/04/25 documented PTSD, and the care plan dated 03/28/26 identified PTSD with interventions in place but without direction regarding PTSD triggers; the corresponding quarterly MDS, dated [DATE], did not include the PTSD diagnosis despite the resident being assessed as cognitively intact. A third resident had a diagnosis report dated 10/15/25 showing PTSD and a care plan dated 01/15/26 documenting a history of PTSD, yet the quarterly MDS, dated [DATE], also omitted the PTSD diagnosis while assessing the resident as cognitively intact. During an interview on 04/14/26 at 1:38 P.M., the MDS Coordinator stated that active diagnoses such as PTSD or bipolar disorder being treated should be documented on the MDS but acknowledged not knowing whether these residents had those diagnoses due to the large facility population.
Failure to Update Care Plans After New or Increased Behaviors and Suicidal Ideation
Penalty
Summary
Facility staff failed to update and individualize care plans following new or increased behaviors, including suicidal ideation and physical aggression, as required after comprehensive assessments. The facility’s policy on MDS 3.0, Care Assessment Summary and Individualized Care Plans, dated 01/06/23, lacked direction for staff on updating care plans with new interventions after new or increased behaviors. For one resident involved in a resident-to-resident altercation on 01/27/26, progress notes documented that the resident was the aggressor and reported that the holy spirit had taken over his/her body and that he/she did not need medication. However, the quarterly MDS showed the resident as cognitively intact without hallucinations or delusions, and the care plan dated 03/31/26 did not include new interventions after the altercation. Another resident, assessed as cognitively intact with depression and care planned as low risk for suicide, had no care plan guidance for staff interventions when suicidal ideation, self-harm statements, or self-harm attempts occurred. Progress notes documented that this resident reported feeling manic and wanting to hurt self, was found with a shoestring around the neck, and was later transferred to the hospital after being found with a charger cord tied tightly around the neck. Additional residents with documented aggressive or behavioral incidents, including pushing another resident to the floor and engaging in a physical altercation, and lashing out at staff and having verbal altercations, were assessed on their MDS as cognitively intact without physical or verbal behavioral symptoms. Their care plans, dated in early 2026, did not include new interventions after these incidents and lacked guidance for staff on managing behaviors. Interviews with an LPN, the administrator, and the MDS coordinator confirmed that care plans should be updated after new or increased behaviors or self-harm statements, but also revealed gaps in practice and awareness, including the MDS coordinator’s lack of knowledge about whether these behaviors were documented on PASARR for the affected residents.
Failure to Timely Report Allegation of Physical Abuse to State Agency
Penalty
Summary
Facility staff failed to report an allegation of physical abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse and neglect policy, dated 06/12/24, defined physical abuse as handling a resident with more force than is reasonable and required that all alleged violations involving abuse be reported immediately, but no later than two hours after the allegation is made if the events involve abuse or result in serious bodily injury. The facility census was 227. Review of the DHSS complaint/facility self-report database showed no documentation that the facility reported the allegation of physical abuse involving one resident. During an interview, the administrator stated that all allegations of abuse should be reported to DHSS within two hours and acknowledged responsibility for submitting the report. The resident involved had an annual MDS dated 01/06/26 showing he/she was cognitively intact, independent with ambulation, and had diagnoses including unspecified impulse disorder, schizoaffective disorder bipolar type, and ADHD. In an interview on 02/18/26 at 12:18 P.M., the resident reported that on the previous night a CNA held him/her by the coat collar at the neck area with a fist and slammed him/her against a wall near a doorway; the resident reported no injury and was unsure if there were witnesses. The facility’s investigation documentation, dated 02/18/26, recorded that the resident reported on 02/17/26 at approximately 7:38 P.M. that the CNA grabbed and pushed him/her, and that there were no direct witnesses and no injuries. The administrator reported being notified of the allegation at approximately 8:00 P.M. on 02/17/26 by an LPN, began an online report to DHSS, but closed the computer without confirming that the report was successfully submitted, resulting in the failure to report the abuse allegation within the required timeframe.
Failure to Supervise During Fire Drill and Inadequate Medication Security
Penalty
Summary
Facility staff failed to ensure the safety and supervision of residents in a secured unit during a fire alarm test, resulting in multiple incidents of elopement and inadequate monitoring. During the fire drill, staff did not monitor the doors on the Tiger Medical Unit, which allowed a resident with significant behavioral and psychiatric diagnoses to exit the facility undetected. Surveillance footage confirmed that the resident left the building and was not noticed missing until several hours later, despite missing dinner, smoke breaks, and scheduled medications. Hourly face checks were not completed as required, and documentation was inaccurate, with checks recorded after the resident had already eloped. Additionally, two other residents were able to leave the facility through an exit door and fence during the same fire drill, as no staff were assigned to monitor these points of egress. Staff interviews revealed a lack of clear assignments and communication regarding door monitoring during fire drills, and head counts conducted after the drill were incomplete and not systematically performed. The facility's fire drill policy did not address specific staffing assignments or door monitoring procedures for secured units during drills or emergencies. The facility also failed to properly store and secure medications for several residents. Observations found unattended medications in resident rooms and on medication carts, with residents who wander frequently present in these areas. Staff interviews confirmed that medications were sometimes left out and not always administered under direct supervision, contrary to facility policy. These lapses in medication security and supervision created opportunities for residents to access medications unsafely.
Dietary sanitation and hand hygiene failures
Penalty
Summary
Facility staff failed to perform hand hygiene as often as necessary and using approved techniques while working in the dietary area. A dietary aide washed soiled dishes in the mechanical dishwashing station and then put away sanitized dishes from the clean side without washing hands. The aide stated he/she had rinsed hands after placing soiled dishes into the machine and thought that was sufficient. Other observations showed a cook and another dietary aide washing hands for only three seconds before preparing or serving food, and a staff member handling a cellular phone and trash can lid with bare hands before washing hands at the sink. The dietary manager and administrator stated staff should wash hands after touching dirty items and should scrub with soap for 20 to 30 seconds. The facility also failed to allow sanitized dishes to air dry before storage. Observations showed wet metal food service pans, plastic service trays, dessert plates, and dessert bowls stacked together on storage racks and in a plate warmer cart. A dietary aide removed sanitized plates from the clean side of the mechanical dishwashing station while they were still wet, stacked them together, and placed them in the cart. The dietary manager and administrator stated clean dishes should air dry before being put away, and the dietary manager said staff were trained on this requirement. Additional observations showed the ice machines used to supply ice to residents did not drain through an air gap, wet cleaning cloths were left on countertops instead of being stored in sanitizer buckets, and kitchen equipment and surfaces were not maintained in a sanitary condition. The report described thick accumulations of dried substances on the exterior and floor beneath the mechanical dishwasher, dirt and debris on kitchen floors, food debris and stains on walls and doors, dust and debris on ceiling vents, food debris and a slimy white substance in steamtable wells, and dirt and unidentifiable substances on the exterior and interior surfaces of an ice machine and its scoop. The dietary manager and administrator stated staff were responsible for cleaning the kitchens daily and following the cleaning schedules, and the maintenance director stated there was not a routine schedule for cleaning vents and ceilings.
Incomplete Water Management Program
Penalty
Summary
Facility staff failed to develop and implement complete policies and procedures for inspection, testing, and maintenance of the facility’s water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire’s Disease. Review of the facility’s Water Management Program documentation showed it did not contain a facility-specific risk assessment, control measures related to identified risk areas, corrective actions to take if control measures were not within specified ranges, or documentation of quarterly water system testing. During the Life Safety Code tour, surveyors observed the facility had a cooling tower, multiple ice machines, and multiple water sources throughout the building, and that all water sources were not in regular use. In interview, the maintenance director stated he/she did not know who was responsible for the water management plan, was unaware of the facility policy directing ten samples quarterly, flushed water heaters twice a year without documenting the flushes, cleaned the cooling tower without documenting the cleaning, and was not aware of any facility-specific water management policies related to control measures or corrective actions. The administrator stated the water management program should include monitoring water temperatures, risk areas, Legionella sample testing, and corrective measures, but was not familiar with facility-specific water sampling procedures or control measures and was not aware the program lacked facility-specific control measures or corrective actions.
Failure to Train Staff on Behavioral Health Needs and Resident-Specific Interventions
Penalty
Summary
Facility staff failed to ensure that staff members possessed the necessary competencies and skills to meet the behavioral health needs of residents, as evidenced by multiple incidents involving residents with behavioral health diagnoses. Staff did not receive adequate training on resident-specific behaviors and interventions, and there was a lack of education on how to access and implement individualized care plans. This deficiency was observed through staff inaction during escalating resident-to-resident altercations, where staff did not intervene or utilize care planned interventions to de-escalate situations, resulting in physical altercations between residents. Additionally, staff interviews revealed uncertainty and lack of knowledge regarding when to call behavioral crisis codes and how to access or apply resident-specific interventions. Several residents with complex behavioral health needs, including diagnoses such as schizophrenia, bipolar disorder, PTSD, and impulse disorders, were involved in repeated incidents of aggression, verbal altercations, and physical assaults. In one instance, two residents engaged in a verbal and physical altercation while staff failed to intervene according to care plan interventions or call a behavioral crisis code in a timely manner. Staff members supervising the residents did not implement de-escalation techniques or follow the individualized interventions outlined in the residents' care plans. Documentation of these incidents was also lacking, with no investigation or nursing notes reflecting the altercations. Interviews with staff and residents further highlighted the deficiency, with staff expressing fear and lack of preparedness to manage residents with severe behavioral health needs. Staff reported not being trained on mental health interventions, de-escalation techniques, or how to access and apply care plan interventions. Residents reported feeling unsafe and stated that staff did not intervene until altercations became physical. The facility's failure to provide adequate training and education for staff on behavioral health needs and individualized interventions contributed directly to the incidents and ongoing unsafe environment for both residents and staff.
Resident Dignity Not Maintained During Medication Pass and Meals
Penalty
Summary
Facility staff failed to maintain resident dignity and self-determination when residents were required to line up outside the enclosed nurse's station door for medication administration and communicate with staff through a small hole in the plexiglass. During observation, a CMT stood inside the nurse's station with pre-popped medication cups while residents waited in line at the closed door, and the CMT handed medications to residents one cup at a time through the door. Another observation showed a resident bent over to speak to the CMT through an approximately three-inch circular hole in the glass, with the resident placing an ear to the opening to hear responses. Residents and staff described the nurse's station setup as not dignified and not homelike. One resident said talking through the hole was "pretty much jail," and another said it was "more prison like." NA staff, a CMT, the RCC, the DON, and the administrator all acknowledged that residents speaking through the hole in the nurse's station glass was not dignified, and the DON and administrator stated staff should not be passing medications from behind the nurse's station. Facility staff also required residents to stand in line to receive meal trays in the Tiger Lane dining room. Observations showed multiple residents lined up at the kitchen window waiting for lunch trays while no staff were present in the dining room to serve residents at the tables. Residents stated there were not enough chairs in the dining room, that they could not sit while waiting, and that standing in line was frustrating. Observations confirmed only nine dining room chairs were present while 44 residents were on Tiger Lane, and staff and leadership acknowledged that residents were standing in line for food and that there were not enough chairs or staff to serve residents at the tables.
Insufficient Dining Room Chairs Prevented Residents From Sitting to Eat
Penalty
Summary
Reasonably accommodate the needs and preferences of each resident was not provided when facility staff failed to ensure there were enough dining room chairs in multiple dining areas. The facility census was 231, and the report states that chairs were missing or broken in the Tiger Medical Unit, Tiger Lane, the men's behavioral dining room, and the women's behavioral dining room. The facility policy titled Promoting/Maintaining Resident Dignity stated residents would be provided equal access to quality care and that personal choices would be considered when providing care and services. Observations showed residents eating without a chair or leaving the dining room because seating was unavailable. On the Tiger Medical Unit, residents were seen standing in the hallway with food trays, standing at tables to eat, or moving so another resident could sit. On Tiger Lane, only nine chairs were observed for 44 residents, and staff and residents reported that there were not enough chairs for everyone who wanted to eat in the dining room. One resident who used a wheelchair said he/she wanted to transfer into a regular dining room chair to eat but could not because there were not enough chairs. Another resident said he/she ate in his/her room because of the lack of chairs, and another said residents were seen standing to eat. In the behavioral dining rooms, seven chairs were observed for 20 residents in the men's unit and five chairs for 16 residents in the women's unit. Staff stated the lack of chairs caused residents to not eat, go to their rooms to eat, or become upset because they wanted to eat together. Multiple staff members reported that chairs were broken, residents took chairs to their rooms, and more chairs had been ordered months earlier but had not arrived. The DON and administrator both stated it was not dignified for residents to have to stand and eat, and the administrator said a capital expense request for new chairs had been submitted but not approved.
Poor Room Conditions and Delayed Laundry Services
Penalty
Summary
Facility staff failed to provide residents with a safe, clean, comfortable, and homelike environment. Survey observations showed multiple resident rooms and common areas with dirty floors, stained walls, missing or broken trim, cracked or missing tiles, broken furniture, uncovered vents and light fixtures, damaged doors and windows, and air conditioning units covered in dirt and debris. Bathrooms were observed with missing toilet tank lids, uncovered exhaust fans, bowed or missing ceiling tiles, rusted fixtures, leaking toilets, and stained floors. The report also described common areas such as dining rooms, hallways, nurse stations, and shower rooms with chipped or missing paint, exposed drywall, dirt buildup, and other visible damage. Several resident rooms were repeatedly observed in poor condition over multiple days. One resident’s bathroom toilet had brown staining and water leakage around the base, and the resident stated the toilet had been leaking for about a month and had not been fixed. Another resident’s room had debris scattered around the bed, a dark substance on the floor, dirty linens, and a toilet that was broken for about a week. Other rooms were observed with dirty bedding, stained privacy curtains, broken dressers, exposed nails, missing mattress on a bed, damaged windows that would not open or close properly, and floors with dirt, debris, feces, urine, or unknown dark substances. Staff interviews reflected that some concerns were not noticed, were not consistently reported, or were difficult to keep up with because of staffing shortages and frequent turnover. Facility staff also failed to ensure residents had timely access to clean clothes and linens and failed to assist residents with laundry as needed. Observations and resident interviews showed piles of dirty clothing in resident rooms, residents without clean pants, underwear, socks, sheets, or pillowcases, and residents wearing hospital gowns or dirty clothes while waiting for laundry to be returned. Residents reported that laundry could take one to three weeks to come back, and one resident said staff had not checked to see whether he or she wanted clean linens. Staff interviews confirmed that the washer on the unit had been broken for an extended period, that laundry staffing was limited, and that dirty clothes were not always being bagged, labeled, and sent to laundry consistently.
Failure to Provide Bed Hold Notices and Ombudsman Transfer/Discharge Notifications
Penalty
Summary
Facility staff failed to provide written bed hold information to residents and/or their representatives at the time of transfer to the hospital and failed to send transfer/discharge notices to the Office of the State LTC Ombudsman for eight sampled residents. The facility policy titled Bed Hold required written notification to the resident and resident representative before transfer or discharge, and required notice to the Ombudsman, including a monthly list or notice as soon as possible for emergency or immediate discharges. The facility census was 231. Review of the records for Residents #4, #7, #9, #12, #91, #93, #100, and #150 showed multiple hospital transfers and returns to the facility, but the records did not contain documentation that bed hold notices were issued to the resident or responsible party. The records also did not contain documentation that the Ombudsman was notified of the transfers and discharges. For several residents, there were repeated hospitalizations and returns over the course of the review period, yet the required notices were still absent from the medical record. An email from the Ombudsman dated 11/25/25 stated that transfer/discharge logs had not been received since around the same time the prior year. During interviews, an LPN said bed hold paperwork was given to the resident if they were their own responsible person, but was unsure who handled it for guardians and was not sure the bed holds were issued consistently. The SSD said the Administrator issued bed holds and that he/she had only been told once about notifying the Ombudsman, while the Administrator said the charge nurse should issue the bed hold and that the SSD should send the Ombudsman notifications. The DON said charge nurses were responsible for issuing bed holds and that the SSD should send a monthly report to the Ombudsman, but he/she did not know the notifications were not being done.
Failure to Update Care Plans for Changed Resident Needs
Penalty
Summary
The facility failed to review and revise comprehensive care plans for 10 of 45 sampled residents whose needs had changed. The facility policy stated that comprehensive care plans are to be developed by an interdisciplinary team, reviewed and revised after each comprehensive and quarterly MDS assessment, and updated when resident needs change. Interviews with staff showed inconsistent understanding of who was responsible for updating care plans, with some staff stating the MDS staff or Care Plan Coordinator handled updates, while others said nursing staff could also update them. The Care Plan Coordinator also stated that communication about changes needing care plan updates was not consistent and that he/she often did not learn of changes until a three-month review. Resident #12 had a quarterly MDS showing moderate cognitive impairment, pressure ulcer risk, a Stage III pressure ulcer, and diagnoses including hypertension, ESRD on dialysis, and diabetes. The record also showed a physician order for wound treatment and a progress note identifying the wound as a Stage III pressure ulcer acquired on 10/13/25 with specific wound care instructions. The resident’s care plan, last dated 08/20/25, was not updated to include the pressure ulcer or related interventions. Resident #19 had a diagnosis of psoriasis, orders for ketoconazole shampoo, prednisone, and a dermatology consult for severe psoriasis, and was observed with significant dry, flaky skin on the scalp, face, and neck, yet the care plan dated 08/29/25 did not include psoriasis or interventions. Resident #57 was assessed as cognitively intact and not wandering, but a quarterly elopement assessment found the resident at risk for elopement/wandering; the care plan did not include that risk or interventions. Resident #58 had an order for almond milk due to intolerance of regular milk, but the care plan did not include the dietary requirement, and observations showed the resident was not provided an alternative to regular milk. Resident #76 had code green and behavioral notes documenting suicidal statements, a shirt tied around the neck, and attempts to place items around the neck, but the care plan in use did not include suicidal ideation or related interventions. Resident #82 had a significant change assessment showing hospice services and multiple diagnoses, but the care plan did not include hospice interventions. Resident #91 had an annual MDS showing significant weight loss, with weights dropping from 183.2 lbs to 160 lbs, but the care plan did not include the weight loss. Resident #117 had a reentry elopement assessment showing risk for elopement/wandering, but the care plan did not include that risk. Resident #185 had edema documented in the medical record and was observed with swollen, tight, red hands, but the care plan dated 03/12/25 did not contain edema. Resident #211 had monthly weights showing a 7% loss in one month, but the care plan did not include the weight loss or interventions. Staff interviews confirmed that hospice status, skin conditions such as psoriasis and edema, significant weight loss, diet orders, pressure ulcers, elopement risks, and suicidal ideation should have been on the care plans, but these changes were not reflected in the residents’ plans of care.
Failure to Provide ADL Care, Hygiene, and Nail Care
Penalty
Summary
Facility staff failed to provide care to maintain personal hygiene, grooming, bathing, and nail care for four residents. The deficiency was identified through observation, interview, and record review for Residents #211, #233, #149, and #77, out of a sample of 45 residents in a facility census of 231. The facility policy titled Activities of Daily Living stated that residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene, and that the facility would maintain individual objectives of the care plan and periodic review and evaluation. Resident #233 had severe cognitive impairment, Parkinson's Disease, Alzheimer's Disease, and dementia, and required moderate assistance with personal hygiene, bathing, and toileting hygiene. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, and to assist with clothing choices. However, point of care documentation showed nail care did not occur on one day and a shower was refused on another day without documentation of reapproach. Progress notes did not document refusals. Observations over several days showed the resident wearing the same gray sweatshirt and blue sweatpants, with oily and unkempt hair, strong body odor, and long fingernails with debris. Staff interviews indicated the resident's fingernails had not been reported to the RCC or CMT, and the RCC stated staff had not reported shower refusals or nail concerns. Resident #149 had moderate cognitive impairment, dementia, diabetes, and TBI, and required supervision or touch assistance for bathing, dressing, and personal hygiene. The care plan directed staff to assist with clothing choices and monitor and report changes. Point of care documentation showed no refusals of nail care, bathing, or personal hygiene, and progress notes did not document refusals. Observations showed the resident wearing stained clothing repeatedly, with oily and disheveled hair, strong body odor, and long fingernails with brown debris. The resident was also observed eating with dirty fingers and long fingernails after a meal tray was placed in the room. Staff interviews stated the resident had worn the same clothes all week, had not been showered by the aide, and that the resident's fingernails were dirty and should not be used for eating. The RCC stated no one had reported shower refusals or fingernail concerns. Resident #211 had moderate cognitive impairment, dementia, major depressive disorder, adjustment disorder, antisocial personality disorder, and TBI, and required moderate assistance with personal hygiene, bathing, toileting hygiene, and oral hygiene. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. Point of care documentation showed no refusals of nail care, bathing, or personal hygiene, and no bath or shower was documented as offered. Progress notes did not document refusals. Observations showed the resident wearing stained clothing, with urine odor, oily hair, long fingernails with brown debris, and later bare feet covered in a thick black substance. The resident was also observed eating with dirty fingers and long fingernails. Staff interviews stated the resident had worn the same clothes all week, had not been showered, and that the fingernails were dirty and should not be used for eating. The RCC stated no shower refusals or fingernail concerns had been reported. Resident #77 had moderate cognitive impairment, Alzheimer's Disease, dementia, psychotic disorder, ROM impairment to both lower extremities, used a wheelchair, and required moderate assistance with personal hygiene, bathing, and toileting hygiene. The care plan directed staff to check nail length and trim and clean nails on bath day and as necessary, provide sponge baths when needed, and reapproach residents who resisted ADLs. Point of care documentation showed no refusals of nail care, bathing, or personal hygiene, and progress notes did not document refusals. Observations showed long fingernails with debris, oily and unkempt hair, foul body odor, and the resident eating with fingers at times. During incontinence care, staff did not clean the resident's fingernails. Staff interviews stated that dirty fingernails were not being reported, that residents' fingernails should be checked daily and cleaned before and after meals, and that refusals should be documented in notes and on the care plan. The DON stated refusals for ADL care were not documented for these residents, and the administrator stated there was no good answer for why the residents wore the same clothes, had body odors, and had dirty fingernails all week.
Nurse Aides Not Trained Within Required Time Frame
Penalty
Summary
Facility staff failed to ensure that nine nurse aides completed the nurse aide training program within four months of employment. Review of the CNA reports showed that NA D, NA I, NA P, NA V, NA W, NA X, NA Y, NA Z, and NA AA each had hire dates ranging from 03/24/25 through 08/26/24, and the files for each did not contain documentation that the aide completed a nurse aide training program. The facility’s policies did not include a policy for NA qualifications. During interviews, NA V stated he/she was still working as a NA during the survey week and explained that he/she had been in CNA classes when the instructor quit, leaving the class unfinished. NA V said he/she had been waiting to learn what to do next and continued working because the facility needed staff. The DON, Administrator, and HR all stated they were aware of the 120-day training requirement, but the instructor’s abrupt departure delayed completion; they also stated the aides continued working as NAs because of staffing needs.
Failure to Document Controlled Substance Administration in Narcotic Record
Penalty
Summary
Facility staff failed to document the administration of controlled substance medications in the Control Drug Record book at the time of administration for three residents. The facility policy stated that controlled substances obtained from a non-automated medication cart or cabinet are to be recorded on the designated usage form, that the Controlled Drug Record serves as the source for documenting patient-specific narcotics dispensed from the pharmacy, and that two licensed nurses are to account for controlled substances at the end of each shift. The report identified that the facility census was 231 and that three of 45 sampled residents had discrepancies between the MAR and the individual patient narcotic record. For one resident with diagnoses including anxiety disorder, bipolar disorder, schizophrenia, diabetes mellitus, and arthritis, the MAR showed Tramadol HCL 50 mg, two tablets every six hours as needed, was administered once, but the individual patient narcotic record did not document that administration. During observation, the CMT was unable to find the Tramadol card during the narcotic count, and the narcotic record showed one tablet remained. For a second resident with diagnoses including anxiety disorder, depression, bipolar disorder, and schizophrenia, the MAR showed Clonazepam 0.5 mg twice daily was administered twice on one day and twice on another, but the narcotic record did not document two administrations on one day and did not document the morning dose on the other day. During observation, the CMT was unable to find the Clonazepam card during the narcotic count, and the narcotic record showed three tablets remained. For a third resident with diagnoses including anxiety disorder, depression, bipolar disorder, schizophrenia, oppositional defiant disorder, and substance abuse history, the MAR showed Suboxone 4 mg/1 mg twice daily was administered twice, but the individual patient narcotic record did not document those administrations. During observation, the RCC counted 51 doses remaining while the narcotic record showed 53 doses remaining. Interviews with the CMT, RCC, DON, and Administrator confirmed that staff were expected to document narcotic administration in real time in the Control Drug Record book and reconcile narcotic medications at shift change, but the DON stated he/she was not aware the three residents' narcotic counts were incorrect.
Loose Medications Found in Multiple Medication Carts
Penalty
Summary
Drugs and biologicals used in the facility were not labeled in accordance with currently accepted professional principles when unpackaged, loose medications were found in five of seven medication carts observed. The facility census was 231.1. Review of the facility's Medication Storage Policy, dated 05/18/24, showed the policy did not provide guidance regarding loose medications in the medication carts. During observations on 12/01/2025, surveyors found loose medications in multiple carts: the 200 hall medical unit cart had one crushed pill and one blue and yellow capsule; the 100 hall medical unit cart had two white tablets, one pink tablet, and one white tablet in the narcotic box; the woman's behavior unit cart had three white tablets and one yellow tablet; the men's behavior unit cart had one purple and pink capsule; and the 300 hall medication cart had one red and white capsule and one yellow capsule. During interviews, the CMT said he/she usually tries to check medication carts weekly for loose medications but was not sure of a set schedule and had not been trained on how often to check. The RCC HH was also unsure of the policy but thought CMTs should check weekly. The DON said he/she believed staff should check each shift and complete a full check each week, and the Administrator said he/she expected frequent checks and no loose medications in the carts.
Hot Food Served at Unsafe Temperatures
Penalty
Summary
Facility staff failed to ensure hot food was served at a safe and appetizing temperature in the Main Street and 400 hall dining rooms. During breakfast service in the Main Street dining room, a dietary aide served sausage gravy from the steam table even though the gravy measured 92 dF in the steam table and had not been checked before being placed there. The aide stated the gravy was taken from the oven, transported to the dining room, and placed in the steam table without verifying its temperature, then later checked it at 90 dF but did not send it back to the kitchen because the steam table usually heats it up before service. The dietary manager and administrator stated hot food should be at least 140 dF in the steam table and before service, and that staff are trained to check temperatures and not serve food that does not meet that requirement. On the 400 hall, a dietary aide prepared breakfast trays with scrambled eggs and hashbrowns, placed them on room temperature plates, covered them with insulated plate covers, and set them on an open wheeled bakery rack cart instead of the green insulated food cart that was available in the hallway. The aide stated the insulated cart was supposed to be used to keep food hot but was not used because trays were usually passed quickly. When the trays were observed later, the scrambled eggs and hashbrowns on one resident's tray measured 95 dF, and on two other residents' trays measured 100 dF. The trays were then served to the residents. The dietary manager stated hot food should be at least 140 dF when served, and the administrator stated hot food should be at least 120 dF upon service and that staff are trained to deliver trays in the insulated food cart and check the first tray before it is served.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
Facility staff failed to post the required nurse staffing information daily in an area readily accessible to residents and visitors. The report states the required posting was to include the facility name, current date, resident census, and the total number and actual hours worked per shift by RN, LPN/LVN, and CNA staff directly responsible for resident care. The facility census was 233, and the policy reviewed on 06/26/24 required the staffing sheet to be posted at the beginning of each shift in a clear, readable, and prominent location. Survey observations on the 200 hall, 300 hall, 100 hall medical unit, 100 hall behavioral unit, and the Alzheimer's Unit repeatedly showed no nurse staffing posting visible or accessible to residents and visitors. Staff interviews indicated the posting was not always completed, that hours worked were not written, and that some unit postings had not been filled out for months. The DON stated the staffing posting was posted daily in the front lobby and that RCCs oversaw the unit postings, while the Administrator stated staff were to write the posting on the white board in each unit every day and include the names of staff and their hours worked, but she did not know staff were not doing this daily.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. Specific details about the actions or inactions leading to the deficiency, as well as information about the residents involved or their medical conditions at the time, are not provided in the report.
Failure to Immediately Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors during the review of facility practices and records. The deficiency centers on the facility's failure to ensure that all required parties were promptly informed when significant events impacting the resident occurred, as required by regulation.
Failure to Timely Develop and Review Care Plan
Penalty
Summary
The facility failed to develop the complete care plan within 7 days of the comprehensive assessment. The care plan was not prepared, reviewed, and revised by a team of health professionals as required. This deficiency was identified based on the review of facility records and documentation, which showed that the care planning process did not meet the specified timeline and team involvement requirements.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report does not provide specific details about the actions or inactions of staff, the events leading to the deficiency, or information about any residents involved at the time of the incident.
Failure to Notify Responsible Party After Resident's Change in Condition
Penalty
Summary
Facility staff failed to notify a resident's responsible party after the resident experienced a significant change in condition. According to the facility's Notification of Change policy, staff are required to promptly inform the resident, consult the resident's physician, and notify the resident's representative when there is a change requiring notification, such as accidents resulting in injury or those with the potential to require physician intervention. Review of the resident's records showed that the resident, who was assessed as moderately cognitively impaired, sustained a humeral fracture as confirmed by x-ray. The results were reviewed with the physician, but there was no documentation or evidence that the resident's guardian was notified of the fracture. Interviews with the resident's guardian confirmed that they were not informed about the injury. Further interviews with facility staff, including an LPN, the administrator, and the DON, all indicated that staff are directed to contact the resident's family or guardian in the event of a change in condition. Despite this policy and staff understanding, the required notification to the resident's guardian did not occur following the resident's fracture.
Failure to Revise Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the care plans for two residents following changes in their conditions, specifically after each experienced unwitnessed falls. For one resident, the care plan was last revised prior to a documented fall, and no new fall intervention was added after the incident. The resident was assessed as moderately cognitively impaired and at risk for falls due to confusion, incontinence, and psychoactive drug use. Despite an incident report documenting a fall, the care plan did not reflect any updated interventions addressing this event. For the second resident, the care plan was also not updated after two separate unwitnessed falls. The resident was assessed as cognitively intact and considered low risk for falls, with risk factors including psychoactive medications and extrapyramidal symptoms. Incident reports documented two falls, but the care plan did not include any new interventions following these events. Interviews with staff and administration confirmed that care plans are expected to be updated after such incidents, but this was not completed due to competing assignments and oversight.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The nursing facility failed to ensure that services provided met professional standards of quality. This deficiency was identified based on observations and review of facility practices, which did not align with established professional guidelines. The report notes that the facility did not maintain the required level of care as expected by professional standards, but does not provide specific details about the actions or inactions of staff, nor does it mention any particular residents or their medical conditions at the time of the deficiency.
Failure to Provide Adequate Nursing Staff per Facility Assessment
Penalty
Summary
Facility staff failed to provide adequate nursing staff as determined by their own facility assessment, which was based on the resident population and their care needs. The facility assessment specified the required number of direct care staff for a 24-hour period, including LPNs, CMTs, CNAs, NAs, and an RCC. Review of staffing schedules over several days showed that the facility did not consistently meet these staffing requirements, with particular shortfalls in the number of NAs and the absence of an RCC on multiple days. The average daily census during this period was 235 residents, closely matching the assessment's basis. Interviews revealed that the Staffing Coordinator did not use the facility assessment to determine staffing needs and was not trained to do so. The administrator acknowledged not comparing the facility assessment to the staffing schedule and was unaware of the staffing shortfalls. The DON stated that the staffing schedule should reflect the facility assessment but believed no issues were found when recently reviewed. Staff interviews indicated a perception of adequate staffing, though some noted a need for more education in crisis prevention due to resident altercations.
Failure to Document and Complete Wound Care Treatments
Penalty
Summary
Facility staff failed to maintain professional standards of practice by not completing and documenting wound care treatments as ordered for two residents. For one resident, who was cognitively intact and had orders for multiple wound care treatments including barrier cream, Santyl ointment, and cleansing regimens, the Treatment Administration Record (TAR) showed multiple dates where treatments were not documented as completed. There was also no documentation indicating that the resident refused care on those dates. The physician orders required daily and shift-based wound care, but the records did not reflect that these were consistently provided or refused. Another resident, who was moderately cognitively impaired and had a surgical wound, had physician orders for daily application of xeroform and telfa dressings. The TAR for this resident also showed several dates where the wound care was not documented as completed, and again, there was no documentation of refusal of care. The facility's policy required wound treatments to be documented at the time of each treatment, with additional documentation if treatments were not due or if dressings were intact, as well as documentation of refusals and notifications to physicians or responsible parties. Interviews with staff, including an LPN, the administrator, and the DON, confirmed that treatments should be documented in the medical record and that refusals should be noted on the TAR. The DON acknowledged that missed treatments were identified when providing printed TARs to the surveyor and admitted that audits of the TARs had not been completed due to being too busy. The lack of documentation and failure to follow the facility's wound care policy led to the deficiency.
Sanitation Failures in Kitchen Lead to Potential Food Contamination
Penalty
Summary
The facility staff failed to adhere to proper sanitation procedures in the kitchen, leading to potential food contamination. Observations revealed that sanitized dishes were not allowed to air dry before being stacked, which can promote bacterial growth. Specifically, metal food service pans and plates were found stacked wet, with some containing food debris. Despite being aware of the issue, a dietary aide continued to use these wet dishes to serve food to residents, indicating a lapse in following the facility's policy on dish sanitation. Additionally, the facility's kitchens and kitchenette were not maintained in a clean and sanitary manner, as required by the facility's policies. Observations showed a build-up of food debris and other substances on kitchen equipment and surfaces, including steam tables, floors, and walls. The main kitchen lacked a visible cleaning schedule, and there was an accumulation of lime and calcium deposits on various surfaces. The dietary manager admitted to not having a routine schedule to check the sanitation of the kitchen and was unaware that staff were not following the cleaning schedules. Interviews with staff, including the dietary manager and the administrator, revealed a lack of awareness and enforcement of cleaning protocols. The dietary manager acknowledged responsibility for ensuring cleanliness but was unaware of the extent of the issues. The administrator also admitted to not being aware of the problems and stated that dietary staff should be trained on cleaning schedules and that routine inspections should be conducted. The facility's failure to maintain a sanitary environment and adhere to its own policies resulted in unsanitary conditions that could lead to food contamination.
Commingling of Resident Funds with Facility Operating Funds
Penalty
Summary
The facility failed to prevent the commingling of personal funds for 12 residents with the facility's operating funds, as identified in a review of the facility's records and interviews with staff. The facility's policies, including the Resident Rights policy and the Resident Trust policy, both revised in 2023, clearly state that resident funds must be kept separate from facility funds. However, the Account Receivable Aging report dated October 22, 2024, showed that residents' personal funds were held in the facility's operating account, with credit balances ranging from $184.00 to $6,651.61 for various residents. Interviews with the Business Office Manager and the Corporate Account Receivable manager revealed that the facility did not have written authorization to hold resident funds in the facility account, and both acknowledged that resident funds should not be commingled with facility funds. The Corporate Administrator, who had been overseeing the facility since June 2024, also confirmed that the facility lacked written permission to hold these credits and emphasized the importance of reviewing Account Receivable and billing weekly. The new administrator, who started the week of the survey, was informed of these responsibilities.
Failure to Refund Resident Funds Timely
Penalty
Summary
The facility failed to provide refunds of personal funds to residents from the facility operating account within 30 days for three residents who were discharged. The facility's policy requires that upon the death of a resident, the facility must convey resident funds and a financial accounting of those funds within 30 days to the individual or probate jurisdiction administering the resident's estate. Additionally, within five days of a resident's discharge, the facility is required to provide an up-to-date accounting of resident funds. However, the facility's Account Receivable Aging report showed that three residents had credit balances that were not refunded within the required timeframe. Interviews with facility staff revealed a lack of awareness and responsibility for the outstanding refunds. The Business Office Manager was unaware of why the refunds had not been processed, while the Corporate Account Receivable Manager acknowledged the issue but cited being behind on work as the reason for the delay. The new administrator, who started at the facility recently, was also unaware of the outstanding balances and stated that the business office and administrator are responsible for reviewing accounts receivable and billing. The Corporate Administrator, who had been at the facility since June, was also unaware of the outstanding credit balances until informed during the survey.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by numerous observations of unclean and poorly maintained resident rooms and common areas. Observations included black scuff marks, sticky floors, broken furniture, and debris in various resident rooms and common areas. Additionally, there were reports of feces in a resident's bathroom that had not been cleaned, leading to an unpleasant and unsanitary environment. Interviews with residents and staff revealed dissatisfaction with the cleanliness and maintenance of the facility, with some residents expressing that their rooms were not cleaned after previous occupants moved out. The facility's housekeeping and maintenance policies were not consistently followed, as evidenced by the lack of deep cleaning and maintenance in resident rooms and common areas. Staff interviews indicated that there were often insufficient housekeeping staff on weekends, leading to inadequate cleaning and maintenance. The housekeeping supervisor admitted to not conducting regular checks for cleanliness, and the maintenance director was unaware of certain maintenance issues until they were pointed out by surveyors. Residents reported issues with their wheelchairs, such as missing armrests and built-up debris, which were not addressed despite being reported to staff. The facility's failure to maintain clean and functional assistive devices further contributed to the deficiency. The lack of coordination and communication among staff, as well as insufficient staffing levels, were significant factors in the facility's inability to provide a safe and comfortable environment for its residents.
Inadequate Weekend Activities and Inaccurate Calendar
Penalty
Summary
The facility staff failed to provide an ongoing activity program designed to meet the residents' interests, mental, and psychosocial well-being on the weekends for six residents out of 35 sampled residents. The activities calendar posted on Tiger Lane was inaccurate, listing events such as Father's Day in October, which confused residents. Interviews with residents revealed dissatisfaction with the limited activities offered on weekends, primarily consisting of Bingo and church services, leading to boredom and a lack of engagement. Interviews with staff, including Certified Medication Technicians, Certified Nurse Aides, and the Activities Director, highlighted the challenges faced in providing adequate activities on weekends. The facility had only one activity staff member available on weekends, which limited the variety and frequency of activities. Staff expressed that more activities could prevent residents from becoming bored and potentially getting into conflicts with each other. The Activities Director acknowledged the inaccuracies in the posted calendar and the difficulty in arranging activities without sufficient staff support. The Director of Nursing and Corporate Administrator recognized the need for scheduled weekend activities and the importance of an accurate activity calendar. They noted that incorrect events, such as Father's Day in October, could negatively impact residents' moods, especially those with a history of trauma. The lack of diverse and engaging activities on weekends was a significant deficiency, affecting the residents' quality of life and psychosocial well-being.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility staff failed to ensure that hot food items were served at a safe and appetizing temperature, as observed during meal service on the 400 and 500 halls. The facility's Dietary Food Preparation policy requires hot foods to be served at temperatures greater than 135 degrees Fahrenheit, preferably between 160 to 170 degrees Fahrenheit. However, observations revealed that the internal temperatures of hot food items, such as chicken paprikash with pasta and squash, were significantly below the required temperature, measuring at 109.4 degrees Fahrenheit and 95.7 degrees Fahrenheit, respectively. The dietary manager acknowledged the temperature discrepancy but continued to serve the food without reheating it to the proper temperature. Further observations showed that the dietary aide prepared meal trays using room temperature plates and covered them with metal plate covers that had open holes, which did not retain heat effectively. The trays were then placed on an open wheeled bakery rack cart for delivery. Interviews with staff members revealed a lack of awareness regarding the correct serving temperatures for hot foods, with one staff member incorrectly believing that 72 degrees Fahrenheit was acceptable. Residents reported that their food was often served cold, indicating a recurring issue with maintaining appropriate food temperatures. The dietary manager admitted that the metal plate covers with holes were used due to storage limitations and acknowledged that this contributed to the problem of cold food. Additionally, the dietary manager did not routinely check the temperatures of foods served on carts in the unit, and there was no communication with the administrator regarding the need for different plate covers. The administrator was unaware of the issues with food temperatures and stated that the dietary manager was responsible for monitoring food temperatures, highlighting a lack of oversight and communication within the facility's management.
Failure to Conduct Pre-Employment Screenings
Penalty
Summary
The facility staff failed to conduct necessary pre-employment screenings for four out of ten new employees, which is a violation of their policy. The policy requires the Human Resources department to perform pre-employment checks to ensure applicants have not committed disqualifying crimes, are not excluded from federal or state healthcare programs, and are eligible to work in the United States. Specifically, the checks should include a Criminal Background Check (CBC) through the Missouri Highway Patrol or a Family Care Safety Registry (FCSR) check, and an Employee Disqualification List (EDL) check. However, the records showed that these checks were either requested or completed after the employees were hired, which is against the facility's policy. The personnel records revealed that Dietary Aide S, [NAME] Y, Housekeeper N, and Activity Aide K were hired before the completion of the required checks. For instance, Dietary Aide S was hired on 09/25/23, but the FCSR check was requested on 09/27/23. Similarly, [NAME] Y was hired on 12/04/23, with checks completed on 12/06/23. Housekeeper N and Activity Aide K also had their checks completed after their respective hire dates. During interviews, the Human Resources representative acknowledged the oversight, stating that the expectation is for all checks to be completed before hiring. The administrator also expressed that they were unaware of the incomplete checks prior to the hiring dates.
Documentation Lapses in Medication and Treatment Administration
Penalty
Summary
The facility staff failed to document the administration of medications and treatments for three residents, leading to a deficiency in meeting professional standards of quality. Resident #115, who had intact cognition and a diabetic foot ulcer, did not have documented wound treatments and pain assessments on multiple occasions in September and October 2024. The resident reported that the wound clinic recommended daily bandage changes, but facility staff changed it every three to four days, indicating a discrepancy in care. Resident #132, with severe cognitive impairment and a venous ulcer, also experienced lapses in documentation. The Treatment Administration Record (TAR) lacked entries for wound treatment and the application of barrier cream after incontinence on several days in October 2024. This lack of documentation suggests that the necessary treatments may not have been administered as prescribed. Resident #219, who had moderate cognitive impairment and a feeding tube, had missing documentation for changing the syringe kit, cleansing the feeding tube site, and flushing the feeding tube with water. These omissions occurred throughout August, September, and October 2024. Interviews with the Resident Care Coordinator (RCC) and the Director of Nursing (DON) revealed that missing signatures on the TARs and MARs were not reported, and the facility's dashboard for tracking missed medications was not effectively utilized.
Failure to Supervise Resident with Risky Behavior
Penalty
Summary
The facility staff failed to provide adequate supervision for a resident with a history of inserting foreign objects into their colostomy bag and stoma, leading to multiple hospitalizations. The resident, who was assessed as cognitively intact, had documented incidents of inserting objects such as a paperclip, fork, spoon, and other foreign items into their colostomy bag and stoma. Despite these repeated incidents, the resident's care plan did not include specific interventions to address this behavior, and staff did not implement or document any corrective actions following each occurrence. Interviews with facility staff, including the Charge Nurse and Director of Nursing (DON), revealed that there were no interventions attempted after each incident, and the care plan lacked strategies to prevent the resident from accessing silverware or other potential objects. The DON acknowledged that if interventions had been attempted, it might have prevented future incidents. The facility's failure to implement and document appropriate interventions and supervision measures contributed to the resident's repeated hospitalizations due to the insertion of foreign objects.
Failure to Update Care Plans for Colostomy Bag Use and Interventions
Penalty
Summary
The facility staff failed to document and update care plans for two residents regarding the use of colostomy bags and necessary interventions. Resident #2, who was cognitively intact and used an ostomy bag, had a care plan that did not include directions for the use of the colostomy bag, despite having a physician's order for it. The Director of Nursing (DON) and the MDS Coordinator acknowledged the oversight and admitted that the care plan should have been updated to include this information. Resident #1, also cognitively intact and using a colostomy bag, had a history of inserting foreign objects into the colostomy bag and stoma, leading to multiple hospitalizations. Despite these incidents, the care plan had not been updated with new interventions since February 2024. Interviews with the Charge Nurse, DON, and the administrator revealed that no new interventions were attempted or documented after each incident, although they agreed that such actions should have been taken and recorded in the care plan.
Failure to Notify Guardian of Resident's Hospital Transfer
Penalty
Summary
Facility staff failed to notify a resident's responsible party when the resident was transferred to the hospital from a wound care appointment. The facility's policy requires staff to inform the resident, consult the resident's physician, and notify the resident's representative of significant changes in the resident's condition or when a transfer occurs. However, in this case, the staff did not document any notification to the resident's guardian about the transfer. The resident, who was cognitively intact, had a surgical wound on the right foot and several diagnoses, including metabolic encephalopathy and diabetes with circulatory complications. The resident's care plan included a left below-the-knee amputation and a right transverse foot amputation. Interviews with facility staff, including an LPN, the DON, and the Resident Care Coordinator, revealed that there was an expectation to notify the guardian, but it was not done. The guardian was unaware of the transfer until contacted by the hospital for permission to treat the resident.
Failure to Maintain Infection Control Program
Penalty
Summary
The facility staff failed to maintain an infection prevention and control program to provide a safe and sanitary environment, leading to the potential spread of COVID-19 and other infections. Staff did not follow acceptable infection control practices, such as separating residents who tested positive for COVID-19 from those who tested negative or had only been exposed. This failure increased the risk of contracting COVID-19 for several residents due to prolonged exposure. Additionally, staff did not consistently wear the appropriate Personal Protective Equipment (PPE) when interacting with COVID-19 positive residents, nor did they remove and dispose of contaminated PPE appropriately. Observations revealed multiple instances where COVID-19 positive residents were not isolated properly. For example, the door to a room with two COVID-19 positive residents was left open, and a Certified Nurse Aide (CNA) was observed sitting close to one of the residents with only an N95 respirator on, lacking gloves, face shield, or gown. Other observations showed COVID-19 positive residents without masks, doors to their rooms open, and no PPE stations outside the rooms. Staff, including maintenance workers and the assistant administrator, entered rooms of COVID-19 positive residents without full PPE and continued to wear the same N95 masks after exiting the contaminated areas. Further observations indicated improper PPE removal and disposal practices. Staff were seen removing PPE in hallways and placing contaminated PPE in regular trash bags instead of bio-hazard bags. Interviews with staff, including CNAs, housekeepers, and the Director of Nursing (DON), confirmed that there was confusion and inconsistency regarding the proper use and disposal of PPE. The DON acknowledged that staff should wear full PPE when entering COVID-19 positive rooms and should remove PPE inside the room, placing it in red bio-hazard bags, not regular trash bags.
Failure to Complete Neurological Checks and Documentation After Un-witnessed Falls
Penalty
Summary
Facility staff failed to complete 72-hour neurological checks and fall follow-up documentation for two residents who had un-witnessed falls. The facility's Post Fall Protocol requires neurological assessments and detailed documentation following an un-witnessed fall, but these were not completed for the residents in question. Resident #1, who was cognitively intact and independent for mobility, had un-witnessed falls on two separate occasions, but the required neurological checks and documentation were not found in the medical record. Similarly, Resident #2, who was cognitively intact and used a wheelchair for mobility, also experienced an un-witnessed fall, and the necessary follow-up was not documented in the medical record. Interviews with various staff members, including LPNs, CMTs, RCCs, and the DON, revealed inconsistencies in the understanding and execution of the facility's Post Fall Protocol. Staff members acknowledged that neurological checks should be initiated and documented in Point Click Care (PCC) for 72 hours following an un-witnessed fall. However, there was confusion about who was responsible for ensuring these tasks were completed, with some staff indicating that the DON or RCCs were ultimately responsible. Despite this, the required documentation was not completed for the residents involved. The DON admitted that some staff had trouble using the PCC system and occasionally resorted to paper documentation, which was then scanned into PCC. However, this process was not consistently followed, leading to gaps in the required neurological checks and follow-up documentation. The failure to adhere to the facility's Post Fall Protocol resulted in incomplete assessments and documentation for the residents who experienced un-witnessed falls.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sedalia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rest Haven Health Care Center | 3.8 mi | ★★★★★ | 4 | 1 |
| Fair View Health Care Center | 5.3 mi | ★★★★★ | 1 | 0 |
| Sylvia G Thompson Residence Center, Inc | 6.5 mi | ★★★★★ | 13 | 0 |
| E W Thompson Health & Rehabilitation Center | 6.8 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Care Center | 15.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Four Seasons Living Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.