Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Golden Years Center For Rehab And Healthcare during CMS and state inspections, most recent first.
A facility failed to ensure dependent residents received bathing services and that bathing was documented per resident preference and policy. Four sampled residents with needs ranging from partial to substantial/maximal assistance had no baths or showers documented for an entire month, and interviews and observations showed dirty clothing, poor grooming, body odor, and residents reporting they went weeks without showers. Staff said one CNA handled bathing for the whole facility, evenings and weekends did not provide baths, missed baths were not rescheduled, and the DON could not provide proof of auditing bathing documentation.
Incomplete and inaccurate shower documentation: The DON directed a CNA and another CNA to backfill shower sheets for several residents, and the records showed multiple shower and skin assessment entries that the CNA later said never occurred. Residents also reported not receiving the documented showers, including one resident who said he/she went weeks without a shower and others who said they received far fewer showers than recorded. The facility’s own staff stated shower documentation was supposed to be completed on the day care was provided, but the sheets were created and signed after the fact.
A laundry area wall had a large moldlike substance and another moldlike area behind a stainless-steel sink. Staff interviews indicated water entered through a boarded window, the dumbwaiter area, and possibly a past leak behind the sink, with standing water reported after heavy rainstorms and the walls described as sweating.
The facility used its van with an expired vehicle registration to transport residents to physician appointments several times a week, despite having a policy requiring safe, compliant transportation and the availability of other transportation services. Emails between facility administration and the parent company showed ongoing awareness that the van’s registration had expired and that the title was needed to renew it. Observation confirmed the expired plate sticker, and review of transportation logs showed repeated use of the van for resident appointments while some residents were transported by outside companies. In interviews, the van driver, an LPN, and the Administrator all acknowledged that the van’s license had expired the previous year, that administration knew about it, and that the van continued to be used for resident transport during this period.
Kitchen sanitation and food storage deficiencies: Surveyors observed excessively scored cutting boards shedding plastic particles, a microwave with spills and food debris, a manual can opener blade with sticky buildup, a dented can still stored on a dispenser rack, chipped plastic plate covers, and paper, plastic, and food debris on the walk-in freezer floor and under racks. The DM stated damaged packaging should be separated for return to the vendor and that food prep items were cleaned after each use, while the Administrator said kitchen staff should follow best industry sanitation practices.
Incomplete Legionella and Waterborne Pathogen Prevention Program: The facility failed to maintain a facility-specific IPC program for Legionella and other water-borne pathogens. Survey review found missing ASHRAE #188 risk assessment elements, an incomplete CDC toolkit, no completed CDC Legionella Environmental Assessment Form, no written water-flow/risk-area analysis, no outbreak plan, no testing protocols or action plans, and no site log book documentation. During the LSC walk-through, surveyors observed extensive water systems, sinks, washers, sprinkler systems, boilers, resident room plumbing, bathing rooms, and kitchen water equipment. The Administrator said the only Legionella material was old and outdated, and the DOM said he/she had no responsibilities or training for Legionella prevention.
Delayed smoking assessments were identified for three residents who smoked. One resident was cognitively intact and had only two smoking safety screens in the EMR, another had Parkinson’s disease, Alzheimer’s disease, impaired vision, and needed a smoking apron and supervision while staff observed the resident smoking with the lit cigarette held close to the apron-covered stomach, and a third resident with cerebral infarction and impaired cognition had no smoking care plan focus or interventions in place. The DON stated the assessments should have been completed upon admission, quarterly, and with changes in condition.
Failure to Post Required Nurse Staffing Information: The facility did not post the daily nurse staffing sheet with the resident census or the actual hours worked for RN, LPN, CMT, and CNA staff responsible for resident care per shift. Observations showed the posting was incomplete across multiple days and did not reflect the required 12-hour shifts. The Staffing Coordinator said the census had not been included since the start of the year and weekend postings were not updated, while the DON stated the staffing sheet should include two 12-hour shifts, census, and actual hours worked.
Missing monthly DRRs were identified for four residents with significant medication needs, including high-risk meds and complex diagnoses such as CKD, diabetes, psychiatric disorders, and bladder cancer chemotherapy. The facility policy required monthly pharmacist DRRs with documentation of clinically significant issues and follow-up, but the requested reviews could not be found for multiple months. Staff, including the ADON and DON, stated the DRRs should have been completed monthly and acknowledged the records were not retrievable.
Insulin administration error rate exceeded the 5% threshold when LPNs failed to properly prime insulin pens for three residents with DM receiving Lispro insulin. Observations showed one LPN administered doses without priming, and another primed incorrectly by expelling insulin before attaching the needle and then giving the dose without proper priming. The DON stated nurses were expected to prime insulin pens with 2 units before the ordered dose, and the facility did not monitor competency in insulin pen use.
A resident with dementia and anxiety, who was his/her own responsible party, was moved to a different room, including a locked memory care unit, without documented written notice or a signed agreement for the room change. The care plan indicated the room move had been discussed and agreed to, but the resident later reported not agreeing, becoming very upset and tearful, and feeling trapped in the locked unit. Staff, including CNAs and an agency LPN, stated that residents were supposed to receive written notice and that all parties should agree before a room change, but they were unsure if this occurred for this resident. EMR review showed no guardian or DPOA and no uploaded agreement related to the move, and the DON confirmed the resident had not been notified in writing and acknowledged unawareness of the regulatory requirement.
Two residents were affected when staff failed to follow and document physician orders for diagnostic testing. One resident with urinary retention, neuromuscular bladder dysfunction, and an indwelling catheter had multiple UAs ordered and marked as completed in the system, but the EMR contained no notes of urine collection attempts, refusals, or any UA results, despite care plan notes that the resident sometimes refused catheter care. Another resident with C. diff enterocolitis and morbid obesity fell while rising from a commode; after an X-ray could not be obtained, a CT of the back and right side was ordered, but the resident reported not being informed of the CT or a scheduled date, and the hospital scheduler stated the CT order was not received until days later and was initially invalid, preventing scheduling. Facility leadership and staff acknowledged that all MD orders should be followed and that attempts, refusals, and fax confirmations should be documented, but such documentation was absent in these cases.
A resident with dementia and agitation was receiving multiple psychotropic medications, including scheduled antianxiety, antidepressant, antipsychotic, and anticonvulsant drugs. Staff documented repeated episodes of pacing, wandering, aggression, sexual inappropriateness, and restlessness, but progress notes did not show detailed behaviors, triggers, or non-pharmacological interventions before PRN lorazepam was given. The care plans were general and did not include comprehensive target behaviors or individualized interventions, and the PRN lorazepam order lacked a stop date.
An LPN administered gabapentin through a resident’s PEG tube without first confirming tube placement by measuring tube length or checking pH of aspirated contents. The LPN aspirated tan fluid, flushed the tube, gave the medication, and restarted the feeding pump. The DON stated staff were expected to verify placement by aspiration, but the facility did not check pH and had no monitoring to ensure proper placement checks were done.
A resident with a tracheostomy and severe cognitive impairment had suctioning supplies observed improperly stored, including an unlabeled suction cannister, an uncovered catheter hanging from the suction machine, and a used catheter returned to its original packaging. An agency LPN said the catheter could be reused and that he/she had not been educated on trach care, while the DON stated trach suctioning was a sterile procedure and catheters were to be discarded after each use; the suction machine was also observed covered with a pillowcase.
Unclear dialysis access orders were not clarified. A resident with CKD and dialysis dependence had care plan and physician orders that directed staff to monitor a shunt site and check for bruits and thrills, while the record also described a chest port. Staff gave conflicting explanations about whether the resident had a fistula, graft, or port, and the chart lacked documentation that the orders were discussed with the physician for clarification. The DON and Administrator stated the orders needed to be clarified immediately.
Failure to individualize TIC for a resident with PTSD: A resident with a long history of trauma, PTSD, anxiety, depression, and other MH diagnoses had no PTSD-specific care plan identifying triggers, avoidance strategies, or staff responses when triggered. The resident reported triggers such as male caregivers, bowel movement smells, yelling, criticism, and being moved quickly, and said the facility never discussed PTSD needs or care planning. Staff interviews showed the behavior book lacked PTSD information, the MDS Coordinator had not received TIC education, and Social Services had not asked the resident what interventions or counseling might help.
The facility did not provide required behavioral health services, failed to implement PASRR processes, and did not ensure administration of psychotropic medications for several residents with serious mental illness. Staff lacked training in de-escalation and behavioral health, and did not document or address escalating aggressive behaviors, resulting in an unsafe environment for both residents and staff.
Two residents did not receive necessary medical care as ordered, including missed doses of anti-rejection and psychotropic medications and lack of required wound care. Staff failed to communicate with physicians and the transplant team, did not document or reconcile medications, and lacked training in caring for post-transplant and psychiatric residents. These failures led to severe health complications, including infection, hospitalization, and behavioral crises.
A resident who was recently admitted after a kidney transplant did not receive prescribed antirejection and immunosuppressive medications due to failures in medication reconciliation, ordering, and administration. Staff were unaware of the process for handling medications sent from the hospital, did not ensure timely pharmacy delivery, and failed to notify the physician or take action when medications were unavailable. The resident was readmitted to the hospital with sepsis and undetectable antirejection medication levels, confirming the missed doses.
Two residents were subjected to physical and verbal abuse by another resident with a history of mental health disorders, leading to one resident leaving the facility due to fear and humiliation, and another nonverbal, cognitively impaired resident suffering pain, visible injury, and emotional trauma after being struck and pushed in a wheelchair. Staff and witnesses confirmed the incidents, and the facility did not prevent or adequately intervene in the aggressive behaviors, despite policies prohibiting abuse.
Staff at the facility did not receive adequate training or education in behavioral health management, resulting in an inability to safely care for residents with complex psychiatric and behavioral needs. Multiple staff members reported feeling unprepared and fearful, and there was a lack of incident reporting, care plan updates, and behavioral interventions for residents exhibiting aggressive, violent, or self-harming behaviors. This led to repeated incidents of harm to both staff and residents, as well as frequent involvement of law enforcement.
A resident's dignity was violated when an LPN called the resident "dumb" during a care interaction, leading to the resident becoming visibly upset, expressing emotional distress, and requesting not to have the LPN as a caregiver. Multiple staff witnessed the incident and confirmed the resident's account, and the facility's policy on resident rights was not upheld.
The facility did not maintain a full-time DON or ensure RN coverage for at least eight hours per day, seven days a week. During a period between the termination of the previous DON and the hiring of a new DON, staff—including an LPN acting as ADON—confirmed that RN coverage was inconsistent and agency RNs were only used occasionally. Staff often relied on phone consultations with former DONs for guidance, rather than having an on-site RN or DON as required.
A resident with morbid obesity and complex care needs was transferred to a hospital without proper discharge documentation, reassessment, or a 30-day notice. The facility refused to readmit the resident after hospitalization, citing inability to meet care needs, and did not provide required notifications regarding appeal rights or bed-hold policies.
Two residents did not receive all prescribed medications, and required blood pressure monitoring was not completed for one resident with orders for as-needed antihypotensive medication. Missed doses were not documented on the MAR, and there was no evidence of physician notification or progress note entries explaining the omissions, despite facility policy and staff interviews indicating these steps were required.
Two residents received medications and water flushes via G-tube without verification of tube placement or measurement of external tube length, as an LPN did not check placement before administration. Facility leadership and staff were unaware of current best practices for G-tube placement verification, and no policy for G-tube medication administration was provided.
The facility failed to maintain cleanliness and proper food storage standards in the kitchen, with issues including debris buildup, improper food storage, unlabeled containers, and uncleanable cutting boards and spatulas. The Dietary Manager and Dietary Cook acknowledged these deficiencies during interviews.
The facility failed to provide required in-service training for dementia care and abuse prevention for three CNAs, with inconsistent training offerings and incomplete documentation of attendance, as confirmed by staff interviews and training records review.
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Bank statements showed no interest payments, and the Corporate Director of Fiscal Services was unaware of any changes. The Business Office Manager could not locate authorization forms for these residents, all of whom had legal guardians.
The facility failed to maintain water temperatures at handwashing faucets in several resident rooms at or above 105°F, with observed temperatures ranging from 84.5°F to 103.1°F. Additionally, the facility did not maintain clean sprinkler heads in various areas and failed to repair two stand-up lifts with cracked bases. Staff acknowledged these issues but did not take immediate corrective actions.
The facility failed to notify the ombudsman of resident discharges/transfers for three residents. The Social Services Designee had been emailing the list of discharges to an incorrect email address, resulting in the ombudsman not being informed as required.
The facility failed to ensure a resident's care plan included necessary PT, OT, and ST, despite orders and initiation of these therapies. The omission was due to incomplete documentation following a change in the facility's computer systems.
The facility failed to update care plans for five residents with changes in their conditions and needs, and did not invite a resident to their care plan meeting. Issues included unupdated hospice care, missing IV antibiotics, and overdue care plan goals. Interviews revealed that care plans were not consistently updated due to a change in computer systems.
The facility's Activity Director did not meet the required qualifications, lacking formal training and certification, leading to a deficiency identified by surveyors.
The facility failed to provide ordered Restorative Aide (RA) services to three residents, leading to a decline in their Range of Motion (ROM). Staff interviews and documentation revealed that RAs were frequently pulled to work as CNAs, resulting in inconsistent delivery of RA services.
The facility failed to ensure proper maintenance and sanitation of respiratory equipment for several residents with COPD and CHF. Observations revealed undated and improperly stored oxygen tubing and nebulizer masks, and interviews with staff highlighted inconsistencies in responsibilities and practices.
The facility failed to ensure an RN was on duty for at least eight consecutive hours a day, seven days a week, as required. The facility's staffing schedule and interviews revealed that there was no RN coverage on certain days, particularly weekends, despite the facility's policy and CMS reports indicating the need for adequate RN staffing.
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications.
The facility failed to monitor medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations showed a blank temperature log and expired medications, including Acetaminophen and glycerin suppositories. Staff interviews revealed a lack of knowledge about responsibilities for these tasks, and the DON confirmed that night shift staff were responsible for temperature logs, while the DON or ADON should audit for expired medications.
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Despite residents informing staff about their dental needs, no appointments were scheduled, and care plans did not reflect any dental issues. Staff were generally unaware of the residents' dental needs.
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Residents reported receiving cold food almost every day, and the Dietary Manager did not take effective measures to address the issue. Observations showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. Staff confirmed that food temperatures were not monitored at the point of service.
The facility's administration failed to implement a plan of correction by the designated date, resulting in continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits due to the abrupt departure of the previous administrator, leading to a lack of continuity and oversight.
The facility failed to identify and correct quality deficiencies through its QAPI plan, leading to continued deficient practices affecting residents' well-being. The facility did not complete 12 out of 16 required audits, and the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position.
The facility failed to maintain an infection prevention and control program by not providing TB testing for five sampled residents. The facility's policy required TB screening for all residents, but records showed no evidence of TB testing or screening for the sampled residents. Interviews revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly.
The facility failed to offer and document pneumococcal and influenza vaccinations for five residents, despite policies requiring these actions. Interviews revealed a lack of follow-through and oversight by the admitting nurses and administration.
The facility failed to provide and document COVID-19 vaccinations for three residents, compromising the infection prevention and control program. Interviews revealed inconsistencies in the vaccination process and lack of proper documentation, leading to this deficiency.
The facility failed to update a resident's code status from full code to DNR despite having an advance directive indicating DNR. The admitting nurse did not ensure the resident's wishes were reflected on the chart, and there was no clear process for auditing code statuses.
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of admission. Critical information was missing, and residents were unaware of their care plans. Interviews revealed that baseline care plans were not being printed, signed, or provided to residents or their families.
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. Discrepancies in the records for Oxycodone administration and improper handling of medications left at a resident's bedside were observed, indicating non-compliance with the facility's policies.
Failure to Provide and Document Required Bathing Services
Penalty
Summary
The facility failed to ensure dependent residents received bathing services and that bathing was documented according to resident preferences and facility policy. The deficiency involved four sampled residents who were unable to complete ADLs independently and who had care plans, Kardex entries, and MDS assessments showing they required partial to substantial assistance with bathing, with some residents also having incontinence, impaired mobility, dementia, diabetes, dialysis, wounds, or other conditions affecting hygiene needs. Facility policy stated residents would receive bathing in accordance with their preferences, care plan, and safety needs, and that residents unable to carry out ADLs would receive the necessary services to maintain personal and oral hygiene. For Resident #2, records showed scheduled bath days on Monday, Wednesday, and Friday with partial to moderate assistance required, but the April POC documentation showed no baths or showers documented for the month. A social worker reported the resident was seen at dialysis wearing the same dirty clothes on multiple visits, with bodily fluids on clothing and a urine odor, and that the resident said the facility was not bathing him/her. The resident was observed with unclean clothing with apparent blood spots and spills, greasy and dirty hair, and a urine odor, and stated he/she wanted at least two showers per week, had gone several weeks without a shower, and had recently gone 6 weeks without one. For Resident #3, records showed scheduled bath days on Tuesday, Thursday, and Saturday with partial to moderate assistance required, but no baths or showers were documented for April. For Resident #4, records showed the resident needed bathing assistance and was to be set up and supervised, yet no baths or showers were documented for April. The resident stated he/she wanted more showers, had not received two showers per week, had gone over 4 weeks without a shower before the one received the day before the interview, and felt embarrassed and dirty when not showered for long periods. For Resident #5, records showed scheduled bath days on Tuesday, Thursday, and Saturday with substantial to maximal assistance required, but no baths or showers were documented for April. The resident was observed in dirty clothes with food and drink spills, unkept greasy hair, and foul body odor, and stated he/she wanted two to three showers per week, had not had a shower for almost two weeks, only got 2 showers in the whole month of April, and was upset and embarrassed by not being bathed. Staff interviews described that one CNA was responsible for bathing all residents in the facility, that the bath aide worked Monday through Friday, and that evenings and weekends did not provide baths or showers. Staff stated residents should receive at least two baths or showers per week, but the one bath aide could not keep up with the facility’s bathing needs, missed baths were not rescheduled, and some residents had gone weeks without bathing. The DON stated he/she was responsible for auditing bathing documentation but could not provide proof of auditing, and also stated he/she was not aware if the facility had a resident bathing schedule.
Incomplete and inaccurate shower documentation
Penalty
Summary
The facility failed to ensure that residents’ medical records were complete and accurate when the DON directed CNA B and CNA C to retroactively complete and sign Skin Monitoring: Comprehensive CNA shower sheets for prior dates. The report states that documentation was supposed to be factual, objective, timely, and completed at the time of service or no later than the shift in which the care occurred, with late entries clearly identified. Instead, shower sheets for multiple residents were completed after the fact and signed with dates that did not match the actual timing of the documentation. For Resident #2, the annual MDS showed cognitive intactness and partial to moderate assistance needed for bathing. The shower sheets provided by the DON showed entries for multiple April dates indicating either completed skin assessments or refusals, and CNA B signed and dated those entries. However, CNA B stated he/she did not give the resident any showers or complete any skin assessments in April, and the resident stated he/she was not receiving showers twice a week, had recently gone 6 weeks without a shower, and did not refuse showers in April. For Resident #3, the annual MDS showed cognitive intactness, inability to make needs known, and partial to moderate assistance with bathing. The shower sheets contained entries for numerous April dates, including one undated entry, and CNA B signed and dated the sheet for those dates. CNA B stated he/she did not give the resident any showers or assess the resident’s skin on those dates and did not provide any showers or skin assessments during April. For Resident #4, the annual MDS showed moderate cognitive impairment and partial to moderate assistance with bathing. The shower sheets listed several April shower dates with CNA B’s signature and dates, but CNA B stated no showers or skin assessments were provided in April, and the resident said no showers were received for the entire month. For Resident #5, the quarterly MDS showed cognitive intactness, ability to make needs known, and substantial to maximal assistance with bathing. The shower sheets documented multiple April showers and skin checks, but CNA B stated none of those showers or assessments occurred, and the resident reported only two showers in the whole month and none since 4/20/26.
Laundry Wall Had Water Intrusion and Moldlike Substance
Penalty
Summary
The facility failed to maintain the inside laundry wall on the parking lot side in good repair to prevent water from entering the laundry area and failed to prevent the growth of a moldlike substance on the laundry wall. During observation with the Administrator and Maintenance Person, surveyors saw an area of wall 8 feet 7 inches high by 15 feet wide covered in a moldlike substance, along with another moldlike area behind a large stainless-steel sink measuring 14 inches high by 4 feet wide. Interviews showed that water had entered the laundry area from multiple sources. The Housekeeping Supervisor said water sometimes came in through the window with the board on it from the parking lot side when it rained and that water had stood in the laundry area after heavy rainstorms. The Former Laundry Supervisor and former staff reported water coming through the dumbwaiter area and flooding during rainstorms, while the Maintenance Person acknowledged the moldlike substance and said the walls in the laundry sweat. The Administrator stated the wall behind the washing machine had been cleaned with bleach and a mold killer and then painted, but staff also reported that the moldlike substance remained after a past leak may have been fixed.
Use of Facility Van with Expired Registration for Resident Transportation
Penalty
Summary
The facility failed to ensure its transportation van was properly licensed in accordance with State law while continuing to use it to transport residents to medical appointments. Review of the facility’s transportation policy showed it committed to providing safe, non-emergency transportation with a well-maintained van and appropriate liability and insurance coverage. Emails between the facility’s administrative team and the parent company documented ongoing awareness that the van’s registration had expired and that the title was needed to complete registration, with multiple communications about tracking down or obtaining duplicate titles and identifying facilities with expired registrations. Observation of the van showed a license plate sticker indicating expiration in 2025, and review of the transportation log showed multiple instances over several days in which residents were transported to physician appointments using the facility van, while some residents were transported by outside transportation companies. During interviews, the van driver stated that the van was used several times a week to transport residents, confirmed the license had expired the previous year, and reported being told the facility would pay any ticket if the van was pulled over, adding that other transportation services were available and that they would not drive their personal vehicle with expired tags. An LPN similarly reported that the van’s license had expired the previous year, that administration was aware, that the van was used a couple of times a week for resident appointments, and that administration was responsible for keeping the license current and probably should not have been driving it with expired tags. The Administrator acknowledged that the van’s license had expired the previous year after the new company purchased the facility, that the parent company was having difficulty obtaining the title from the previous owner and had referred the matter to its legal department, and that the van continued to be used several times a week for resident transportation despite the expired license, even though other transportation companies were available.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to keep the walk-in freezer floor clean, failed to keep food preparation equipment in sanitary condition, failed to maintain plastic cutting boards and plate covers in good condition to avoid food safety hazards, and failed to separate damaged foodstuffs. During the initial kitchen inspection with the Dietary Manager, surveyors observed white and green cutting boards that were excessively scored and shedding small plastic particles, a microwave with spills, splatters, and food debris on the rotating plate, bottom, and sides, a 6-pound can of Mandarin oranges with a dented edge on the large-can dispenser rack, and paper, plastic, and food debris on the walk-in freezer floor and under racks. On follow-up inspection, the cutting boards remained excessively scored, the manual can opener blade had a sticky substance built up on it, the dented can was still on the dispenser rack, and several maroon plastic plate covers on a Baker's rack had chipped edges. On the final kitchen inspection, the cutting boards were still excessively scored and the maroon plate covers' edges remained chipped. The Dietary Manager stated that damaged food packaging should be separated for return to the vendor, that prepared food should be free of foreign substances, that electrical food preparation items were cleaned after every use, and that the walk-in freezer floor was cleaned at least twice a day. The Administrator stated that kitchen staff should be following best industry sanitation practices.
Incomplete Legionella and Waterborne Pathogen Prevention Program
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to establish and maintain a comprehensive, facility-specific infection prevention and control program designed to prevent the development and transmission of Legionella and other water-borne pathogens. Review of the water-borne pathogen prevention paperwork, last reviewed in October 2022 and removed from a binder labeled Disaster Plan, showed there was no facility-specific risk assessment using ASHRAE standard #188, the CDC toolkit assessment was incomplete with pages 6 through 36 missing, and there was no completed CDC Legionella Environmental Assessment Form. The paperwork also lacked a written explanation of water flow through the facility, identification of potential risk areas with assessments of each area’s risk level, a facility-specific outbreak plan for Legionella or other waterborne pathogens, testing protocols with acceptable control ranges, action plans for when control limits were not met, and documentation of a site log book with dated cleanings, sanitizing, descaling, and inspections. During the Life Safety Code walk-through, the water main supply was observed entering the basement of an older attached building and spreading through the laundry, a dry fire sprinkler system, former administrative offices, and then to the newer building addition. The surveyor observed at least two commercial clothes washers in the older building’s basement, numerous sinks and unused water pipes throughout the building, a complete wet fire sprinkler system in the newer building, public restrooms, housekeeping closets with mop/service sinks and eyewash stations, water boilers, hot water storage tanks, hot and cold running water piping throughout six resident room hallways, at least 55 resident rooms with private and/or shared bathrooms and sinks, a Beauty Shop with a sink, and at least three bathing rooms. In the kitchen, the surveyor observed a sanitizing three-sink area, a chemical low-heat dish-washing machine, a hand-washing sink, a steam table, and an ice machine in the adjacent service hallway. The Administrator stated there was not really anything for Legionella except what had been taken out of the disaster manual and that the documentation was old and outdated. The DOM stated he/she had no responsibilities regarding Legionella prevention practices and had no training on it.
Delayed Smoking Assessments for Residents Who Smoked
Penalty
Summary
The facility failed to ensure smoking assessments were completed in a timely manner for three residents who smoked, based on observation, interview, and record review. The facility policy titled Resident Smoking stated residents who smoked were to be asked about tobacco use during admission and at each quarterly or comprehensive MDS assessment, and were to be reassessed if they had a decline in condition or cognition. Review of the records showed Resident #20, Resident #65, and Resident #4 each had smoking-related assessments documented on 8/22/25, but no additional smoking assessments were found in the EMR through 1/23/26. Resident #20’s care plan stated the resident smoked, the son brought cigarettes, staff were to assist to and from the smoking area as needed, and the resident was alert and able to hold a cigarette without difficulty. The resident’s smoking safety screens showed the resident was safe to smoke with supervision, and the Significant Change MDS showed the resident was cognitively intact and used tobacco. The DON stated Resident #20 should have had more than two safe smoking assessments in the EMR. Resident #65 had diagnoses including Parkinson’s disease, Alzheimer’s disease, and abnormal posture, and the nicotine habit care plan stated the resident smoked, needed staff assistance to and from the smoking destination, and was to wear a smoking apron. The smoking safety screen showed cognitive loss, visual deficits, dexterity problems, inability to light a cigarette independently, and a need for a smoking apron with supervision. Observations showed the resident on the smoking patio with eyes closed, head hanging downward, and the lit cigarette held close to the apron-covered stomach; staff and CNAs stated the resident needed reminders to hold the cigarette up and wore the apron for safety. Resident #4 had a diagnosis of cerebral infarction, a Significant Change MDS showing moderately impaired cognition and tobacco use, but no smoking care plan focus or interventions were in place, and the DON stated the resident should have had a smoking assessment completed upon admission and that it was completed too late after admission.
Failure to Post Required Nurse Staffing Information
Penalty
Summary
The facility failed to post the daily nurse staffing information so that it included the facility census and the actual hours worked for RNs, LPNs, CMTs, and CNAs directly responsible for resident care per shift. Observation on 1/21/26, 1/22/26, 1/27/26, 1/28/26, and 1/29/26 showed the staffing posting did not include the resident census and did not show actual hours worked for licensed and unlicensed staff for each 12-hour shift, even though the facility census was 67 residents. Review of the facility Nurse Staffing Posting Information policy dated 5/13/2025 stated the Nurse Staffing Sheet would be posted daily, would contain the facility census and the total number and actual hours worked for licensed and unlicensed nursing staff responsible for resident care per shift, and would be posted at the beginning of each shift with updates for staff absences and actual hours worked. During interview, the Staffing Coordinator said staffing sheets were posted at the beginning of the day shift Monday through Friday, the resident census had not been included since the first of January 2026, staffing sheets were not updated on weekends, and weekend staffing sheets were posted each Friday and changed on Mondays. The DON stated the staffing sheets should have included two 12-hour shifts, the resident census, and the actual hours worked for licensed and unlicensed nursing staff, and that licensed charge nurses were responsible for updating staffing sheets at the beginning of each shift.
Missing Monthly Drug Regimen Reviews for Four Residents
Penalty
Summary
The facility failed to ensure a licensed pharmacist completed monthly drug regimen reviews for four sampled residents: Resident #69, Resident #10, Resident #7, and Resident #6. The facility policy stated that drug regimen reviews were to be conducted upon SNF PPS admission and throughout the resident’s stay, with documentation of any clinically significant medication issues and how they were addressed. The requested monthly DRRs were not available for review for multiple months for each of these residents, and the facility could not produce the records when asked. Resident #69’s record showed admission to the facility and a quarterly MDS indicating the resident was cognitively intact, received daily injections, and received high-risk medications. However, no DRRs were available for January through June 2025. Resident #10’s record showed admission to the facility and a quarterly MDS indicating moderate cognitive impairment and high-risk medication use, but no DRRs were available for January through June 2025. Resident #7’s record showed diagnoses including chronic kidney disease stage 4, type 2 diabetes, urinary retention, hypertension, and major depressive disorder, with the care plan showing several high-risk medications since at least 7/2/24; no DRRs were available for January through June 2025 or December 2025. Resident #6’s record showed diagnoses including anxiety disorder, schizoaffective disorder, bipolar disorder with psychotic features, major depressive disorder, and hypertension, with the care plan showing several high-risk medications in 2025 and added interventions related to bladder cancer chemotherapy. No DRRs were available for January through June 2025 or September through November 2025. During interviews, staff stated the ADON was responsible for ensuring the monthly DRR was done, the DON said the DRR should have been done monthly, and both the ADON and DON stated they could not locate the requested DRRs for these residents.
Insulin Pen Priming Errors
Penalty
Summary
The facility failed to ensure the medication administration error rate remained below 5% when licensed nurses did not prime insulin pen needles before administering insulin to three sampled residents, resulting in a medication error rate of 11.54%. The facility’s insulin pen policy dated 5/16/2025 stated that a new needle was to be used for each injection and that insulin pens were to be primed prior to each use by attaching the needle, removing the outer cover, dialing 2 units, and confirming at least one drop of insulin appeared on the needle tip before setting the ordered dose. Resident #27 had diabetes mellitus and orders for Lispro insulin, including a sliding-scale dose; during observation, an LPN obtained a blood glucose result of 179, removed the insulin pen, attached the needle, and dialed 8 units without priming the pen. Resident #61 also had diabetes mellitus and orders for Lispro insulin; during observation, an LPN obtained a blood glucose result of 180, removed the insulin pen, attached the needle, and dialed 25 units without priming with 2 units first. Resident #56 had diabetes mellitus and an order for Lispro insulin 12 units before meals; during observation, an LPN dialed 2 units and depressed the plunger before attaching the needle, then attached the needle, dialed 12 units, uncapped the needle, and administered the insulin without properly priming the pen. In interview, the LPNs stated they did not know insulin pens were to be primed with 2 units before the intended dose, and the DON stated licensed nurses were expected to prime insulin pens and that the facility did not monitor competency in insulin pen use.
Failure to Provide Written Notice and Obtain Agreement for Resident Room Change
Penalty
Summary
The facility failed to honor a resident’s right to be informed and to exercise self-determination regarding a room change. A resident with unspecified dementia of unspecified severity without behavioral disturbance and an anxiety diagnosis was admitted as his/her own responsible party, with no guardian or DPOA documented. The resident’s care plan noted dementia and documented that on 1/6/26 a room move was discussed and the resident agreed, and that on 1/7/26 staff were assisting with the move when the resident became upset and stated a desire to leave the facility. A quarterly MDS dated 1/8/26 showed the resident had severely impaired cognition and no wandering behavior. During a later interview, the resident reported not agreeing to the room move, becoming very upset and tearful, not understanding why he/she had been moved to a locked unit, and feeling trapped there, and was unable to state whether written notice of the room change had been received. Record review of the EMR showed the resident had no guardian or DPOA, was his/her own responsible party, and there was no signed agreement uploaded related to the room move. Multiple staff interviews (two CNAs and an agency LPN) confirmed that all residents were supposed to receive written notice of room moves and that all parties needed to agree before a room change, but they were unsure whether this resident had received written notice; the agency LPN reported the resident was upset and refused to move while being escorted down the hall. The DON confirmed the resident had not been notified in writing about the room move, was unsure why written notification had not been provided, and stated unawareness of the regulation, while acknowledging the resident should have been notified in writing. The facility’s own Resident Rights policy stated that information about resident rights and responsibilities would be given orally and in writing, but there was no documentation that written notice of the room change had been provided to this resident.
Failure to Follow and Document Physician Orders for UA and CT Imaging
Penalty
Summary
The deficiency involves the facility’s failure to ensure physician orders were followed and appropriately documented for two residents. One resident with urinary retention, neuromuscular bladder dysfunction, severely impaired cognition, and an indwelling catheter had physician orders for urinalyses in December 2025, with the electronic order status showing both tests as completed. However, review of the electronic medical record revealed no nursing notes related to collection of the ordered urine specimens and no laboratory results for any urinalysis in December. The resident’s care plan included monitoring and reporting signs and symptoms of UTI and noted that the resident had a fixation with the genital area and sometimes refused catheter care, but there was still no documentation that staff attempted to obtain the ordered UAs, that the resident refused, or that collection was otherwise unsuccessful. For the second resident, who had diagnoses including enterocolitis due to C. difficile and morbid obesity, an unwitnessed fall occurred while the resident was attempting to stand from a commode. An X-ray was ordered but could not be obtained due to the resident’s abdominal size, and the physician then ordered a CT scan of the back and right side. The facility’s order summary showed the CT scan order, and staff interviews indicated that the order was to be faxed to a local hospital. The resident later reported being unaware that a CT scan had been ordered and not being given a scheduled date for the procedure. A hospital scheduling manager reported not seeing a CT order for the resident until several days after the order date and stated that the CT had not been scheduled because the facility sent an invalid order that required correction before scheduling. The administrator, CNAs, LPNs, and the DON all stated that physician orders were expected to be followed as written and that failed attempts to collect UAs or send out imaging orders should be documented in the EMR, MAR, or TAR, including confirmation of fax receipt when applicable. The DON confirmed there was no documentation that the UAs for the first resident could not be collected and no documentation confirming that the CT order for the second resident had been sent or received before the date identified by the hospital scheduler.
Incomplete psychotropic documentation and PRN antianxiety use
Penalty
Summary
The facility failed to ensure documentation of non-pharmacological behavioral interventions was attempted before administering PRN antianxiety medication, failed to document events or triggers preceding behaviors, failed to ensure the PRN antianxiety medication had a stop date, and failed to include comprehensive symptoms, target behaviors, and individualized interventions for one resident who was receiving multiple psychotropic medications. The resident had dementia with agitation, was severely cognitively impaired, and was receiving scheduled antianxiety, antidepressant, antipsychotic, and anticonvulsant medications. The resident’s record showed repeated behavioral concerns including sexually inappropriate behavior, pacing, wandering, exit-seeking, agitation, aggression, insomnia, and resistance to care. Progress notes documented multiple episodes in which lorazepam was given PRN for behaviors such as pacing, aggression, anxiety, restlessness, and attempting to elope, but the notes did not describe the specific behaviors in detail, what events preceded them, or what non-pharmacological interventions were attempted before the medication was administered. One note also showed lorazepam was given when the resident was complaining of pain, even though the medication was not indicated for pain. The resident’s care plans identified general issues such as sexually inappropriate behavior, secured unit needs, agitation, and elopement risk, but they did not include comprehensive individualized interventions tied to the resident’s known preferences and triggers. The record noted the resident liked music and fresh air, and staff interviews described additional individualized triggers and calming approaches, such as giving the resident space, providing something to do with his/her hands, or offering a book, photos, food, or drink. The resident’s January 2026 psychotropic orders also included PRN lorazepam without a stop date/duration date, despite the facility policy stating PRN psychotropic orders require a limited duration and documentation when extended.
G-tube placement not verified before medication administration
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube had tube placement confirmed before medication administration in accordance with facility policy and current standards of practice. Resident #13 was admitted with a diagnosis of gastrostomy status and had a care plan and physician orders directing staff to check PEG tube placement before flushes, medications, and feedings by verifying tube integrity, measuring tube length from the ostomy to the end of the tube, and monitoring residuals. During observation, an LPN prepared gabapentin for administration, turned off the feeding pump, uncovered the resident’s abdomen, disconnected the extension tubing, and aspirated a small amount of tan liquid from the G-tube medication port. The LPN did not first measure or observe the tube length, did not measure the pH of the aspirated contents, and then flushed the tube with water, administered the medication mixed with water, flushed again, reconnected the extension tubing, and restarted the feeding pump. During interview, the LPN stated he/she had not looked at or measured the G-tube length before flushing and giving the medication, knew auscultation was no longer used, and said aspiration was the only method he/she had been using to assess placement. The LPN also stated pH testing had never been done at the facility. The DON stated licensed nurses were expected to check G-tube placement by aspiration before medication administration, that the facility did not check pH when using aspiration, and that there was no monitoring in place to ensure nurses correctly checked G-tube placement.
Tracheostomy suction supplies were improperly stored and staff were not competent in suctioning procedure
Penalty
Summary
The facility failed to ensure appropriate tracheostomy suctioning supplies were stored correctly and that staff were trained and competent in the correct method of suctioning for a resident with a tracheostomy. The resident had diagnoses including diffuse traumatic brain injury and other tracheostomy complication, and the care plan and orders directed staff to suction the trach as needed, change the suction cannister when three-quarters full, and provide tracheostomy care every day and night shift. The resident's significant change MDS showed severe impairment and did not indicate the resident had a tracheostomy. Observations showed the suction cannister was not labeled with a date on multiple occasions, the suction catheter was hanging uncovered from the suction machine, and later the used suction catheter was placed back into its original packaging. The suction machine was also observed covered with a pillowcase. During interviews, an agency LPN stated the catheter could be reused after cleansing with sterile water, that it was acceptable to store it in the original packaging, and that he/she had not been educated on tracheostomy care at the facility. The DON stated tracheostomy suctioning was a sterile procedure, suction catheters were to be discarded after each use, the cannister needed a date label, and staff should not have been storing used catheters in the original container or covering the suction equipment with a pillowcase.
Unclear dialysis access orders were not clarified
Penalty
Summary
The facility failed to ensure dialysis-related physician orders were clarified for a resident with chronic kidney disease stage 4 and dependence on renal dialysis. The resident's care plan and physician orders referenced monitoring a dialysis shunt site for signs and symptoms of bleeding or infection every shift and checking for bruits and thrills every day and night shift, but the record also described the resident as having a port in the right chest. The facility's hemodialysis policy required that physician orders for dialysis include the location and type of access and that residents with external dialysis catheters be assessed every shift for dressing integrity and soiling. Review of the resident's records showed no documentation in the progress notes from November 2025 through January 2026 that the dialysis access orders were discussed with the physician for clarification. The MAR documented that staff were following the orders to monitor the shunt site and to check for bruits and thrills on both day and night shifts. The MDS identified the resident as moderately cognitively impaired and receiving dialysis treatments. During interviews, staff gave conflicting descriptions of the resident's dialysis access and the meaning of the orders. The ADON initially stated the resident had a port on the chest related to bradycardia, then later observed the resident's upper right chest and described checking for a whooshing sound and feeling for blood flow. An LPN stated that a fistula and a port were not the same thing and that a port in the chest would not have orders to check for bruits and thrills, while another LPN said a port in the chest was external tubing and that the nurse should check for bruits and thrills in the chest. The DON and Administrator stated the orders should show the resident's type of access site and that if the access site was in the chest, bruits and thrills would not be checked; they also stated the resident's orders needed to be clarified and nurses should have contacted the physician immediately.
Failure to Individualize Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to collaborate with a resident who had a history of trauma to identify triggers that could re-traumatize the resident and to develop individualized care plan interventions to reduce exposure to those triggers and lessen their effect. The resident had diagnoses that included PTSD, anxiety disorder, major depressive disorder, mood disorder, borderline personality disorder, bipolar disorder, and schizoaffective disorder. The resident’s psychiatric history also included recurrent MDD, PTSD, bipolar disorder, alcohol abuse with alcohol-induced psychotic disturbance with hallucinations, past suicidal thoughts, and a prior overdose on prescription medications. The resident’s records showed a history of sexual and emotional abuse by an ex-spouse, nightmares and flashbacks in the past, and an attack by another resident at the facility before moving to another unit. A TIC assessment dated 1/4/25 showed the resident felt guilty for past events, experienced a frightening or traumatic event, and was triggered by violence or acting out that caused re-experiencing of the traumatic event or flashback. The resident’s significant change MDS showed the resident was cognitively intact, felt down and depressed, had anxiety disorder, depression, and PTSD, and took medications for anxiety and depression. The comprehensive care plan did not include a PTSD-specific plan with triggers, instructions for avoiding triggers, guidance for staff response when triggered, or interventions related to who should provide personal care for toileting hygiene, showers, and dressing. It also did not show whether the resident might benefit from counseling services or a support group. The resident stated that male caregivers, bowel movement smells, yelling, criticism, and being jerked quickly out of bed were triggers, and said the facility had never talked with the resident about PTSD needs or care planning. Staff interviews showed CNA staff were not aware of the PTSD diagnosis, the behavior book did not contain information on the resident’s behaviors or PTSD, the MDS Coordinator had not received TIC education, and the Social Services Director stated the resident had never been asked what services or interventions might help with PTSD.
Failure to Provide Behavioral Health Services and Medication Management
Penalty
Summary
The facility failed to provide appropriate treatment and behavioral health services to multiple residents with known mental health diagnoses and behavioral health histories. For three sampled residents, the facility did not implement required Preadmission Screening and Resident Review (PASRR) processes, failed to create or update care plans with necessary interventions for behaviors, and did not ensure the administration of prescribed psychotropic medications. One resident with a complex psychiatric history, including paranoid schizophrenia, anxiety disorder, and substance dependence, was admitted without the facility having the PASRR on file, and staff did not administer the resident's psychotropic medications as ordered. This resident exhibited escalating aggressive behaviors, including physical aggression toward staff and other residents, verbal outbursts, and attempts to elope, with no documented incident reports, care plan updates, or behavioral interventions during these episodes. Staff interviews revealed a lack of training and competency in managing behavioral health needs. Multiple staff members, including LPNs, CNAs, and housekeepers, reported not receiving education or in-service training on de-escalation techniques, behavioral health, or abuse and neglect prevention. Staff expressed feeling unprepared and unsafe when caring for residents with aggressive behaviors, and several reported that their concerns and requests for guidance from facility leadership were ignored. Documentation showed that staff were instructed not to document certain behavioral incidents, and there was a lack of behavior monitoring, incident reporting, and psychiatric follow-up for residents exhibiting significant behavioral symptoms. Other residents and staff reported feeling unsafe due to the aggressive behaviors of affected residents, with some residents stating they were traumatized or unable to sleep due to fear. Law enforcement was called multiple times to manage out-of-control behaviors, and police officers expressed concern about the facility's ability to manage residents with behavioral health needs. The facility's failure to provide required behavioral health services, medication management, and staff training resulted in an environment where both residents and staff were at risk, and appropriate care and oversight were not provided for residents with serious mental illness and behavioral challenges.
Failure to Administer Critical Medications and Provide Wound Care
Penalty
Summary
The facility failed to meet the medical needs of two residents, resulting in significant deficiencies. One resident was admitted with end stage renal disease and a recent kidney transplant, requiring strict adherence to a complex medication regimen including multiple immunosuppressants and specific wound care for a surgical site. Upon admission, the facility did not document a review of the medication list with the facility physician, failed to ensure the availability and administration of critical anti-rejection medications, and did not provide the ordered wound care for two and a half days. Staff documented that medications were not given because they were waiting for pharmacy delivery, despite the medications being sent with the resident from the hospital. There was also a lack of documentation and communication regarding the resident's transplant status, infection control needs, and high-risk medication protocols in the care plan. The facility's staff, including the DON, LPNs, and CMTs, demonstrated a lack of knowledge and training regarding the care of post-transplant residents and the importance of timely administration of high-risk medications. Interviews revealed that staff were unaware of the significance of missed doses, did not know who was responsible for ensuring medication availability, and failed to notify the resident's physician or transplant team about missed medications and wound care. The wound care nurse and other staff expressed discomfort and lack of experience with the required wound care, leading to further delays. Attempts by the resident's transplant team to communicate with facility staff were unsuccessful, and the transplant team was not informed of the missed medications or wound care lapses. As a result of these failures, the resident was admitted to the hospital with undetectable levels of anti-rejection medication, sepsis, and a necrotic surgical wound, requiring IV antibiotics and multiple surgeries. In a separate incident, another resident did not have their psychotropic medications reconciled or administered, leading to behavioral outbursts and eventual hospitalization for psychiatric care. The facility's policies for medication administration, wound care, and special needs management were not followed, and there was a breakdown in communication and documentation at multiple levels of staff responsibility.
Failure to Administer Critical Antirejection Medications Post-Transplant
Penalty
Summary
A significant medication error occurred when a resident, recently admitted following a kidney transplant, did not receive critical antirejection and immunosuppressive medications as ordered. The resident was discharged from the hospital with a supply of essential medications, including Tacrolimus, Myfortic, Prednisone, Valganciclovir, and Bactrim, and had a therapeutic level of antirejection medication at the time of discharge. Upon admission, the facility failed to document the presence of these medications, and the care plan did not address the need for post-transplant antirejection therapy. Facility staff did not administer the ordered medications on multiple occasions, citing that they were waiting for the pharmacy to deliver them. Medication Administration Records (MAR) and medication card observations confirmed that several doses were missed, and staff documented the absence of medication as the reason. Interviews with staff, including the DON, CMT, and LPNs, revealed a lack of knowledge regarding the process for reconciling and ordering medications upon admission, as well as uncertainty about who was responsible for ensuring timely medication availability. Staff also reported that the DON was informed about the missing medications, but no action was taken to resolve the issue or notify the attending physician. The resident was subsequently readmitted to the hospital with sepsis and a near-undetectable level of antirejection medication, as confirmed by laboratory results and the transplant team. Hospital and transplant staff confirmed that the resident had received all necessary medications prior to discharge and that missing even a single dose could result in serious harm. The facility's failure to ensure the resident received prescribed antirejection medications led to a significant medication error and placed the resident at risk for organ rejection and severe illness.
Failure to Prevent Resident-to-Resident Abuse Resulting in Physical and Emotional Harm
Penalty
Summary
The facility failed to protect two residents from physical and verbal abuse by another resident, resulting in both physical harm and emotional distress. One resident with a history of paranoid schizophrenia, anxiety disorder, delusional disorder, and personality disorder engaged in aggressive behaviors, including attempting to punch another resident and making verbal threats. This included threatening to slit the throat of another resident, which led to that resident leaving the facility out of fear, embarrassment, and humiliation. The affected resident reported feeling unsafe, which disrupted their rehabilitation and stroke recovery. Another incident involved the same aggressive resident physically assaulting a cognitively impaired, nonverbal resident with a history of stroke, hemiplegia, apraxia, dysarthria, aphasia, and major depressive disorder. The aggressive resident was observed pushing the nonverbal resident in a wheelchair at high speed, then striking the resident multiple times on the head and shoulders. Witnesses reported that the nonverbal resident was visibly scared, in pain, and left with a scalp bruise and red marks, requiring hospital evaluation. Multiple staff and a housekeeper witnessed the incident, and the nonverbal resident's responsible party confirmed the emotional and physical impact of the assault. The facility's policy required the prevention of all forms of abuse, including resident-to-resident altercations, and mandated staff intervention and protection of residents from harm. Despite these policies, the facility did not prevent or adequately intervene in the repeated aggressive behaviors of the resident with a history of mental health disorders, resulting in physical and psychological harm to two vulnerable residents. Staff interviews and resident accounts confirmed that the incidents were reported to administration, but the affected residents and others in the facility expressed fear and distress due to the ongoing threat posed by the aggressive resident.
Failure to Ensure Staff Competency in Behavioral Health Management
Penalty
Summary
The facility failed to ensure that staff possessed the necessary competencies and skills to meet the behavioral health needs of residents, particularly those with complex psychiatric and behavioral conditions. Multiple staff members, including LPNs, CNAs, housekeepers, and medication technicians, reported not receiving training on behavioral management, de-escalation techniques, or abuse and neglect prevention. Staff expressed fear and a lack of confidence in their ability to safely care for residents exhibiting aggressive, violent, or self-harming behaviors. Interviews revealed that staff were not provided with guidance or interventions to manage residents with significant behavioral health needs, and some staff were assigned to one-on-one supervision without any relevant training or instructions. Several residents with serious mental illnesses, including schizophrenia, schizoaffective disorder, borderline personality disorder, and a history of substance abuse, exhibited frequent and severe behavioral disturbances. These included physical aggression toward staff and other residents, verbal outbursts, attempts to elope, destruction of property, and expressions of suicidal ideation. Documentation showed that these behaviors were ongoing and that staff and other residents felt unsafe. Despite these incidents, there was a lack of incident reporting, care plan updates, behavior monitoring, and documentation of nonpharmacological or pharmacological interventions in the residents' records. The facility's policies required annual in-service training for nurse aides, including behavioral health, and mandated that training be based on the special needs of the resident population. However, the report found that these policies were not implemented effectively, as evidenced by the lack of staff education and competency in managing behavioral health issues. The facility assessment identified a significant number of residents with behavioral health needs, but staff competencies did not align with these requirements. The absence of appropriate training and support led to repeated incidents where staff were unable to manage resident behaviors, resulting in harm to staff and residents, involvement of law enforcement, and ongoing distress within the facility.
Resident Dignity Violated by LPN's Derogatory Remark
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to respect a resident's dignity by calling the resident "dumb" during an interaction. The incident began when the resident requested a pain pill and subsequently became upset, raising their voice at a Certified Nurse Aide (CNA). The LPN and CNA assisted the resident with a Hoyer lift, during which the resident expressed that the nurse did not care about them. The LPN attempted to reassure the resident but ultimately responded to the resident's question about being dumb by saying, "are you dumb, no you are not," though the resident did not understand the response. Multiple witness statements confirmed that the LPN used the word "dumb" in reference to the resident, and the resident reported feeling hurt and upset by the comment, stating that being called dumb was particularly painful due to past experiences. Further witness accounts indicated that the LPN engaged in an argument with the resident, accusing the resident of making negative reports to management. The LPN was reported to have raised their voice, told the resident not to ask for anything further, and made additional derogatory remarks. The resident was visibly upset, expressed a desire to change rooms to avoid the LPN, and reported the incident to the facility's administration. Staff who interacted with the resident after the incident observed that the resident was crying, angry, and emotionally distressed, which was noted to be out of character for the resident. The facility's policy on resident rights, which mandates that all residents be treated with dignity and respect, was not followed in this instance. The Interim Director of Nursing acknowledged that calling a resident dumb would be a violation of the resident's dignity. The incident was reported and investigated, with staff and administrative interviews confirming the resident's account and the inappropriate conduct of the LPN.
Failure to Maintain Full-Time DON and Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, and did not have a Director of Nursing (DON) on a full-time basis for a period of time. Review of facility policies and the facility assessment confirmed that the expectation was to have a full-time DON, who is a RN, and to employ RNs for at least eight hours daily, every day of the week. Interviews with the Administrator, DON, LPNs, Social Services Director, Assistant Director of Nursing (ADON), and Administrator in Training (AIT) consistently revealed that the facility was without a full-time DON from the termination of the previous DON until the hiring of the new DON, and that RN coverage for the required hours was not consistently provided. The ADON, who is an LPN, filled in for some DON duties during this period, but was not a RN. Employee records confirmed the gap in DON coverage, with the previous DON terminated and the new DON starting nearly a month later. Staff interviews indicated that during this period, RN coverage was supplemented only occasionally by agency staff, and there were times when no RN was present in the facility for the required hours. Staff would sometimes call the previous DON or a PRN DON for guidance when needed, but this did not meet the requirement for on-site RN coverage or a full-time DON.
Failure to Follow Proper Discharge Procedures and Notification Requirements
Penalty
Summary
The facility failed to follow the required process for discharging a resident, specifically neglecting to reassess the resident and properly identify and document how the facility could not meet the resident's needs. The resident in question had a history of morbid obesity, localized edema, depression, anxiety, reduced mobility, and was bedbound. The resident required significant assistance with activities of daily living and had recently experienced a decline in condition, resulting in hospitalization. Despite these complex needs, the facility did not provide the necessary documentation or notification regarding the resident's needs, appeal rights, or bed-hold policies at the time of discharge. Upon the resident's transfer to the hospital, the facility failed to send appropriate discharge paperwork and did not issue a proper 30-day notice of discharge. The hospital attempted to return the resident to the facility, but the facility refused to readmit the resident, citing inability to meet the resident's care needs due to increased weight and lack of appropriate equipment and staffing. Communication between the hospital and the facility was inadequate, with the facility not responding to multiple attempts by the hospital to coordinate the resident's return. Interviews with facility staff confirmed that the decision not to readmit the resident was based on the facility's inability to care for the resident's increased weight and complexity of care. Staff acknowledged that a 30-day notice and appropriate placement should have been arranged prior to discharge, but these steps were not taken. The facility also did not reassess the resident for possible readmission after the hospital transfer, and no evidence was provided that the resident received required notifications regarding appeal rights or bed-hold policies.
Failure to Document and Notify Physician of Missed Medications and Incomplete Blood Pressure Monitoring
Penalty
Summary
The facility failed to ensure that physician notification was completed and documented regarding missed medications for two out of four sampled residents, and did not ensure blood pressure monitoring was completed for a resident with a physician's order to administer medication based on blood pressure readings. Facility policy required that medications be administered according to physician orders, and that any withheld, refused, or late medications be properly documented on the Medication Administration Record (MAR), with notification to the physician and documentation in the progress notes. For one resident with diagnoses including hypothyroidism and hypertensive heart disease, there were multiple instances where levothyroxine was not documented as given, and no blood pressure readings or administration of midodrine (ordered as needed for hypotension) were recorded over the review period. There was no documentation in the progress notes regarding the reasons for missed doses or any notification to the physician about these missed medications. The resident reported that nurses often did not give all prescribed medications and did not take blood pressure readings as required for medication administration. Another resident with epilepsy, schizoaffective disorder, and violent behaviors had several missed doses of antipsychotic medications (quetiapine and Zyprexa) that were not documented as given on the MAR. Interviews with staff confirmed that the expected procedure was to notify the pharmacy, DON, and physician when medications were not available or not administered, and to document these actions in the progress notes. However, there was no evidence that these procedures were followed, and the facility lacked a system for routine review of MARs for missed medications.
Failure to Verify and Document G-Tube Placement Prior to Use
Penalty
Summary
The facility failed to ensure and document the correct measurement and verification of gastrostomy tube (G-tube/PEG tube) placement prior to administering fluids, medications, and feedings for two residents. Observations showed that an LPN administered water flushes and medications through the G-tubes of both residents without first checking the tube's placement or measuring the external length, as recommended by current clinical guidelines. The LPN did not inspect the tube or verify its position before proceeding with care. Review of the residents' medical records revealed physician orders and medication administration records specifying the use of G-tubes for enteral feeding and medication administration. However, there was no documentation that tube placement was checked or verified prior to these procedures. The LPN admitted during an interview that placement was not checked and stated that the outdated method of injecting air and auscultating was the only method known, and was unaware of the current standard of measuring tube length at the entry point. Further interviews with facility leadership, including the Assistant Administrator and Assistant Director of Nursing, confirmed a lack of knowledge regarding the correct method for verifying G-tube placement. They acknowledged that placement should be checked before use but were unfamiliar with the recommended practice of measuring and documenting the tube's external length. Additionally, the facility was unable to provide a policy for administration of medication via G-tube when requested.
Facility Fails to Maintain Cleanliness and Proper Food Storage Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage standards in the kitchen and food preparation areas. Observations revealed a heavy buildup of debris, including cups, paper, dust, and food debris behind and under the ice machine. Additionally, there was a heavy buildup of dust on the fan over the door across from the coffee station. Two bottles of soy sauce that required refrigeration after opening were found stored on a lower shelf instead of being refrigerated. A bowl of an unidentified yellow substance was found in the kitchen reach-in refrigerator without proper wrapping. Three cutting boards were observed with numerous stains and grooves, making them not easily cleanable, and three spatulas were found frayed or split open. Black debris was present on the pipes behind the dishwasher, and debris was found under the six-burner stove. Containers with brown and clear liquids were not labeled, and the blower vent cover over the door across from the coffee maker station had a heavy buildup of dust. The sprinkler heads were also found with grease buildup. Interviews with the Dietary Manager (DM) and Dietary Cook (DC) revealed that the DM had taken over management of the kitchen recently and was unaware of the condition of the pipes behind the dishwasher. The DM acknowledged that dietary staff should inspect the cutting boards and that an in-service regarding the cutting boards had not been conducted. The DM also stated that dietary staff were expected to clean behind and under the ice machine every night, clean the blower vent cover weekly, use labels for substances that were not easily identified, and follow the labels on condiment containers. The DM expected the night shift staff to clean and mop before leaving for the evening and to cover and protect food in the refrigerator. The spatulas should have been replaced when they started getting frayed. The DC admitted to placing syrup in a bottle without labeling it.
Failure to Provide Required In-Service Training for CNAs
Penalty
Summary
The facility failed to provide the required nurse aide in-services that included dementia care and abuse prevention training for three sampled CNAs (CNA B, H, and J) from April 2023 through April 2024. The facility's policy mandated that all nurse aides participate in regularly scheduled in-service training classes, including at least 12 hours of training per year, covering topics such as dementia management and abuse prevention. However, the review of the facility's in-service training attendance records revealed that several training sessions were either not attended by the CNAs or no training records were provided for certain months. Specifically, CNA B, H, and J missed multiple training sessions, and there were no records for several months, indicating a lack of consistent training offerings by the facility. Interviews with facility staff, including the Incoming Administrator, Certified Medication Technician B, CNA D, CNA E, the Staffing Coordinator, and the DON, confirmed the inconsistencies in training. The Incoming Administrator acknowledged that the sign-in sheets provided were incomplete and that if staff did not sign in, it was assumed they did not receive the training. CNA D and CNA E reported not attending any in-service training since their employment at the facility, with CNA E specifically noting the absence of abuse, neglect, exploitation, or dementia training. The DON admitted that in-services had not been consistently offered in the past year and that the documentation of training hours was lacking. The facility's failure to provide the required in-service training for dementia care and abuse prevention for the sampled CNAs highlights a significant deficiency in ensuring that nurse aides have the necessary skills to care for residents. The lack of consistent training offerings and incomplete documentation of training attendance contributed to this deficiency, as confirmed by multiple staff interviews and the review of training records.
Failure to Manage Resident Funds Properly
Penalty
Summary
The facility failed to ensure residents who allowed the facility to manage their funds received interest payments and did not have signed authorization forms for three residents. Review of bank statements from April 2023 through March 2024 showed no interest payments. The Corporate Director of Fiscal Services confirmed the absence of interest and was unaware of any changes to the account. Additionally, there were no authorization forms found for three residents, all of whom had legal guardians. The Business Office Manager, who started in January 2023, stated that authorization forms were typically placed behind guardianship paperwork but could not locate them for these residents.
Facility Fails to Maintain Water Temperature, Cleanliness, and Equipment
Penalty
Summary
The facility failed to maintain the water temperature at the handwashing faucets in resident rooms 517, 520, and 523 at or above 105°F. Observations showed water temperatures ranging from 84.5°F to 103.1°F, which were below the required standard. The Maintenance Director admitted to not allowing the water to run for at least two minutes during temperature testing, which contributed to inaccurate readings. This deficiency potentially affected at least 30 residents who resided in those areas or used those facilities. Additionally, the facility failed to maintain the cleanliness of sprinkler heads in the therapy area, Main Dining Room, and side Dining Room, as well as the nurse's station, where dust was observed. The facility also failed to maintain two stand-up lifts, which had cracks in their bases. Staff members, including CNAs and the Maintenance Director, acknowledged the presence of these issues but did not take immediate corrective actions. The Director of Nursing indicated that staff were expected to report and create work orders for damaged equipment, but this protocol was not consistently followed, leading to the continued use of the damaged lifts.
Failure to Notify Ombudsman of Resident Transfers/Discharges
Penalty
Summary
The facility failed to notify the ombudsman of resident discharges/transfers for three residents out of 17 sampled residents. The facility's policy on transfer and discharge did not include the requirement to notify the ombudsman. Specifically, Resident #48 was sent to the hospital due to seizures and returned to the facility, but the ombudsman was not notified. Similarly, Resident #23 and Resident #268 were discharged to the hospital with their return anticipated, but the ombudsman was not informed of these transfers either. An email from the ombudsman indicated that they had not received transfer/discharge logs from the facility since September 2023. During an interview, the Social Services Designee (SSD) revealed that they had been working in the role for about six months and had been emailing the list of resident discharges to an incorrect email address. The outgoing Administrator confirmed that the SSD was responsible for sending the list of discharges/transfers to the ombudsman and that the SSD had been using an incorrect email address. This miscommunication resulted in the ombudsman not being notified of the resident transfers/discharges as required.
Failure to Include Required Therapies in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected the need for Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). The resident, diagnosed with Cerebral Palsy, was admitted with orders for PT, OT, and ST evaluations and treatments. However, the care plan only included risks related to falls and the need for assistance due to Cerebral Palsy, without any mention of the required therapies. This omission was identified during a review of the resident's care plans and physician orders, which showed that the therapies had been initiated but not documented in the care plan. Interviews with the MDS Coordinator and the Director of Nursing (DON) revealed that the MDS Coordinator was responsible for writing and updating care plans. The MDS Coordinator admitted that some care plans were not completed or up to date due to a change in the facility's computer systems. The DON confirmed that the MDS Coordinator and department heads were responsible for updating their respective portions of the care plans. This lapse in documentation led to the deficiency noted in the report.
Failure to Update Care Plans and Invite Residents to Meetings
Penalty
Summary
The facility failed to update care plans for five residents with changes in their conditions and needs. Resident #65, who was moderately cognitively impaired, was admitted to hospice care, but the care plan was not updated to reflect this change. Resident #41's care plan indicated the need for IV antibiotics for a wound infection, but the resident was not receiving these antibiotics as observed over several days. Additionally, Resident #37, who was cognitively intact, was not invited to their care plan meeting, and there was no documentation to show that the resident or their family had been invited to any care plan meetings. Resident #13's care plan was last updated several months after admission, with all care plan goals overdue and no indication of whether goals had been achieved or new goals established. Similarly, Resident #19's care plan, which included psychoactive medication for anxiety and agitation, had overdue goals and no updates on goal achievement or new objectives. Resident #52's care plan, which included management for COPD, tracheostomy, hypertension, anxiety, and depression, also showed overdue goals with no updates or new objectives. Interviews with the MDS Coordinator and the DON revealed that care plans should be completed upon admission, quarterly, with any significant change, and annually. However, due to a change in computer systems, some care plans were not done or up to date. The MDS Coordinator and DON acknowledged that care plans were overdue and that there was no documentation of resident or family invitations to care plan meetings. The DON also noted that anyone on the Interdisciplinary Team could update care plans, but this was not consistently done.
Unqualified Activity Director
Penalty
Summary
The facility failed to have an activity program directed by a qualified Activity Director. The current Activity Director, who also handles Human Resources and Medical Records, did not meet the qualifications outlined in the facility's job description. The job description required a high school diploma or GED, two years of experience in a social or recreational program within the last five years, or completion of a state-approved training course. However, the Activity Director only had a high school diploma, was a Certified Nursing Assistant (CNA) and a Certified Medication Technician (CMT), and had been working part-time in activities for about a year without any formal training in activities or completion of the Activity Director class. The outgoing Administrator confirmed that the individual did not meet all the necessary requirements for the position. During interviews, the Activity Director admitted to not having any training in activities and not having taken the Activity Director class. The outgoing Administrator also acknowledged that while there was an Activities Director certificate available, the current Activity Director had not completed it. This lack of proper qualifications and training for the Activity Director role led to the deficiency identified by the surveyors.
Failure to Provide Ordered Restorative Aide Services
Penalty
Summary
The facility failed to ensure that Restorative Aide (RA) services were provided as ordered to prevent further decline of Range of Motion (ROM) for three residents. Resident #2, diagnosed with Cerebral Palsy, was supposed to receive RA services three times a week, but records showed that the resident only received services twice a week. The Director of Nursing (DON) and other staff members were unsure if the resident was receiving the required RA services, and the RA admitted to being frequently pulled to work as a Certified Nursing Assistant (CNA), which impacted the delivery of RA services. Resident #61, who had Hemiplegia and Hemiparesis following a stroke, was supposed to receive RA services five times a week for upper extremity exercises and splint management. However, there was no documentation of RA services being provided in March, and only four instances of RA services in April. Observations showed that the resident's hand braces were not applied as required, and staff interviews confirmed that the RA was often pulled to work as a CNA, leading to a lack of consistent RA services. Resident #37, with diagnoses including difficulty in walking and osteoarthritis of the knee, was supposed to receive RA services two to three times a week for upper extremity exercises. Documentation showed that the resident received minimal RA services, with several missed opportunities and instances of refusal without follow-up attempts. Interviews with staff and the resident indicated that the RA was frequently pulled to work as a CNA, resulting in inconsistent delivery of RA services. The DON acknowledged that the RA should have documented and performed the required services, but the RA was often reassigned to CNA duties.
Failure to Maintain and Sanitize Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper respiratory care for several residents, specifically in the maintenance and sanitation of oxygen tubing and nebulizer equipment. Resident #33, who has COPD, was observed with a nebulizer mouthpiece that was not stored in a bag and had a brown tinge around it. The resident was unaware if the staff ever washed the mouthpiece. Resident #268, who has CHF and COPD, had undated oxygen tubing and CPAP machine tubing that was not stored in a bag. The resident had not used the CPAP machine for a couple of weeks due to the absence of a mask and was unsure when the oxygen tubing was last changed. Resident #267, who also has COPD, had a nebulizer mask that was not stored in a bag or dated, and the resident had not seen the staff clean the mask since starting to use the nebulizer a few days ago. Resident #17, who has COPD and is on oxygen therapy, had oxygen tubing that was not stored in a bag or dated, and the resident declined to talk about it. Interviews with staff revealed inconsistencies and misunderstandings regarding the responsibilities for changing and cleaning respiratory equipment. LPN A stated that night CNAs were responsible for changing oxygen tubing weekly and that all oxygen equipment should be stored in a clean bag with the date written on it. CNA F mentioned that CNAs changed the oxygen tubing every few weeks and that nurses were responsible for cleaning nebulizer and CPAP masks. The Director of Nursing indicated that oxygen tubing should be changed weekly and stored in a clean bag with the date, and that nurses were responsible for cleaning CPAP and nebulizer masks after each use. The facility's failure to adhere to proper protocols for changing and cleaning respiratory equipment led to unsanitary conditions and potential risks for residents with respiratory conditions. The lack of a clear and consistent policy, as well as the absence of proper documentation and storage practices, contributed to the deficiencies observed during the survey.
Failure to Ensure RN Coverage 8 Hours Daily
Penalty
Summary
The facility failed to ensure a Registered Nurse (RN) was providing services for at least eight consecutive hours a day, seven days a week. The facility had a census of 67 residents. The RN Coverage policy was requested but not provided at the time of exit. The facility's Staffing policy, dated April 2007, indicated that licensed RN staff were available to provide and monitor the delivery of resident care services. However, the Center for Medicare and Medicaid Services (CMS) Staffing Reports from April 1 to December 31, 2023, showed the facility triggered for a One Star Staffing Rating and excessively low weekend staffing. The facility's current employee list showed three RNs employed, including the Director of Nursing (DON), a Regional Director of Nursing PRN, and another RN. The staffing schedule from April 1 to April 14, 2024, revealed that on April 4, 2024, the DON was out of the facility, and no other RN was on the staffing schedule for that day. Interviews conducted on April 19 and April 22, 2024, confirmed the lack of RN coverage. The Staffing Coordinator stated that there was no RN in the building on April 4, 2024. The DON admitted that while there was always RN coverage from Monday to Friday, there was generally no RN at the facility on weekends, and he/she was on-call every other weekend. The DON acknowledged that there should be an RN in the building for at least eight hours a day, every day of the week, but this requirement was not consistently met.
Failure to Respond to Medication Regimen Review Recommendations
Penalty
Summary
The facility failed to ensure that the Medication Regimen Review (MRR) was responded to for four sampled residents out of 17 sampled residents. The Consultant Pharmacist made recommendations regarding medication adjustments and assessments, but there were no documented responses from the physicians in the residents' electronic health records. This lack of response was observed for residents with complex medical histories, including mental health conditions and chronic pain, who were on multiple psychotropic and pain medications. For Resident #42, the Consultant Pharmacist recommended a gradual dose reduction (GDR) of psychotropic medications and the completion of the Abnormal Involuntary Movement Scale (AIMS) assessment. However, there was no response to these recommendations in the resident's electronic health record. Similarly, Resident #19 had no AIMS reports available despite the pharmacist's recommendation to update the AIMS assessment every six months due to antipsychotic use. Resident #24's MRRs showed repeated recommendations for dose reduction or discontinuation of certain medications, but there were no responses from the physician. Resident #41 had a potential duplicate order for pain medications, and again, there was no response from the physician. Interviews with facility staff revealed a lack of clarity and follow-through in the process of handling MRRs, with the Director of Nursing (DON) acknowledging that physicians should respond to all recommendations but failing to ensure this was consistently done.
Failure to Monitor Medication Refrigerator Temperatures and Remove Expired Medications
Penalty
Summary
The facility failed to monitor the medication refrigerator temperatures and remove expired medications in the Rehabilitation Unit. Observations revealed that the temperature log for the medication refrigerator was blank from January through April 18, 2024. Additionally, expired medications, including Acetaminophen suppositories with an expiration date of January 2023 and glycerin suppositories with an expiration date of March 7, 2024, were found in the refrigerator without open dates recorded. Interviews with staff members, including LPNs and CMTs, indicated a lack of knowledge regarding who was responsible for filling out the temperature log and checking for expired medications. The Director of Nursing (DON) confirmed that the night shift nursing staff was responsible for monitoring and recording the medication refrigerator temperatures daily. The DON or the Assistant DON (ADON) were supposed to audit the temperature logs to ensure compliance. The DON also stated that either he/she, the ADON, or a designee was responsible for auditing expired medications in the medication refrigerator and medication carts. However, the observations and staff interviews indicated that these procedures were not being followed, leading to the presence of expired medications and unmonitored refrigerator temperatures.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to ensure that four residents with broken or missing teeth were seen by a dentist. Resident #37 had broken dentures and had not seen a dentist since being admitted to the facility. Despite informing the nurse about the need for dental care, no action was taken. The resident's care plan and physician's visit records did not reflect any dental issues, and staff were unaware of the resident's need for denture repair. Resident #53 had broken teeth and had signed an authorization for dental care, but had not seen a dentist in over a year and a half. The resident expressed a desire to have all teeth pulled and dentures made, but no dental appointment was scheduled. The care plan and physician's orders did not indicate any dental issues, and staff were unaware of the resident's dental needs. Resident #267 had no top teeth and some bottom teeth, but had not seen a dentist in the 11 months of being at the facility. The resident had informed the nurse about the need for dental care, but no action was taken. Similarly, Resident #32 had broken or missing teeth and had not seen a dentist since admission. The resident had requested dental care, but no appointment was scheduled. The care plans for these residents did not address their dental issues, and staff were unaware of the need for dental appointments.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe and appetizing temperatures, as evidenced by multiple observations and resident complaints. Two residents, who were cognitively intact, reported receiving cold food almost every day and raised the issue during resident council meetings. The Dietary Manager (DM) acknowledged the problem but did not take effective measures to address it. Observations during meal service showed that hot foods were not maintained at the required temperature of 120 F, and cold foods were not kept at or below 41 F. For instance, a burger sandwich and tater tots were served at temperatures significantly below the required levels, and pineapple chunks were served at 59.5 F, which is 18 degrees above the acceptable limit. The DM admitted to not monitoring food temperatures at the point of service and was unaware of the required temperature standards for serving food to residents. Further observations and interviews revealed that the issue was particularly prevalent among residents receiving room trays. Staff members, including Certified Medication Technicians (CMTs) and Certified Nursing Assistants (CNAs), confirmed that they had not seen anyone from the dietary department checking the temperatures of room trays. The DM also confirmed that the dietary staff only took temperatures at the first serving of food and not at the last serving. This lack of monitoring and adherence to temperature standards led to residents consistently receiving cold meals, which was a significant concern raised during resident council meetings and individual interviews.
Failure to Implement Plan of Correction
Penalty
Summary
The facility's administration failed to implement a plan of correction (POC) by the designated date, resulting in continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility had a census of 64 residents at the time of the survey. The Administrator policy, dated April 2007, outlined that a licensed Administrator was responsible for the day-to-day functions of the facility, serving as a liaison to the governing board, medical staff, and other professional and supervisory staff, and for the evaluation and implementation of recommendations from the facility's Quality Assessment and Assurance Committee. However, the facility failed to complete 12 out of 16 required audits, including those for Ombudsman notifications, Medication Administration Records (MAR)/Treatment Administration Records (TAR), resident baths/showers, the Restorative Program, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many of the completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator had sent an email and left the next day, leading to a lack of continuity and knowledge about the audit process. As a result, the audits were not conducted in the last two weeks, contributing to the facility's failure to implement the POC by the correction date. This lapse in administrative oversight and audit completion directly led to the continued deficient practices within the facility.
Failure to Complete and Monitor QAPI Audits
Penalty
Summary
The facility failed to identify and correct quality deficiencies through its Quality Assurance and Performance Improvement (QAPI) plan, leading to continued deficient practices that potentially affected the residents' physical, mental, and psychosocial well-being. The facility's QAPI program was designed to establish data-driven processes to improve the quality of care and life for residents, but it was not effectively implemented. Specifically, the facility did not complete 12 out of 16 required audits, including those for ombudsman notifications, medication administration records, resident baths/showers, restorative programs, resident weights, oxygen, dialysis, psychotic medications, expired medications, dental appointments, food temperatures, and resident vaccines. During an interview, the Corporate Administrator revealed that many completed audits went missing when the previous administrator abruptly left the position about two weeks prior. The previous administrator's sudden departure left the facility without knowledge of the audit process, resulting in the audits not being conducted in the last two weeks. This failure to complete and monitor the audits as part of the QAPI process contributed to the ongoing deficient practices within the facility, affecting the overall quality of care provided to the residents.
Failure to Conduct TB Testing for Residents
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not providing Tuberculosis (TB) testing for five sampled residents. The facility's policy required TB screening for all residents, including a two-step TB skin test (TST) upon admission if no prior documentation existed. However, the records for Residents #33, #48, #60, #61, and #173 showed no evidence of TB testing or screening as per the facility's policy. Interviews with the outgoing administrator, Licensed Practical Nurses (LPNs), and the Director of Nursing (DON) revealed that the responsibility for administering TSTs was assigned to nurses, but the tests were not conducted or documented properly. Resident #33 had a documented first and second step TST in late 2019 and early 2020, but no further TB screenings were provided after January 2021. Resident #48 had an order for an annual Purified Protein Derivative (PPD) test, but no PPD was given as per the March 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR). Resident #60's hospital discharge paperwork indicated no current TB symptoms or contact, but there were no physician orders or records for a TST or screening. Resident #61 and Resident #173 also lacked physician orders and records for TB testing or screening. The outgoing administrator admitted to being unaware that TSTs were not being done, and the DON confirmed that no one tracked when the TSTs were given or read. The facility's failure to follow its own TB screening policy and ensure proper documentation led to the deficiency in maintaining an effective infection prevention and control program. The lack of TB testing and screening for the sampled residents indicated a significant lapse in the facility's adherence to its infection control protocols.
Failure to Offer and Document Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program by not offering pneumococcal and influenza vaccines to five sampled residents. The facility's policies required that all residents be offered these vaccines unless medically contraindicated or previously vaccinated, and that documentation of the offer, acceptance, or refusal be maintained in the resident's medical record. However, the facility did not provide records showing that the vaccines were offered or administered to Residents #33, #48, #60, #61, and #173, nor did they document any medical contraindications or refusals for these residents. Resident #33, who was cognitively intact and diagnosed with COPD, stroke, and hemiplegia, had no records of being offered or receiving the pneumonia vaccine. Resident #48, who was severely cognitively impaired, also had no records of being offered or receiving the pneumonia vaccine. Resident #60, who was cognitively intact and had type 2 diabetes, hemiplegia, and obstructive sleep apnea, had no records of being offered or receiving either the pneumococcal or influenza vaccines. Resident #61, who was severely cognitively impaired and had acute respiratory failure, a tracheostomy, and hemiplegia, had no records of being offered or receiving either vaccine. Resident #173, who was admitted following joint replacement surgery and had obstructive sleep apnea, also had no records of being offered or receiving either vaccine. Interviews with facility staff revealed that the responsibility for offering and documenting vaccinations was assigned to the admitting nurses, but there was a lack of follow-through and oversight. The outgoing administrator admitted to being unaware that the immunizations were not being done, and the Director of Nursing acknowledged that the expected documentation and follow-up were not completed. This failure to adhere to the facility's vaccination policies resulted in the deficiency noted by the surveyors.
Failure to Provide and Document COVID-19 Vaccinations
Penalty
Summary
The facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases by not providing the COVID-19 vaccine to three sampled residents. Resident #60, who was cognitively intact and had conditions such as Type 2 diabetes and obstructive sleep apnea, had no orders for a COVID-19 vaccine and no records of being offered the vaccine or education regarding its risks and benefits. Similarly, Resident #61, who was severely cognitively impaired and had acute respiratory failure and a tracheostomy, also had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education. Resident #173, admitted with diagnoses including aftercare following joint replacement surgery and obstructive sleep apnea, had no orders for the COVID-19 vaccine and no records of being offered the vaccine or education either. The facility census was 67 residents at the time of the survey. Interviews with facility staff revealed inconsistencies and gaps in the process of offering and documenting COVID-19 vaccinations. The Outgoing Administrator admitted to being unaware that COVID-19 immunizations were not being done and mentioned that the responsibility had been shifted to the nurses without proper follow-up. The Assistant Director of Nursing (ADON) and Licensed Practical Nurses (LPNs) provided conflicting accounts of the vaccination process, with some stating that the ADON usually handled vaccinations and others indicating that the admitting nurse was responsible. The Director of Nursing (DON) confirmed that the COVID-19 vaccine and education were supposed to be offered to all new residents, but the process was not consistently followed, and documentation was lacking. The facility's policies on vaccination and infection control were not adhered to, leading to a failure in offering and documenting COVID-19 vaccinations for the sampled residents. The lack of a systematic approach and clear responsibility for administering and documenting vaccinations contributed to this deficiency. The facility's failure to provide the COVID-19 vaccine and proper education to the residents compromised the infection prevention and control program, as evidenced by the missing documentation and inconsistent practices among the staff.
Failure to Update Resident's Code Status to DNR
Penalty
Summary
The facility failed to ensure that a resident's code status was accurately updated from full code to Do Not Resuscitate (DNR). Resident #61 was admitted with a full code status, but an advance directive dated 2/8/24 indicated a DNR status. Despite this, the resident's care plan dated 3/13/24 and the Physician's Order Sheet (POS) dated April 2024 still reflected a full code status. Interviews with staff revealed that the admitting nurse was responsible for ensuring the resident's wishes were reflected on the chart, but this was not done. Additionally, there was no clear process for auditing residents' charts to ensure the most up-to-date code status was documented. The Assistant Director of Nursing (ADON) acknowledged that the resident's code status should have been changed to DNR once the advance directive was received from the family, but this was missed. The Director of Nursing confirmed that the admitting nurse was responsible for ensuring the resident had a code status upon admission and that it should be listed on the face sheet and POS. The failure to update the resident's code status was a significant oversight, as it did not align with the resident's documented treatment preferences and advance directive.
Failure to Provide Baseline Care Plans
Penalty
Summary
The facility failed to provide two residents with a written summary of a baseline care plan within 48 hours of their admission. For Resident #41, the nursing admission screening was partially completed, missing critical information such as medications and the identity of the person who completed the screening. The resident reported not knowing anything about a care plan, and the Director of Nursing (DON) confirmed that the baseline care plan was not done. Similarly, for Resident #60, although a baseline care plan form was completed, it lacked signatures and evidence that the resident was provided with a copy. The resident also reported not being aware of a baseline care plan meeting. Interviews with the DON, Assistant DON, and MDS nurse revealed that the baseline care plans were typically done in the resident's room but were not being printed, signed, or provided to the residents or their families. The facility's policy required a baseline care plan to be developed within the first 48 hours of admission to meet the resident's immediate care needs, but this was not adhered to in these cases. Both residents had significant medical needs, including wounds, high-risk medications, and mobility impairments, which were not adequately addressed due to the lack of a proper baseline care plan.
Medication Administration and Documentation Deficiencies
Penalty
Summary
The facility failed to accurately document the administration of pain medication for one resident and ensure another resident had taken their prescribed medications. For Resident #41, the facility's records showed discrepancies in the administration of Oxycodone. The Medication Administration Record (MAR) indicated that the medication was not administered on two specific dates, but the narcotic count sheet showed it was given 26 more times than documented on the MAR. Interviews with the LPN and the Director of Nursing (DON) confirmed that proper documentation was not maintained, and there were no nurses' notes explaining the discrepancies on the MAR. For Resident #33, the facility failed to ensure the resident took their prescribed medications. Observations revealed that the resident had pills left at their bedside, which they had forgotten to take. The resident confirmed that the nurse had left the pills the previous night. The facility's policy and interviews with staff, including a Certified Medication Technician (CMT) and an LPN, indicated that medications should not be left at the bedside without a physician's order, and staff should observe the resident taking the medication. The DON confirmed that the resident did not have an order to leave medications at the bedside and that staff should have ensured the medications were taken. These deficiencies highlight the facility's failure to adhere to its medication administration policies, leading to improper documentation and potential risks for the residents involved. The lack of proper documentation and failure to ensure medication intake could have serious implications for resident care and safety.
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Illustrative
What surveyors actually found near you
We read the 262 citations issued within 25 miles in the last 12 months — including the 6 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
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Illustrative
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Nursing homes near Harrisonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadow View Health & Rehabilitation | 1.4 mi | ★★★★★ | 15 | 0 |
| Crown Rehab And Healthcare Center | 2 mi | ★★★★★ | 0 | 0 |
| Aspire Senior Living Pleasant Hill | 9.4 mi | ★★★★★ | 2 | 0 |
| Sunrise Nursing & Rehabilitation | 10.3 mi | ★★★★★ | 1 | 0 |
| Foxwood Springs Living Center | 12.3 mi | ★★★★★ | 1 | 0 |
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