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 Lakeview Health Care & Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to report an allegation of sexual abuse to state authorities within the required two-hour timeframe after a cognitively intact resident with multiple psychiatric diagnoses reported being forced to touch another resident’s genitals in a dining room. A CNA observed the contact and notified an LPN, who separated the residents and obtained conflicting accounts, including a statement from the alleged victim that the act was forced. The facility’s investigation documented the allegation but did not show timely notification to the Department of Health and Senior Services, and state records confirmed the report was not made until more than 24 hours later. In interviews, the administrator stated the event was viewed as consensual and linked to the residents’ prior sexual history, while the LPN reported having informed the administrator the same day that the resident said the act was forced.
A facility failed to maintain a clean, comfortable, homelike environment when strong foul odors were repeatedly observed at the entrance, in a hallway, and in resident rooms. Staff also failed to address damaged room walls and broken wheelchairs, including a wheelchair with a taped and cracked armrest and another with a frayed foot cushion exposing foam. A resident reported the odor was present every day and never went away, and the maintenance director said the repair needs had not been reported to him/her.
Failure to provide needed personal hygiene and grooming assistance. Three residents who were dependent on staff for ADLs were observed with long facial hair, long or curled nails, soiled hands, stained clothing, and urine odor despite care plans calling for grooming, nail care, and toileting support. A CNA said there was not enough time to complete tasks such as shaving and nail care, and the DON said these care tasks were only getting done about half the time depending on staffing.
Pureed foods were not reheated or held at required temperatures before being served. A dietary manager blended pureed chicken, cauliflower au gratin, and mushroom rice, then placed them on the steam table without checking temps after blending; measured holding temps were 130 F, 124 F, and 120 F, and the pan lid was left partially open. The DM said temps should have been checked after blending and again before service, and an administrator said he/she was unsure of the required reheating temp for pureed foods.
Survey Binder Not Kept Current or Publicly Posted: The facility failed to keep complaint investigation results available in a prominent public location and did not post the location for the reports. Observations of the survey binder at the nurse’s station showed it lacked investigation results and related documentation for multiple complaint investigations, and the DON/administrator stated the binder had not been updated for a while even though the information was available in the office.
Staff did not report an allegation of physical abuse involving a resident with moderate cognitive impairment and serious mental illness to DHSS within the required two-hour timeframe. Although the incident was documented and investigated internally, the DON, ADON, and corporate nurse decided not to report the allegation because the investigation did not substantiate abuse, resulting in a failure to comply with mandated reporting requirements.
A resident with multiple diagnoses, including GERD, was discharged from the hospital with an order for Omeprazole 40 mg once daily. Facility staff incorrectly transcribed this order as 'give 40 capsules by mouth one time a day,' and this error was entered into the resident's records without being identified or clarified by the ADON or DON, who were responsible for reviewing and entering medication orders.
Staff did not review and revise the care plans for two residents after they experienced falls, despite facility policy requiring care plan updates following such incidents. Both the MDS Coordinator and DON acknowledged that new interventions should have been added but were overlooked, resulting in the care plans not reflecting necessary changes after the falls.
Facility staff failed to follow COVID-19 testing protocols, resulting in symptomatic residents not being tested. Two residents with symptoms consistent with COVID-19 were not tested, despite the facility's policy requiring testing of symptomatic individuals. The DON acknowledged multiple symptomatic residents and known positive cases but did not initiate outbreak testing due to corporate advice against further testing.
The facility did not have a Registered Nurse (RN) on duty for at least eight consecutive hours per day, seven days a week, as required. The RN staff schedule for June, July, and August 2024 showed multiple days without RN coverage. The DON acknowledged the risk of not having an RN available in emergencies, and the administrator was unaware of the coverage gaps.
The facility did not employ a qualified dietitian or clinically qualified nutrition professional full-time, failing to designate a qualified Director of Food and Nutrition Services. The dietary supervisor, in the role for three months, had only completed food handler courses and had not started a food service manager course due to staffing shortages. The administrator believed the dietary manager could complete training post-hire.
The facility failed to develop and update comprehensive person-centered care plans for residents, including one who returned from a hospital stay without resumed diabetes monitoring. Other residents lacked updated care plans for bed rails, contractures, and behavioral symptoms, despite observations and assessments indicating these needs. The DON and CPC acknowledged the requirement for quarterly updates, but deficiencies persisted.
The facility failed to enforce its smoking policy, allowing residents to keep smoking materials in their rooms, including those using oxygen, posing a fire hazard. Staff interviews revealed a lack of awareness and enforcement of the policy, leading to the deficiency.
The facility staff failed to maintain a medication error rate below 5%, resulting in a 50% error rate. Errors included incorrect dosages and late administration times, affecting four residents. A CMT administered incorrect calcium carbonate dosages, and medications were given late due to staffing issues. Additionally, an RN failed to prime an insulin pen before use, leading to potential dosing errors.
The facility failed to complete the two-step PPD skin test for TB for four employees, including the DON, LPN, Dietary staff, and MDS coordinator, as per policy. The second step was administered too soon for some, and one employee's file lacked documentation. Interviews revealed a lack of adherence to the TB testing policy, with the DON responsible for ensuring compliance but unsure why tests were not completed correctly.
The facility failed to provide engaging weekend activities for residents, as required by their policy. Despite having an activity calendar, the weekends lacked staff-led activities, leaving residents with limited options like puzzles and coloring sheets. Interviews with residents and staff revealed dissatisfaction and a lack of awareness about the need for weekend activities, resulting in a deficiency in meeting residents' needs for engagement.
The facility staff failed to complete the required nurse staffing information, omitting the facility census on multiple occasions. The daily staffing sheets for August and September 2024 showed numerous instances where the census was not recorded, and several dates where the sheets were not provided. The DON and administrator expect the night shift nurse to complete the sheets daily, but acknowledged that busy shifts may have led to these omissions.
Facility staff failed to provide necessary treatment and services to prevent and manage pressure injuries for a resident. The staff did not complete weekly wound assessments or notify the physician when the resident's pressure injury worsened. The resident, with multiple health conditions, developed multiple open wounds, including a stage 3 pressure injury, which were not properly assessed or documented. Interviews revealed a lack of communication and documentation regarding the resident's wound care, contributing to the deficiency.
Failure to Timely Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
Facility staff failed to report an allegation of sexual abuse to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. The facility’s abuse, neglect, exploitation, and misappropriation prevention program, revised April 2021, states staff will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property and report any allegations within timeframes required by federal requirements. Resident #1, assessed as cognitively intact on a quarterly MDS dated 2/12/26, had diagnoses including schizoaffective disorder, bipolar type, major depressive disorder, generalized anxiety disorder, and bipolar disorder. On 3/29/26, CNA A reported to LPN B that Resident #1 was seen touching Resident #2’s privates in the main dining room; CNA A separated the residents, and LPN B interviewed both residents. Resident #1 stated Resident #2 forced him/her to touch his/her privates, while Resident #2 denied the allegation. The facility’s investigation, dated 3/30/26, documented that Resident #1 reported assisting Resident #2 in playing with his/her privates but stated he/she was forced to assist. The investigation record did not show that facility staff contacted DHSS within the required two-hour timeframe after the allegation was reported. Review of the DHSS database confirmed that the facility did not report the allegation of sexual abuse until more than 24 hours after Resident #1 made the allegation. During interviews, the administrator stated he/she would have reported within two hours if the act was not consensual and claimed he/she was not informed that Resident #1 said he/she was forced until 3/30/26, characterizing the situation as involving residents with a past sexual history who were upset because they were caught. However, LPN B stated that on 3/29/26 at 10:12 A.M. he/she called the administrator and explained in detail that Resident #1 said he/she was forced into the sexual act, and that the administrator responded that the residents had a sexual history, so it was okay.
Foul Odors, Wall Damage, and Broken Wheelchairs
Penalty
Summary
The facility failed to provide a comfortable and homelike environment when staff did not minimize strong foul odors in the entranceway, the 400 hallway, and resident rooms. Observations on multiple days showed a foul strong odor at the facility entrance and in the 400 hallway, and a strong foul odor in resident occupied rooms, including one room where the wall behind the bed was gouged and chipped. One resident stated the odor was present every day, sometimes worse than others, and that some areas were worse than others, adding that it seemed to be part of the facility and never went away. The facility also failed to repair damaged equipment and wall surfaces. Resident #9 was observed in a wheelchair with a right armrest hanging to the side and secured with black tape, and a left armrest that was torn and cracked. Resident #3 was observed in a wheelchair with a frayed foot cushion exposing inner foam on multiple observations. The wall behind the bed in one resident room remained gouged and chipped across several observations. The maintenance director stated staff were expected to document repair needs in the maintenance request log, but no one had notified him/her or documented the wheelchair repairs, and he/she did not know about the wall repairs. The administrator stated staff were expected to complete maintenance work orders when they noticed something was broken.
Failure to Provide Needed Personal Hygiene and Grooming Assistance
Penalty
Summary
Facility staff failed to ensure residents who were unable to complete activities of daily living received the necessary care and services to maintain personal hygiene. The facility’s ADL policy stated residents unable to perform ADLs should receive appropriate support and assistance with bathing, dressing, grooming, oral care, and toileting in accordance with the plan of care. Surveyors identified three residents who were dependent on staff for personal hygiene and who had care plans directing staff to provide grooming and nail care, but whose observed condition showed those needs were not being met. Resident #3’s MDS showed cognitive impairment, no behaviors or care rejection, and dependence on staff for personal hygiene, with diagnoses of dementia and diabetes. The care plan stated the resident was totally dependent on staff for personal hygiene. Shower sheets for December 2025 and January 2026 did not document refusal of shaving or nail care on multiple dates. During several observations, the resident was seen with long facial hair, long jagged fingernails, and visibly soiled hands with buildup under the fingernails, including while eating and while in bed, in a wheelchair, and at the nurse station. Resident #42’s MDS showed moderate cognitive impairment and need for some assistance with personal hygiene, and the care plan directed staff to check nail length, trim, and clean nails on bath days and as needed. On observation, the resident’s feet had long and curled toenails, and the resident stated staff had not offered to trim the toenails during showers or since admission. Resident #45’s MDS showed cognitive impairment, no care rejection, dependence on staff for toileting, dressing, and personal hygiene, frequent urinary incontinence, and occasional bowel incontinence, with diagnoses of schizophrenia and diabetes. The care plan directed staff to provide toileting assistance, frequent checks, and nail care, yet the resident was observed with long fingernails, long facial hair, stained clothing, visible debris on pants, and a strong smell of urine. A CNA stated there had not been time to shave or provide nail care, and the DON stated shaving and nail care were only getting done about 50 percent of the time depending on staff working.
Pureed Foods Served Without Proper Reheating or Holding Temperatures
Penalty
Summary
Food and drink were not maintained at a safe and appetizing temperature for residents on pureed diets. The facility’s Cooking and Cooling policy required foods to be cooked thoroughly to the appropriate internal temperature, and the Pureed Food Preparation policy did not give guidance for reheating pureed items according to standardized recipes. The facility’s standardized recipes for pureed rosemary boneless chicken, pureed cauliflower au gratin, and pureed mushroom rice directed staff to reheat the items to 165 F after blending and to maintain an internal holding temperature of 135 F or 140 F, depending on state regulations. During observation, the dietary manager blended pureed rosemary boneless chicken, pureed cauliflower au gratin, and pureed mushroom rice and placed each item into metal pans on the steam table without checking internal temperatures after blending. The lid over the pans was not fully closed, with about a two-inch gap. Internal temperatures measured while the food was on the steam table were 130 F for the chicken, 124 F for the cauliflower au gratin, and 120 F for the mushroom rice. The dietary manager later stated he/she should have checked temperatures immediately after blending and again before placing the food on the steam table, and the administrator stated he/she was not sure what temperature pureed foods should be reheated to after blending. A resident on a pureed diet said the food is sometimes lukewarm and that he/she will not eat it if it is not hot.
Survey Binder Not Kept Current or Publicly Posted
Penalty
Summary
The facility failed to provide complaint investigation results in a prominent and publicly available space for investigations completed from 01/30/25 through 12/08/25. Review of the survey binder located at the nurse’s station showed that it did not contain complaint investigation results or documentation for investigations completed on 01/30/25, 03/11/25, 03/31/25, 05/01/25, 05/06/25, 06/12/25, 07/01/25, 07/04/25, 08/12/25, 09/16/25, 10/02/25, 12/01/25, and 12/08/25. The facility also did not post the location for the reports. Observations on 01/05/26, 01/06/26, 01/07/26, and 01/08/25 showed the survey binder sitting on the nurse’s station, but it still did not contain investigation results or documentation for investigations completed since 01/15/25. During interview on 01/08/26 at 1:29 P.M., the administrator stated he/she was responsible for keeping the survey binder available and up to date for residents and the public to view, said it had not been updated for a while, and stated the information was available in his/her office. The administrator did not provide a reason why the binder was not updated or why a sign alerting the public to the report availability was not posted.
Failure to Timely Report Alleged Abuse to Authorities
Penalty
Summary
Facility staff failed to report an allegation of physical abuse involving a resident to the Department of Health and Senior Services (DHSS) within the required two-hour timeframe. According to the facility's policy, any alleged violation involving abuse or resulting in serious bodily injury must be reported immediately, but no later than two hours. The incident involved a resident with moderate cognitive impairment and diagnoses including Anxiety Disorder, Bipolar Disease, and Schizophrenia, who reported being roughly handled by five to six individuals while being assisted with dressing. The allegation was documented by staff, and the resident was assessed for harm, but there was no documentation that the allegation was reported to DHSS within the mandated timeframe. Interviews with the Director of Nursing (DON), assistant Director of Nursing (ADON), and a corporate nurse revealed that the decision not to report the allegation was based on the internal investigation, which did not substantiate the abuse claim. The DON and ADON acknowledged the policy requirement to report all abuse allegations within two hours, but stated that the report was not made because the investigation did not confirm the abuse. The corporate nurse also indicated that the findings did not meet the threshold for reporting to DHSS. The failure to report the allegation as required constitutes a deficiency in timely reporting of suspected abuse.
Failure to Accurately Transcribe Hospital Discharge Medication Order
Penalty
Summary
Facility staff failed to accurately transcribe a medication order for Omeprazole for one resident following hospital discharge. The resident, who was assessed as cognitively intact and had diagnoses including heart failure, hypertension, and GERD, was discharged from the hospital with an order for Omeprazole 40 mg capsule to be taken once daily. However, upon review of the Physician's Order Sheet and Medication Administration Record, the order was incorrectly transcribed as 'give 40 capsules by mouth one time a day,' rather than the intended single capsule daily. Interviews with facility staff revealed that the Assistant Director of Nursing (ADON) and Director of Nursing (DON) were responsible for reviewing and entering hospital discharge medication orders, but there was no double-checking process between them. The ADON acknowledged responsibility for ensuring accurate transcription and recognized that errors in this process could lead to incorrect medication administration. The DON stated that staff are expected to follow physician orders and clarify any discrepancies, but in this instance, the error was not identified or corrected prior to being entered into the resident's records.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
Facility staff failed to review and revise the comprehensive care plans for two residents who experienced falls. According to facility policy, care plans are to be updated as residents' conditions change, and each fall should prompt a follow-up and the addition of new interventions to the care plan. For one resident, who was assessed as severely cognitively impaired and had a documented fall where they lowered themselves to the floor due to weakness, staff did not add a new intervention to the care plan after the incident. The MDS Coordinator and DON both acknowledged that the event qualified as a fall and that a new intervention should have been added, but it was overlooked. For another resident, assessed as moderately cognitively impaired, staff also failed to document a new intervention in the care plan after the resident slid off the bed onto their buttocks. The MDS Coordinator was unaware of the fall and therefore did not implement a new intervention, while the DON admitted to overlooking the addition of a new intervention. Interviews confirmed that the IDT discusses new interventions after each fall and that the MDS Coordinator is responsible for updating care plans, but in these cases, the required updates were not made.
Failure to Implement COVID-19 Testing Protocols
Penalty
Summary
The facility staff failed to adhere to their COVID-19 testing policy, which mandates testing residents with symptoms of COVID-19 as soon as possible, regardless of vaccination status. Two residents, both cognitively intact, exhibited symptoms consistent with COVID-19, including body aches, vomiting, diarrhea, and respiratory symptoms. Despite these symptoms, neither resident was tested for COVID-19. Resident #1 reported symptoms to multiple staff members without being offered a test, while Resident #2, aware of other COVID-19 cases in the facility, questioned why they had not been tested. The Director of Nursing (DON) acknowledged the presence of four known positive COVID-19 cases in the facility but stated that outbreak testing had not been initiated due to advice from the corporate office, which discouraged further testing to avoid reporting to the state. The infection preventionist and a registered nurse confirmed that symptomatic residents should be tested, yet the facility's administration had not authorized testing for the symptomatic residents. The DON reported that eleven residents exhibited symptoms, but none had been tested due to corporate advice, despite standing orders from a physician to test symptomatic residents.
Failure to Provide 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, as required by their policy. The facility's RN staff schedule for June, July, and August 2024 showed multiple days without RN coverage. Specifically, there were no RNs on duty on several days in June, July, and August. During an interview, the Director of Nursing (DON) acknowledged the lack of RN coverage and expressed concern about the risk of not having an RN available in case of an emergency. The facility administrator was unaware of the RN coverage gaps and stated that daily RN coverage is expected to meet requirements.
Lack of Qualified Director in Food and Nutrition Services
Penalty
Summary
The facility failed to designate a qualified individual to serve as the Director of Food and Nutrition Services, as they did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. This deficiency was identified through interviews and record reviews. The dietary supervisor, who had been in the position for about three months, had only taken food handler courses and had not completed any food service manager courses. The dietary supervisor mentioned that they were supposed to be enrolled in an online food service manager course, but had not started it due to being short-staffed in the kitchen. The administrator acknowledged responsibility for ensuring the dietary manager had the proper training and qualifications but was under the impression that the dietary manager could complete the necessary training after being hired.
Failure to Develop and Update Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for several residents, as required by federal regulations. Specifically, the facility did not create a comprehensive care plan for one resident following their admission and subsequent hospital readmission. This resident, who was cognitively intact and had diagnoses including peripheral vascular disease and diabetes, expressed concern that staff did not resume monitoring their blood sugar levels or provide insulin medication after returning from the hospital. The lack of a comprehensive care plan meant there were no documented interventions for the resident's nutritional status, activities of daily living, urinary incontinence, psychosocial needs, mood, skin, and diabetes management. Additionally, the facility failed to update care plans quarterly in conjunction with the Minimum Data Set (MDS) assessments for several other residents. One resident, who used bed rails and had lower extremity impairments, did not have an updated care plan reflecting the use of side rails, despite observations showing the resident using them. Another resident with mild cognitive impairment and upper extremity impairments did not have a care plan addressing the prevention or care of hand contractures. Similarly, a resident with moderate cognitive impairment and behavioral symptoms did not have an updated care plan to address these behaviors. The Director of Nursing and Care Plan Coordinator acknowledged that care plans should be person-centered and updated at least quarterly, including interventions for identified care areas such as bed rails, contractures, and behavioral symptoms. However, the facility's failure to maintain current and comprehensive care plans for its residents resulted in deficiencies in meeting the residents' individual needs and ensuring their highest practicable well-being.
Failure to Enforce Smoking Policy in Resident Rooms
Penalty
Summary
The facility staff failed to ensure that the residents' environment was free from accident hazards by not enforcing the policy that prohibits smoking materials in resident rooms. Three residents, who were assessed as cognitively intact and identified as independent smokers, were observed with smoking materials in their rooms. Resident #16 was found with cigarettes and a lighter in their room, despite using an oxygen concentrator, which poses a significant fire hazard. Similarly, Resident #27 and Resident #31 were observed with cigarettes and lighters in their rooms, contrary to the facility's smoking policy. Interviews with staff revealed a lack of awareness and enforcement of the facility's smoking policy. A CNA admitted to not knowing the policy details, while an RN stated that unsupervised smokers should keep smoking materials in a locked locker, but acknowledged that residents were found with these materials in their rooms. The DON and the administrator both confirmed that residents using oxygen should not have smoking materials in their rooms due to the fire risk, and that all staff are responsible for ensuring compliance with the policy. However, observations showed that the policy was not being followed, leading to the deficiency.
Medication Administration Errors and Policy Non-Compliance
Penalty
Summary
The facility staff failed to maintain a medication error rate of less than 5%, resulting in a 50% error rate during the observation period. Out of 42 opportunities observed, 21 errors occurred, affecting four residents. The errors included administering incorrect dosages and failing to adhere to prescribed medication administration times. For instance, a Certified Medication Technician (CMT) administered 750 mg of calcium carbonate instead of the prescribed 500 mg to a resident with gastroesophageal reflux disease. The CMT acknowledged the error but was unaware of any required actions following a medication error. Additionally, the facility's medication administration policy was not followed, as medications were administered outside the prescribed time frames. One resident received multiple medications nearly two hours after the scheduled time, and another resident's medications were administered two hours late. The CMT responsible for these errors cited staffing issues as a reason for the delays, indicating that managing both skilled nursing and residential care facility residents was challenging within the required time frames. Furthermore, the facility staff failed to properly administer insulin using a NovoLOG FlexPen. A Registered Nurse (RN) did not prime the insulin pen before administering the dose, contrary to the manufacturer's instructions. This oversight could result in the resident not receiving the full dose of insulin. The RN and other staff members were not adequately trained on the importance of priming the pen with each use, leading to this medication error.
Failure to Complete Two-Step TB Testing for Employees
Penalty
Summary
The facility staff failed to ensure the completion of the two-step purified protein derivative (PPD) skin test for Tuberculosis (TB) in accordance with their policy for four employees out of ten files reviewed. The facility's policy requires all employees to be screened for latent tuberculosis infection (LTBI) and active TB disease using a tuberculin skin test (TST) or interferon gamma release assay (IGRA) and symptom screening prior to beginning employment. The review revealed that the Director of Nursing (DON), Licensed Practical Nurse (LPN) A, Dietary B, and the Minimum Data Set (MDS) coordinator did not have their two-step PPD tests completed within the required time frames. Specifically, the second step of the PPD test was administered too soon after the first step for the DON, LPN A, and Dietary B, while the MDS coordinator's file lacked documentation of the two-step PPD test altogether. Interviews with facility staff, including the Business Office Manager, DON, and the administrator, highlighted a lack of adherence to the facility's TB testing policy. The DON, who is responsible for ensuring the completion of the two-step TB tests, admitted to starting the first step prior to hire but was unsure why some tests were not completed in the appropriate time frames. The administrator was unaware of the deficiencies in the TB testing process and relied on the DON to ensure compliance. The Business Office Manager mentioned that the department heads, including themselves, had COVID-19 when the MDS coordinator was hired, which resulted in the oversight of the TB testing process for that employee.
Lack of Weekend Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the residents' interests on weekends for three residents out of a sample of 12, with a total census of 35. The facility's policy, dated June 2018, mandates that activities should be scheduled seven days a week, allowing residents to participate in planning and conducting these activities. However, the review of the activity calendars for July and August 2024 showed limited and repetitive activities scheduled for weekends, such as coloring sheets, puzzles, and themed days, without any staff-led activities. Interviews with residents revealed dissatisfaction with the lack of weekend activities, with residents expressing a desire for more engaging options, such as watching football during the season. The Activities Director (AD) confirmed that they are not present on weekends and that no staff-led activities are conducted during this time. The Director of Nursing (DON) and the administrator acknowledged the absence of scheduled activities on weekends, despite being aware of the requirement for such activities. The AD and DON were unaware of the need for staff-led activities on weekends, leading to a deficiency in meeting the residents' needs for engagement and interaction during these times.
Failure to Complete Daily Nurse Staffing Information
Penalty
Summary
The facility staff failed to complete the required nurse staffing information, specifically omitting the facility census on multiple occasions. According to the facility's policy, the daily staffing sheet should include the resident census at the beginning of each shift, and these records must be maintained for at least eighteen months. However, a review of the facility's daily staffing sheets for August and September 2024 revealed numerous instances where the census was not recorded. Additionally, there were several dates in August and September 2024 where the daily staffing sheets were not provided at all. Interviews with the Director of Nursing (DON) and the administrator highlighted that the night shift nurse is responsible for filling out and posting the daily staffing sheet, which should include the number of staff, hours worked, and resident census. Both the DON and the administrator expressed that they expect the staffing sheet to be completed daily. The DON acknowledged that the night nurse might have been too busy, leading to the omission of the facility census and the failure to complete the daily sheets. The administrator reiterated that there should be no reason for the absence of daily sheets.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility staff failed to provide necessary treatment and services consistent with professional standards of practice to prevent the development of pressure injuries and promote healing. Specifically, the staff did not complete weekly wound assessments for a resident and failed to notify the physician when the resident's pressure injury worsened. The facility's policy required complete wound assessment documentation weekly for all pressure injuries, but this was not adhered to, as evidenced by incomplete assessments and lack of documentation of wound measurements and descriptions. The resident in question was admitted with multiple health conditions, including Parkinson's disease, coronary artery disease, diabetes, and dementia, and was at risk for pressure injuries. Despite this, the resident's care plan and physician orders did not include specific treatment for a coccyx wound, and the Treatment Administration Record lacked treatment orders for the wound until mid-June. Observations and interviews revealed that the resident had developed multiple open wounds, including a stage 3 pressure injury, which were not properly assessed or documented by the staff. Interviews with facility staff, including a registered nurse and licensed practical nurse, indicated a lack of communication and documentation regarding the resident's wound care. The staff failed to document attempts to contact the physician about the wound's decline, and the facility administrator was unaware of the incomplete wound assessments. The resident's physician confirmed that they were not promptly informed of the wound's condition, which hindered timely treatment adjustments. This lack of documentation and communication contributed to the deficiency in providing adequate pressure ulcer care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Boonville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashley Manor Health & Rehabilitation | 0.5 mi | ★★★★★ | 0 | 0 |
| Riverdell Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Katy Manor | 9.8 mi | ★★★★★ | 0 | 0 |
| Glasgow Gardens | 20.1 mi | ★★★★★ | 0 | 0 |
| Tipton Oak Manor | 20.3 mi | ★★★★★ | 0 | 0 |
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