Below average — CMS composite of the measures below.
The next survey window likely opens around October 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 Lansdowne Village during CMS and state inspections, most recent first.
Staff did not follow posted menus or recipes, resulting in residents not receiving the meals or textures specified, including the omission of breakfast sandwiches and improper preparation of puree diets. Residents' documented meal preferences, such as requests for fresh fruit, were not consistently honored, despite availability. These failures were confirmed by staff and had the potential to impact all residents.
The facility did not maintain an effective pest control program in the kitchen, resulting in repeated observations of live and dead roaches, food debris, and trash in food prep and storage areas. Despite regular pest control visits, documentation was lacking, and cleaning duties were not consistently performed, contributing to ongoing pest activity.
Surveyors found that food was prepared and served in ways that did not ensure palatability, flavor, or proper texture, including pureed eggs that were bland and gritty, watery and undercooked oatmeal, and inconsistently cooked bacon. Trays were sent without basic condiments such as salt, sugar, creamer, or other flavor enhancers. Several cognitively intact residents reported that meals often tasted terrible or were inedible, with items like fried eggs, carrots, and scalloped potatoes described as hard or poorly prepared, and that their documented dislikes were not honored. Residents also reported difficulty obtaining coffee, sugar, creamer, and condiments, especially on one floor, despite repeated complaints in resident council meetings.
Surveyors found that kitchen staff repeatedly failed to follow basic hand hygiene and food safety practices, including not washing hands with hot water, changing gloves without handwashing, handling food after touching masks, phones, and other unclean surfaces, and beginning meal prep without prior handwashing. The designated handwashing sink did not produce hot water during multiple checks. The kitchen environment was repeatedly observed with dirty floors, dried and sticky spills, caked‑on food debris in the 3‑vat sink and dishwashing area, improperly stored dry goods and seasonings left uncovered, and food storage bins kept on the floor with soiled exteriors. Evidence of roach activity and significant debris and moisture damage behind the ice machine were also documented. Review of sanitation policies and daily, weekly, and monthly cleaning checklists showed many required cleaning tasks were either incomplete or undocumented, while meals continued to be prepared and served from this environment to all residents.
Surveyors found that the facility did not notify Medicaid residents or their representatives when resident trust fund balances came within $200 of the Medicaid resource limit or exceeded that limit, despite facility policy and administrative expectations. Several Medicaid residents had account balances well above the allowable threshold with no documented fund balance notifications. In addition, for two residents who died with money remaining in their accounts, the facility did not complete and send required third party liability (TPL) forms within 30 days of death, even though the BOM acknowledged that TPL letters were expected within that timeframe.
Surveyors found that two residents receiving continuous tube feedings did not receive care consistent with physician orders and safe practices. One resident with dysphagia had Jevity 1.5 ordered at a continuous rate, but repeated observations showed that large amounts of formula remained in the bottle when significant volumes should have infused, pumps alarmed "inactive" or with cassette errors while no feeding was delivered, and the same formula bottles were left hanging for more than 24 hours. Another resident with a history of pneumonia and hemiplegia received personal care from a CNA on two occasions while the tube feeding continued to infuse and the head of bed was lowered, with a wound nurse present during one episode who did not intervene. Staff later acknowledged that tube feeding formula should not hang longer than 24 hours and that continuous feedings should be paused and the nurse notified when care requiring lowering the head of bed is provided.
The facility failed to ensure that the interval between the evening meal and breakfast did not exceed 14 hours and did not consistently provide substantial bedtime snacks when that interval was longer. Scheduled meal times and observed service patterns resulted in up to 15–16 hours between dinner and breakfast, while snacks were typically left at the nurse’s station and not routinely passed. Multiple cognitively intact residents reported not receiving evening snacks, not being informed they could request substantial items such as sandwiches, and sometimes going long periods without food, with staff at times refusing sandwich requests because residents had already eaten dinner. Available snacks were generally limited to cookies, chips, and snack cakes, and an inspection of the designated resident refrigerator revealed no sandwiches despite claims they were stored there. Resident council minutes and staff interviews corroborated ongoing complaints about lack of snacks and late breakfasts, and the dietitian confirmed that a substantial snack would be expected when more than 14 hours elapsed between meals.
Staff failed to follow the facility’s hand hygiene, incontinence care, and Enhanced Barrier Precautions (EBP) policies during care for multiple residents who were incontinent and/or had wounds. In several observations, CNAs performed peri-care without cleansing the genital and anal areas, reused the same side of washcloths or wipes for multiple strokes, and did not change gloves or perform hand hygiene between dirty and clean tasks while continuing to handle linens, clothing, and resident items. For residents on EBP due to wounds, CNAs, a wound nurse, and a Wound Practitioner provided high-contact care and wound treatments using gloves only, without required gowns, and door magnets did not specify PPE or high-contact activities. Interviews with CNAs, CMTs, nursing staff, and leadership showed inconsistent understanding of EBP indications, the meaning of red door magnets, and when gowns and gloves were required, despite written policies and stated expectations for proper infection control practices.
Three residents who were dependent on staff for incontinence care were left wet or soiled for extended periods, with staff failing to respond promptly to call lights or check on them as required. Observations showed incomplete cleansing during care, and staff interviews confirmed that inadequate staffing contributed to delays and lapses in following facility policy.
An LPN failed to treat a cognitively intact resident with respect and dignity during medication administration. The facility’s Resident Rights policy required staff to treat residents with kindness, respect, and dignity. During an observed interaction, the resident, who had depression and a psychotic disorder, took ordered medication and began to set the medication cup down, stating they could take care of it themselves when the LPN attempted to take the cup. The LPN’s facial expression became irritated, the LPN turned away from the resident, and in a clearly audible, rude tone stated, “see the type of attitude we have to deal with, you don’t talk to us that way,” before leaving the room and closing the door. The resident reported that staff can be rude and treat them as if they have dementia, despite their ability to care for themselves. Facility leadership later stated that staff are expected to speak respectfully to residents, face them when speaking, and not criticize them.
A cognitively intact resident with COPD had a physician’s order allowing an albuterol inhaler to be kept at bedside, but the facility did not complete or document an assessment of the resident’s ability to safely self-administer medications, nor include self-administration in the care plan as required by policy. The resident reported wanting and needing the rescue inhaler at bedside and initially did not receive it despite the order; later, staff provided the inhaler for bedside use without any documented self-administration assessment. A CMT described usual practices for residents who self-administer, and the DON acknowledged uncertainty about whether this resident had been reassessed after readmission, despite the requirement to assess residents who keep medications at bedside.
Two residents with diabetes were incorrectly coded on their MDS assessments as having received insulin, even though their active medication orders showed only GLP-1 receptor agonists (Ozempic and Mounjaro) administered weekly and no current insulin orders. The MDS Coordinator acknowledged that these medications are not insulin and should not be coded as such, and the Administrator stated an expectation that insulin use be coded accurately, confirming that the assessments did not reflect the residents’ actual treatment during the assessment period.
Surveyors found that the facility failed to prepare and serve fortified "super cereal" and health shakes as ordered for multiple residents requiring fortified diets, and instead served thin, undercooked oatmeal without fortification to both regular and fortified diet trays. A resident with dementia, Parkinson’s disease, significant recent weight loss, and documented need for double portions, fortified foods, house shakes, a divided plate, and 1:1 feeding assistance was observed alone, unable to eat independently, without a shake, and with a nearly full meal tray. On another day, this resident did not receive a breakfast tray at all by late morning despite staff acknowledging the omission, while documentation inaccurately reflected that a house shake was given and that the resident consumed a high percentage of meals.
Surveyors found multiple instances of improper medication and biological storage and labeling, including an undated opened Lispro insulin pen in a nurse cart, an uncapped tube of triamcinolone cream on a treatment cart, and an opened Breo Ellipta inhaler left on a medication room countertop without a resident label. In two separate carts, Nitroglycerin 0.4 mg bottles were present with no identifying resident information, and the LPN and CMT using those carts did not know to whom the medications belonged. One cart also contained several Ensure Plus cartons, including one that had been opened by a CMT and was not kept on ice or refrigerated as required by the manufacturer.
Staff did not schedule required urology follow-up appointments for a resident with recurrent UTIs and severe urethra erosion from prolonged indwelling catheter use, despite multiple physician and hospital orders. The care plan inaccurately documented a suprapubic catheter, and necessary follow-up was not arranged until identified during surveyor review. Nursing and administrative staff were unaware of the missed appointments and the resident's ongoing condition.
A resident with a full code status was found unresponsive with signs of rigor mortis, and CPR was not initiated as per facility policy. Staff interviews revealed uncertainty about when CPR should not be performed, indicating a lack of understanding of the policy. The facility acknowledged the need for improved staff competency in CPR procedures.
Failure to Follow Menus, Recipes, and Resident Preferences in Meal Service
Penalty
Summary
The facility failed to ensure that menus and recipes were followed as written, resulting in residents not receiving meals that met their documented nutritional needs and preferences. During breakfast meal observations, staff did not serve the breakfast sandwiches listed on the menu, instead providing items such as eggs, bacon, and oatmeal. Residents reported through interviews and resident council meetings that the meals served often did not match the posted menus, and this concern had been ongoing without resolution. The Dietary Manager confirmed that breakfast sandwiches should have been served, but staff chose not to prepare them, citing resident limitations and preferences without documented justification or menu changes. Further deficiencies were observed in the preparation of special diets, specifically puree diets. Staff did not follow the facility's puree egg recipe, instead blending scrambled and hardboiled eggs with unmeasured amounts of hot water, resulting in a product that was thick, chunky, bland, and gritty. The recipe book was not consulted during preparation, and the staff member was unsure of the quantities used. Similarly, oatmeal was prepared with unmeasured ingredients and insufficient cooking time, resulting in a thin, watery, and undercooked product. The oatmeal was not pureed for residents on puree diets as required by the recipe, and the staff member admitted to being pressed for time. Additionally, the facility failed to accommodate resident meal preferences as documented on meal tickets. One resident, who was supposed to receive fresh fruit with each meal, consistently did not receive it despite it being listed on the meal ticket and fresh fruit being available in the kitchen. The resident reported receiving the same breakfast daily without the requested fruit, and staff acknowledged that preferences should be followed when possible. These failures had the potential to affect all residents in the facility.
Failure to Maintain Effective Pest Control and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain an effective pest control program in the kitchen, as evidenced by repeated observations of live and dead roaches, food debris, and trash in various areas of the kitchen. Despite having a pest control policy and regular visits from a pest control company, documentation of these visits lacked details on areas treated, recommendations, or findings. Observations during meal preparation revealed multiple instances of roaches crawling on food prep areas, under sinks, behind ovens, and inside storage bins containing serving utensils. Food debris, trash, and dirty dishes were found under and around kitchen equipment, with visible buildup of dirt and debris in floor grout and drains. Staff interviews indicated that cleaning duties were expected to be completed daily, with food debris not to be left overnight. However, observations contradicted these expectations, as food debris and trash were present during early morning meal prep and on subsequent days. The Dietary Manager stated that she had not seen any roaches and reiterated that staff should clean before leaving, but was shown evidence of dead roaches and debris by the surveyor. The Administrator reported that pest control recommendations, if any, were not communicated to her but possibly to the maintenance supervisor. The lack of thorough cleaning and failure to address food debris and trash contributed to the presence of roaches in the kitchen. The pest control program was not effectively implemented, as evidenced by ongoing pest activity and insufficient documentation or follow-up on pest control visits. The facility census at the time was 121.
Unpalatable Food Preparation and Lack of Condiments Affecting Meal Quality
Penalty
Summary
The deficiency involves the facility’s failure to prepare and serve food that is palatable, flavorful, and properly prepared, as well as the failure to provide condiments and seasonings with meals. Surveyors observed a cook preparing pureed eggs by blending scrambled and hardboiled eggs with hot water, resulting in a thick, slightly chunky puree that tasted bland, watered down, and gritty. Oatmeal was prepared with quick rolled oats in hot water, with a small, unmeasured amount of melted butter added; it appeared watery, the oats were not fully cooked, and it had no flavor, only a greasy feel on the lips. A test tray showed oatmeal with no flavor and bacon that was inconsistently cooked, with one piece properly cooked and another flimsy and rubbery with unrendered fat. Breakfast trays were sent out without salt, sugar, or other condiments. Multiple cognitively intact residents reported ongoing concerns about the taste and palatability of the food. Members of the resident council stated the food was terrible, sometimes inedible, with specific complaints about hard fried eggs and poor-quality oatmeal, and that listed dislikes on meal tickets were not honored. One resident reported that the food did not taste right and was inconsistent, with hot dogs offered as an alternative if the main meal was disliked. Another resident stated that food tasted bad, some items such as carrots and scalloped potatoes were too hard to eat, and that residents had difficulty obtaining coffee, sugar, creamer, and condiments, particularly on the second floor. Additional residents described the food as nasty, gross, and horrible, and reported that even offered alternatives were not good. The Dietary Manager and Dietician acknowledged that oatmeal designated as “super cereal” should receive butter and brown sugar, while regular oatmeal did not get additions unless requested, and that bacon should be cooked through with fat rendered, which contrasted with the surveyors’ observations and resident reports.
Widespread Kitchen Sanitation and Hand Hygiene Failures During Food Preparation and Service
Penalty
Summary
The deficiency involves the facility’s failure to store, prepare, and serve food in accordance with professional standards and its own policies over multiple days of observation. Surveyors observed that the designated kitchen handwashing sink did not produce hot water despite being allowed to run for approximately two minutes on several occasions. Staff, including dietary personnel, were unaware of whether the water ever became hot. Handwashing signage posted at the sink specified that hands should be washed with hot running water and outlined proper handwashing steps, but staff did not consistently follow these procedures. The facility’s Administrator and Dietary Manager (DM) later stated that they had not been informed of the hot water issue until the survey, and the Maintenance Supervisor reported he was only told about the problem on the day of the survey. During breakfast meal preparation, surveyors observed multiple instances of staff failing to wash their hands at appropriate times and handling food after contact with potentially contaminated surfaces. One dietary staff member began meal preparation after only donning gloves, without first washing hands. This staff member handled a dirty blender in the 3‑vat sink, then, without washing hands, entered the walk‑in cooler, retrieved a box of individual butter servings, and placed butter on resident trays. After picking up a butter container that had fallen on the floor, the staff member discarded it but again did not wash hands before resuming food handling, instead only changing gloves. The same staff member repeatedly changed gloves without handwashing between tasks, including after washing equipment in the sink and before preparing pureed foods and handling other meal components. Another dietary aide arrived carrying a personal cell phone and wearing a face mask, placed the phone on a serving cart, and later moved it to a food preparation station. After answering the kitchen phone, pulling the face mask down, and handling trays and condiments, this aide did not wash hands or don gloves before continuing to handle resident trays and food items. Although the aide did wash hands at one point, the water at the handwashing sink was noted to be cold. The aide was also observed adjusting a face mask and then continuing to handle syrup containers and cups, and later placing gloves on without washing hands. The DM later stated that staff were expected to wash their hands when they first arrive, when changing gloves, and after touching masks or phones, and that phones should not be placed on food preparation stations. The facility also failed to maintain a clean and sanitary kitchen environment as required by its Nutritional Services Sanitation and Ware Washing policies and its daily, weekly, and monthly kitchen checklists. On multiple days, surveyors observed kitchen floors with dirt and debris, dried and sticky spills, and food items such as a juice cup and tater tot left on floors and carts. In the dry storage room, a single‑serve juice cup lay on the floor surrounded by dried liquid, and oily and sticky spills remained under and near storage racks and the doorway over several days. Dirty dishes with caked‑on food debris from the prior day were left in the dishwashing area. Under the 3‑vat sink, the floor was sticky, with wet cardboard, an opened butter container, and food debris present. The 3‑vat sink’s sanitize basin contained dried, caked‑on meat and food debris, and a baby roach was seen crawling across the shelf above the sink. Additional unsanitary conditions included flour and sugar bins stored on the floor, with exteriors covered in drips and greasy smears and dried puree‑like drips on the sugar bin lid. A two‑tier stainless‑steel table in the back serving area had rusty spots where the finish was missing and dried food drips and greasy spills on the bottom tier, where clean muffin pans and a cutting board were stored. Behind the ice machine, surveyors observed a large amount of debris and trash, a build‑up of a black, thick substance, a leak causing a puddle, and a swollen, wet wall with a hole and dark, fuzzy material. Under the dishwashing sink, an opened single‑serve peanut butter container and crumpled plastic wrap were on the floor. The dishwashing sink contained dried food debris including pickles, onions, strawberries, greens, and other items, and a floor drain near the 3‑vat sink had food debris caked around the edges, with a roach seen crawling out of the drain. Evidence of pest activity was repeatedly documented. Surveyors observed a baby roach near the 3‑vat sink, a large roach crawling from under the stove to under the steam table, and dead roaches on the steam table shelf next to clean dishes and on the floor in front of the steam table. A greasy paper towel was stuck to the bottom shelf of the steam table, and there was a build‑up of debris under the serving station/steam table. The DM acknowledged seeing roaches and stated there was a daily cleaning list that staff were supposed to sign when tasks were completed. Dry goods and seasonings were not properly covered or stored. On multiple observations in the back preparation station, containers of fajita seasoning, ground thyme leaves, rotisserie seasoning, black pepper, and salt were left open on shelves or counters, and a large tub of parsley flakes had no lid. The sugar bin on the floor had its lid propped open. The DM later stated she was unsure where the parsley lid was and acknowledged that seasoning containers and the sugar and salt bin lids should be closed when not in use. Review of the facility’s daily, weekly, and monthly kitchen checklists showed numerous items either left blank or not documented as completed, including cleaning of dishes, sinks, work counters, steam tables, floors, storage areas, ovens, stainless‑steel surfaces, deep fryer, and deep cleaning under prep stations and cook’s areas. These observations and records showed that the facility did not consistently follow its own sanitation and ware washing policies or complete required cleaning tasks, affecting the kitchen environment from which food was prepared and served to all residents.
Failure to Notify Medicaid Residents of Excess Trust Fund Balances and Complete TPL Forms After Death
Penalty
Summary
Surveyors identified that the facility failed to notify Medicaid residents or their representatives when resident trust fund balances approached or exceeded the Medicaid resource limit, as required by facility policy. Review of the business office Resident Statement Landscapes showed that three Medicaid residents had trust fund balances significantly above the Medicaid limit ($12,161.13, $8,496.39, and $7,460.29), with no Resident Fund Balance Notifications documented in their medical records. During interview, the Business Office Manager acknowledged that she had not sent any Resident Fund Balance Notifications when residents reached the $200 threshold below the Medicaid limit and stated she was only now aware that such letters should have been sent. The Administrator stated she expected Medicaid resource letters to be sent when resident balances were within $200 of the resource limit. Surveyors also found that the facility failed to complete and send third party liability (TPL) forms within 30 days for deceased residents who had remaining funds in their accounts. Record review showed that two residents who had expired still had balances of $837.25 and $4,239.70, respectively, with no TPL letters sent. In interview, the Business Office Manager stated that TPL letters should be sent within 30 days of a resident’s death and acknowledged that these letters had not been sent for the deceased residents reviewed. The Administrator stated she expected TPL letters to be sent within 30 days of a resident’s death.
Failure to Provide Ordered Tube Feedings and Safe Positioning During Enteral Nutrition
Penalty
Summary
Surveyors identified that the facility failed to ensure residents receiving tube feeding were provided nutrition as ordered and that tube feeding formula and equipment were properly maintained. One resident with dysphagia oropharyngeal phase had a continuous order for Jevity 1.5 at 65 ml/hr. Multiple observations over several days showed that factory-sealed 1500 ml bottles of Jevity 1.5, labeled with hang times, were not infusing at the ordered rate despite the pump being set correctly. Large volumes of formula remained in the bottles when significant amounts should have infused based on the documented start times and ordered rate, and on at least two occasions the same bottle remained hanging for over 24 hours. The pump was observed alarming “inactive” or “cassette error” with no formula infusing, yet the same bottles continued to hang, and staff did not replace the formula or tubing within the 24-hour timeframe. The observations for this resident showed repeated instances where the amount of formula remaining in the bottle did not match what should have been delivered according to the physician’s order and elapsed time. For example, a bottle hung the previous evening still had nearly the full volume present the next morning, and later in the day the same bottle continued to show minimal infusion despite the pump being set at 65 ml/hr. On another day, a bottle hung early in the morning still had almost the entire volume remaining several hours later while the pump alarmed with an error and no feeding was infusing. On subsequent observation, the same bottle remained in use more than 24 hours after it was hung, with substantial formula still present when, by calculation, the entire bottle plus additional formula should have infused. Staff interviews confirmed that tube feeding bottles and tubing were supposed to be changed at least every 24 hours and that formula should not hang longer than that. Surveyors also found that another resident with a history of pneumonia, stroke, and hemiplegia/hemiparesis, who had an order for continuous Jevity 1.5 at 60 ml/hr via pump with allowance for disconnection for care, received personal care while the tube feeding continued to infuse and the head of bed was lowered. On two separate observations, a CNA entered the room, donned gloves, and lowered the resident’s head of bed to provide personal care while the tube feeding continued without being paused. After care, the CNA then repositioned the resident and elevated the head of bed. During one of these episodes, a Wound Nurse was present for a skin assessment and did not pause the feeding or instruct the CNA to avoid lowering the head of bed while the feeding was running. In interviews, nursing staff, including an LPN and the DON, stated that CNAs should notify the nurse so the pump can be turned off during care and that allowing tube feeding to infuse with the head of bed low increases the risk of aspiration.
Failure to Provide Substantial Bedtime Snacks When Meal Intervals Exceeded 14 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that meals and snacks were provided in a manner that limited the interval between the evening meal and breakfast to 14 hours or less and to provide a substantial bedtime snack when that interval exceeded 14 hours. The facility’s written Meals and Snacks policy required meals to be provided on a regularly scheduled basis and specified that mealtimes be scheduled to ensure a maximum of 14 hours from dinner to breakfast, but the policy did not address the requirement for a substantial bedtime snack when more than 14 hours elapsed between meals. The posted mealtime schedule for several halls showed breakfast from 8:00 A.M. to 9:30 A.M., lunch from 12:00 P.M. to 1:30 P.M., and dinner from 5:00 P.M. to 6:30 P.M., resulting in up to 15 hours between dinner and breakfast. Observations on multiple days confirmed that meals were served during these timeframes, including dinner service as late as 6:30 P.M. and breakfast trays still leaving the kitchen as late as 9:22 A.M. Resident council minutes documented repeated complaints that snacks were not being given out, that residents were not receiving what they ordered, and that beverages were missing from trays. Residents reported that bedtime snacks were left at the nurse’s station and that staff did not routinely pass them unless residents specifically asked, with one resident stating they did not know snacks were available. An activity aide reported that residents frequently complained that breakfast was served late and that they were not receiving evening snacks, and that snacks were not being offered or provided when requested. Interviews with cognitively intact residents revealed that they typically did not receive evening or bedtime snacks, that available snacks were limited to cookies, chips, or snack cakes, and that they were not informed they could receive more substantial items such as sandwiches. Several residents described long intervals without food and difficulty obtaining substantial snacks at night. One resident stated dinner was usually served around 5:00 P.M. but sometimes later, and that they had not been offered snacks in the evening for months except on one recent occasion; they had never been offered a sandwich and would be interested in one, especially when dinner was early or intake was low. Another resident reported that breakfast sometimes arrived as late as 9:30 or 10:00 A.M., that no snacks were offered at night, and that when they requested a sandwich at bedtime, staff refused, stating the resident had already eaten dinner. A different resident reported sometimes going up to 16 hours without food and only being offered insubstantial snacks like chips. Another resident stated that staff sometimes received snacks from the kitchen but did not always pass them out, and that snacks consisted of cookies and snack cakes, not substantial or healthy items; when this resident requested a sandwich at night, staff responded that no sandwiches had been sent and that they were “lucky” to get snacks at all. The dietary manager reported that sandwiches were placed in a resident refrigerator on the first floor, but observation of that refrigerator showed it was largely filled with personal items and contained no sandwiches. The dietitian stated that if more than 14 hours elapsed between dinner and breakfast, a substantial bedtime snack such as a sandwich, fruit cup, yogurt, and cookies would be expected, but also reported being told by the dietary manager that there were not more than 14 hours between meals and that residents were provided mainly snack items like peanut butter bars and chips, without mention of sandwiches.
Failure to Follow Hand Hygiene, Incontinence Care Technique, and Enhanced Barrier Precautions
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene, incontinence care technique, and use of Enhanced Barrier Precautions (EBP). Review of facility policies showed that staff were required to perform hand hygiene at key points during care, use clean surfaces of wipes for each stroke, cleanse the perineal area from front to back including the genital and anal areas, and change gloves with hand hygiene between dirty and clean tasks. The EBP policy required gown and glove use for high-contact resident care activities such as dressing, transferring, providing hygiene, changing briefs/toileting, and wound care for residents with wounds or indwelling devices, with appropriate signage indicating required PPE and high-contact activities. Multiple observations showed staff did not follow these policies during incontinence care. One resident who was always incontinent of bowel and bladder and dependent on staff for personal hygiene had peri-care performed by a CNA who double-gloved, removed only one pair of gloves after cleaning stool, did not perform hand hygiene, then applied barrier cream and a clean brief and adjusted the resident’s pillow while wearing the same soiled gloves. Another resident with severe cognitive impairment, frequent incontinence, and limited mobility was found sitting with feet in a puddle of urine and reported being wet all night; during care, the CNA wore the same gloves throughout, wiped only the buttocks with disposable wipes, did not cleanse the front genital or anal areas, and then dressed and transferred the resident without changing gloves or performing hand hygiene. A third resident, cognitively intact but fully dependent for toileting, reported being left soiled; the CNA providing care did not wear a gown, used the same side of a wet washcloth for multiple wipes to the groin without cleansing the genital or anal areas, then applied a clean brief, handled linens, and adjusted the bed while wearing the same gloves, and left the room without performing hand hygiene. Surveyors also observed failures to implement EBP requirements for residents with wounds. One resident with dementia, a stage 3 heel pressure ulcer, and an EBP order had only a red magnet on the door that did not specify PPE or high-contact activities; a CNA provided incontinence care and dressing without a gown, and later the Wound Practitioner and wound nurse performed wound care on heel and foot eschar without gowns, using only gloves. Another resident with severe cognitive impairment, multiple comorbidities, incontinence, and EBP orders for wounds had a similar red magnet lacking PPE details; a CNA donned gloves in the hallway, provided full incontinence care, dressing, and mechanical lift preparation without changing gloves or performing hand hygiene, and neither the CNA nor the Activities Director wore gowns during the mechanical lift transfer. The Wound Practitioner and wound nurse later performed wound care on this resident’s buttocks wound with gloves only, no gowns. Additional EBP lapses were observed for other residents with wound-related EBP orders. One cognitively intact resident with a weeping right shin wound on EBP had wound care performed by the wound nurse using gloves only, without a gown, despite active drainage and dressing application. Another resident with severe cognitive impairment and a stage 3 pressure ulcer on EBP had wound care to a buttocks wound performed by the Wound Practitioner and wound nurse wearing gloves but no gowns. Interviews with CNAs, CMTs, nursing staff, the wound nurse, ADON, DON, and the Administrator revealed inconsistent understanding of EBP indications, the meaning of the red door magnets, and required PPE. Some staff believed EBP meant only glove use or associated the red magnet with oxygen use, while others stated that gowns and gloves should be used for all hands-on or high-contact care for residents with wounds. Leadership staff stated expectations that hand hygiene be performed when entering and exiting rooms and between dirty and clean tasks, that peri-care include cleaning all potentially soiled areas including genitals, and that gowns and gloves be used for EBP residents during high-contact care and wound care, which contrasted with the observed practices.
Failure to Provide Timely and Complete Incontinence Care
Penalty
Summary
The facility failed to provide timely and thorough incontinence care for three residents who were dependent on staff for personal hygiene. Observations and interviews revealed that these residents were left wet or soiled for extended periods, with staff not responding promptly to call lights or checking on residents as required. In one case, a resident's spouse reported consistently finding the resident wet in the mornings and having to assist with care due to staff inattention. Direct observation showed the resident lying in a saturated brief with urine and stool, and staff did not cleanse all necessary areas during incontinence care. Another resident was found sitting in a puddle of urine with soaked bedding and clothing, stating they had been waiting all night for assistance. The call light was not within reach, and the resident was confused about its use. Staff acknowledged that night shift coverage was insufficient, making it difficult to provide timely care. A third resident, also fully dependent on staff, reported being left wet after using the call light, particularly during evening and night shifts. Observation confirmed the resident was left in a soaked brief for an extended period before staff responded. Facility policy required incontinence care to be provided as directed in the care plan, including checking residents every two hours, performing thorough cleansing, and applying barrier cream as needed. However, staff failed to follow these procedures, resulting in residents remaining wet or soiled for prolonged periods and incomplete cleansing during care. Interviews with staff and the Director of Nursing confirmed that these lapses occurred, and that inadequate staffing contributed to the delays in care.
Failure to Treat Cognitively Intact Resident With Respect and Dignity
Penalty
Summary
The facility failed to honor a resident’s right to be treated with respect and dignity when an LPN spoke rudely to a cognitively intact resident. The facility’s Resident Rights policy dated 4/26/23 stated that residents must be treated with kindness, respect, and dignity, and that resident rights include respect and dignity. Resident #61’s quarterly MDS dated 9/4/25 showed the resident was cognitively intact and had diagnoses of depression and a psychotic disorder. During an observation and interview on 10/1/25 at 8:32 A.M., the resident was sitting up in bed drinking coffee when LPN A entered after knocking and handed the resident a medication cup. After taking the medication, the resident began to set the cup down, and when LPN A attempted to take the cup, the resident stated he/she could take care of it him/herself. LPN A’s facial expression changed to appear irritated, and the LPN turned his/her back to the resident, began walking away, and stated in a clearly audible, rude tone, “see the type of attitude we have to deal with, you don’t talk to us that way,” before exiting the room and closing the door. The resident then reported that staff can be rude, that they treat him/her as if he/she has dementia, and that he/she is able to do things independently. In a subsequent interview, the Administrator, DON, and Corporate Administrator stated that staff should speak to residents with respect, face residents when speaking, and should not criticize them. This deficiency involved one resident out of a sample of 24, with a total facility census of 121, and was based on observation, interview, and record review showing that the LPN’s rude and critical verbal response and demeanor toward a cognitively intact resident did not comply with the facility’s Resident Rights policy requiring respect and dignity.
Failure to Assess and Care Plan Resident for Self-Administration of Bedside Inhaler
Penalty
Summary
The facility failed to ensure a resident’s right to self-administer medications was protected in accordance with its own bedside medication storage policy. The policy required a prescriber’s written order, an interdisciplinary team assessment of self-administration skills, documentation of bedside storage on the MAR and care plan, resident instruction with documentation, and at least once-per-shift nursing checks for usage. For a cognitively intact resident with COPD who had an order for albuterol inhaler "may keep at bedside," the care plan did not address self-administration, and there was no documented assessment of the resident’s ability to safely self-administer medications. The resident reported wanting to keep the rescue inhaler at bedside and stated that the physician had ordered this, but staff initially did not provide the inhaler, telling the resident they needed to speak with the physician. On subsequent observation, the resident produced the albuterol inhaler from the bedside drawer and stated staff had given it to be kept at bedside. Review of the medical record at that time still showed no assessment for self-administration. A CMT reported that if a resident is able to self-administer, the order would indicate the medication may be left at bedside and that residents are educated on proper technique, but also stated there were currently no residents self-administering medications. The DON stated the resident had been assessed in the past but was unsure if reassessment occurred after the last admission, and confirmed that residents requesting to self-administer should be assessed for safety when medications are kept at bedside.
Inaccurate MDS Coding of GLP-1 Therapy as Insulin
Penalty
Summary
The deficiency involves inaccurate completion of the Minimum Data Set (MDS) for two residents with diabetes, where their assessments were incorrectly coded to show they received insulin. For one resident, the quarterly MDS indicated that insulin injections were received on one day during the 7-day look-back period. However, the resident’s order summary showed a standing order for Ozempic, a GLP-1 receptor agonist, administered subcutaneously once weekly for type 2 diabetes, with no indication of insulin use during that period. Ozempic is not classified as insulin and therefore should not have been coded as insulin on the MDS. For the second resident, the quarterly MDS also documented that insulin injections were received on one day during the 7-day look-back period. Record review showed that this resident had previously been on insulin, which was discontinued months earlier, and was subsequently placed on Ozempic and then Mounjaro, both GLP-1 receptor agonists administered subcutaneously. The current order summary reflected a weekly Mounjaro injection, with no active insulin order. During interviews, the MDS Coordinator confirmed that Ozempic and Mounjaro are not insulin and should not be coded as such, and the Administrator stated an expectation that insulin be coded accurately on the MDS, confirming that the assessments did not accurately reflect the residents’ actual medication regimens at the time of assessment.
Failure to Provide Ordered Fortified Foods and One-on-One Feeding Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered fortified foods and adequate nutritional support, including one-on-one feeding assistance, to residents identified as needing enhanced nutrition. The facility’s own policy on weight variances required RD assessment and interventions such as fortification and supplements for residents with significant or unplanned weight loss. During a breakfast meal preparation observation, dietary staff prepared oatmeal using two 42-ounce tubs of quick oats in a 40-quart pot with steaming water, adding an unmeasured amount of melted butter. The oatmeal was described as thin, watery, undercooked, lacking flavor, and greasy, and the cook stated it was not cooked longer due to time pressure. Despite a facility recipe specifying 2½ gallons of water and 3 pounds of instant oatmeal with a defined cooking process, the oatmeal did not meet the described consistency, and super cereal, the facility’s fortified oatmeal product, was not prepared at all that morning. The facility had identified 33 residents who were to receive fortified foods, and its fortified list and RD guidance required that fortified foods, including super cereal, be prepared and served daily to residents with orders. However, during the observed breakfast service, the same oatmeal was served to residents on both regular and fortified diets, and no health (house) shakes were placed on the trays, despite expectations that dietary staff would ensure shakes were included. A CNA later reported not being familiar with fortified foods or super cereal and could not confirm whether residents received them with breakfast. The Dietary Manager and RD both stated that super cereal should be made daily, separate from regular oatmeal, and that house shakes should be provided on trays with meals for residents with orders, but on the observed day these fortified items were not provided as required. The deficiency also involved a specific resident with documented nutritional needs and significant weight loss who did not receive ordered fortified foods, health shakes, or one-on-one feeding assistance. This resident had impaired cognition, dementia, anxiety, and Parkinson’s disease, required substantial/maximal assistance with eating per the MDS, and had experienced unplanned weight loss from 167.8 lbs in April 2025 to 138.4 lbs by early September, and then to 131.0 lbs by the end of September. The care plan and physician’s orders called for a regular diet with double portions, fortified foods with all meals, a divided plate, house shakes with meals, and one-on-one feeding assistance. Observations showed the resident alone in the room at lunch with a regular plate (not divided), attempting but unable to eat spaghetti independently, stating they were done eating despite a nearly full plate, and reporting not receiving a shake. The lunch ticket listed double portions, fortified foods, a 4 oz house shake, and feeding assistance, yet no shake was present and no assistance was provided. On a subsequent morning, the resident did not receive a breakfast tray at all by mid-morning, despite call lights being activated and turned off, and staff acknowledging the resident had not been given a tray. Documentation in the MAR and nutrition intake records indicated a house shake was given and high meal consumption percentages, which conflicted with direct observations that the resident did not receive the ordered shake, fortified foods, or required one-on-one feeding assistance.
Improper Labeling and Storage of Medications and Nutritional Supplements
Penalty
Summary
Surveyors identified a deficiency in the facility’s handling, labeling, and storage of medications and biologicals during review of multiple medication and treatment carts and medication rooms. The facility’s own Storage of Medication policy required medications and biologicals to be stored safely, securely, and properly per manufacturer or supplier recommendations, to be kept in pharmacy-labeled containers, and for opened multi-dose preparations to be dated when first used. Despite this, an opened, undated Lispro insulin pen was found in the top drawer of a nurse medication cart, and the nurse present stated it should have been dated once opened but did not know who had opened or administered it. On the same hall’s treatment cart, an open tube of triamcinolone 0.1% cream was found without a cap, and the nurse acknowledged the medication should have had a cap but reported the cap was lost. Additional observations showed an opened Breo Ellipta 200 mcg/25 mcg inhaler sitting on a medication room countertop without any label identifying the resident to whom it belonged. In one treatment cart, a bottle of Nitroglycerin 0.4 mg was present without a label indicating the resident’s name or expiration date, and the LPN using the cart stated they did not know who the medication belonged to. Another medication cart contained a second bottle of Nitroglycerin 0.4 mg with no identifying name, as well as several cartons of Ensure Plus, one of which was open and not stored on ice or refrigerated, contrary to manufacturer instructions that opened Ensure should be refrigerated. The CMT using that cart stated they did not know who the Nitroglycerin belonged to and confirmed they had opened the Ensure that day.
Failure to Schedule Urology Follow-Up for Resident with Indwelling Catheter
Penalty
Summary
Facility staff failed to ensure that a resident with recurrent urinary tract infections and severe urethra erosion from prolonged use of an indwelling urinary catheter received care consistent with professional standards. Despite multiple physician and hospital orders for regular urology follow-up and catheter exchanges, staff did not schedule the required follow-up appointments with the urologist. The resident's care plan inaccurately documented the presence of a suprapubic catheter, which was not supported by the medical record, and there was no evidence that the necessary urology appointments were made after hospital discharges or as directed by the physician. Record reviews showed that the resident had a history of obstructive and reflux uropathy, bladder-neck obstruction, cognitive impairment, and required maximum assistance for all activities of daily living. Orders included regular catheter care and exchanges, and hospital discharge summaries repeatedly indicated the need for urology follow-up. However, documentation of these follow-up appointments was missing, and interviews with staff and administration revealed a lack of awareness regarding the missed appointments and the resident's ongoing urethra erosion. Interviews with nursing and administrative staff confirmed that the responsibility for scheduling follow-up appointments and transcribing orders fell to the charge nurse upon the resident's return from hospital or physician visits. Despite these expectations, the required follow-up appointments were not made until prompted by the surveyor's investigation, and the oversight was not identified by supervisory staff. The resident experienced ongoing issues with catheter clogging, leakage, and skin breakdown, further highlighting the lack of adherence to professional standards of care.
Lack of Staff Competency in CPR Policy Leads to Deficiency
Penalty
Summary
The facility failed to ensure that their licensed staff was competent in their knowledge of the facility policy regarding when to provide Cardiopulmonary Resuscitation (CPR) for a resident with a full code status. This deficiency was identified when staff members were unsure of the circumstances under which CPR should not be initiated, such as in the presence of clinical signs of irreversible death. The incident involved a resident who was found unresponsive with signs of rigor mortis, and CPR was not initiated as per the facility's policy. The resident in question was cognitively intact but required substantial assistance with daily activities and had a history of cancer, stroke, and other medical conditions. On the day of the incident, the resident had undergone chemotherapy and was reported to be feeling unwell. The resident was last seen alive by staff at 4:30 A.M., and was found unresponsive at 5:55 A.M. with signs of rigor mortis. Despite the resident's full code status, CPR was not performed due to the presence of these signs, which was in accordance with the facility's policy. Interviews with staff revealed a lack of clarity and understanding of the CPR policy, with some staff members unsure of when CPR should not be performed. The facility's investigation confirmed that the resident's condition was related to a gradual decline due to their medical diagnoses. The Director of Nursing and Administrator acknowledged the need for staff to be competent in understanding code status and the facility's CPR policy, highlighting a gap in staff training and knowledge.
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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 Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pine Grove Manor | 0.2 mi | ★★★★★ | 20 | 1 |
| Magnolia Wellness Center | 1.7 mi | ★★★★★ | 10 | 1 |
| Beauvais Rehab And Healthcare Center | 2.1 mi | ★★★★★ | 1 | 0 |
| Carrie Elligson Gietner Health Care Center | 2.3 mi | ★★★★★ | 8 | 0 |
| St Louis Altenheim | 2.3 mi | — | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.