Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lincoln County Nursing & Rehab during CMS and state inspections, most recent first.
Two residents with cognitive impairment and significant mental health and functional needs were subjected to verbal abuse by a housekeeper who yelled, screamed, and used profanity when one resident repeatedly called for help and the other intervened about how the resident was being spoken to. Witnesses, including CNAs and the ADON, reported the housekeeper being in close proximity to a crying resident, shouting obscenities such as “shut the fuck up” and other derogatory language, while the second resident reported being cursed at and called a “bitch” after attempting to defend the first resident. The housekeeper later admitted becoming increasingly angry and "snapping," confirming that he/she yelled and cursed at the resident.
Failure to Provide Required RN Coverage: The facility failed to provide RN coverage for eight consecutive hours each day. Review of the facility assessment identified RN coverage as needed for competent resident care and emergencies, but CMS PBJ data and time sheet review showed multiple days with no RN coverage and several days with only partial RN hours. The Staffing Coordinator said she notified the DON and Administrator when an RN was not scheduled, and the DON and Administrator acknowledged the ongoing RN coverage issue.
Unsafe food storage, poor hand hygiene, and unsanitary kitchen conditions were observed in the dietary dept. Open frozen food was left unsealed, soy sauce requiring refrigeration was stored unrefrigerated, and shortening was kept on the floor. During meal service, staff touched food, equipment, personal items, and trash with bare or soiled gloves, failed to wash hands between tasks, and handled ready-to-eat items improperly. The ice machine had residue buildup and drains without adequate air gaps, and the kitchen floor had heavy food debris and residue under and around equipment.
Surveyors identified multiple failures to maintain a safe, clean, and homelike environment, including resident rooms with holes in drywall, incomplete repairs, and persistent dirt and debris on a resident’s bed sheets despite the resident’s request for linen changes. Hallways had strong urine odors, black scuff marks, and sticky floors, and one room contained piles of trash and food on the floor and food stains on bedding and the mattress. Another room had a persistent urine smell with visible puddles of yellow liquid on the floor and under the bed over an extended period. Additional observations showed missing cove base trim, chipped tiles, loose or missing wardrobe handles, cracked windows, missing shower heads, and significant clutter in several rooms that blocked clear pathways. The Maintenance Director described relying on a binder and verbal reports to learn of issues, while the Administrator stated an expectation that residents have a safe, clean, orderly, and comfortable environment.
Failure to deliver resident mail on regular USPS delivery days. Two residents reported that mail was not received on Saturdays, and one said the BOM picked up mail Monday through Friday. The Administrator stated staff did not deliver mail on Saturdays when the BOM was not the manager on duty, and the BOM was only on duty on weekends about every six weeks.
Medications were not administered as ordered for multiple residents when doses were documented as unavailable during medication passes. Several ordered drugs were listed as unavailable even though matching medications were present in the E-kit, and the record showed no documentation that staff used the E-kit or notified the pharmacy. Residents reported that the facility frequently ran out of scheduled medications, including antibiotics, diabetes injections, and other routine medications.
The facility failed to ensure several residents received needed ADL assistance for bathing, dressing, personal hygiene, and incontinence care. One resident with a hx of stroke had repeated missed or undocumented showers, wore the same clothes across multiple days, and was observed with body odor, greasy hair, and debris on clothing and in hair. Two incontinent residents were observed receiving incomplete pericare, with staff failing to clean all soiled skin areas before replacing briefs or pads. Another resident with severe cognitive impairment had repeated shower refusals and long gaps without documented bathing, with staff and a roommate reporting ongoing hygiene concerns and odors.
Three NAs worked beyond the 4-month CNA training timeframe without documentation of completed CNA training. The DON and Administrator stated the NAs started web-based training, transitioned to in-seat classes, and one was on extended leave; one NA was waiting to test, another had not scheduled the test, and another had not been added back to class. The NAs were still assigned resident care duties, including transfers, incontinence care, and mechanical lift use.
The facility failed to complete annual performance reviews for three CNAs and did not have a process to identify weaknesses or provide regular in-service education based on those reviews. The facility policy required evaluations at 90 days and annually, but the employee files for CNA D, CNA E, and CNA F had no documentation of annual performance evaluations. The Administrator believed the DON or ADON handled the reviews, while the DON said she did not complete formal evaluations or identify weaknesses for education, and the ADON said she did not track CNA evaluations or staff education.
Expired medications and disorganized storage were found on multiple med carts and in medication storage areas. Surveyors observed expired or undated stock and resident-labeled meds, unclear or missing expiration dates, a mixed-in foreign pill in a melatonin bottle, and staff personal items stored with meds. Staff and the DON gave inconsistent accounts of who was responsible for checking carts and storage areas, while the consultant pharmacist said monthly spot checks did not include every medication or the stock room.
Infection Control and EBP Failures During Resident Care Staff failed to follow infection control practices during incontinence care, hygiene, and transfers for several residents. Observations showed CNAs and NAs wearing gloves without hand hygiene, failing to change gloves between dirty and clean tasks, and touching clean surfaces and other residents after contaminated care. For residents with wounds or pressure ulcers, staff also did not consistently wear gowns during high-contact care despite EBP signage and orders for gown-and-glove use.
Failure to Preserve Resident Dignity During Toileting: Staff told a resident with impaired cognition, bowel and bladder incontinence, and dependence for toileting hygiene to urinate and defecate in an incontinence brief instead of assisting with toilet use. The resident said this made him/her feel like nobody cared, and staff interviews confirmed the resident preferred sitting on the toilet for bowel movements and had previously been assisted to use a commode with a hoyer lift.
Failure to Notify Physician and Resident Representative of Change in Condition: A resident with hypotension, impaired cognition, and a care plan to report deterioration had repeated low BP readings and then developed SOB, increased pain, inability to swallow, low O2 sats, weakness, and inability to stand. An LPN documented the decline and oxygen use, but the record did not show timely notification of the physician or the resident’s representative, and a later very low BP reading was also not reported to the charge nurse or physician.
A resident who required extensive assistance with drinking did not have a care plan addressing fluid assistance, and staff repeatedly failed to offer fluids despite the resident’s dry lips, dry mouth, and frequent requests for water. Observations showed the water pitcher was often out of reach, and staff, including an NA and CNA, did not offer fluids when entering the room or providing care to the roommate. Interviews confirmed the resident could not use the call light and needed staff to anticipate and frequently offer fluids.
A resident with PTSD, depression, anxiety, and a history of childhood abuse had PASRR documentation identifying a need for trauma-informed services and behavioral monitoring, but the care plan did not include the resident’s PTSD triggers or interventions to prevent re-traumatization. Staff interviews showed the LPN was unaware of a PTSD trauma assessment, Social Services did not complete one, and the DON stated PTSD and PASRR information should be addressed in the care plan.
A resident with vascular dementia became combative during care, resulting in skin tears, as staff failed to identify behavioral triggers, implement non-pharmacological interventions, or update the care plan. Multiple CNAs and LPNs reported not receiving dementia care training, and key information about the resident's behavioral responses to staff of the same gender was not communicated or documented. The facility did not provide a dementia care policy or evidence of staff training.
The facility failed to provide adequate care for several residents, including maintaining comfortable positioning, nail care, and regular bathing. A resident with hemiplegia was left in an uncomfortable position without repositioning, another had unclean fingernails, and three residents did not receive showers as per their care plans. Staff interviews revealed issues with following up on care refusals and maintaining hygiene standards.
The facility failed to provide adequate staffing, resulting in missed showers and inadequate personal hygiene for residents. Despite an assessment indicating the need for 112 CNA hours per day, the facility consistently fell short, impacting resident care. Interviews with staff confirmed the challenges in maintaining basic care due to insufficient staffing.
A LTC facility failed to maintain a safe medication system, with incidents of tampered morphine and Ozempic insulin, and missing oxycodone from the emergency kit. Policies for storing and handling controlled substances were not followed, with improper documentation of narcotic counts and lack of audits contributing to the deficiencies.
The facility failed to maintain safe and appetizing food temperatures, as residents reported receiving cold meals. Observations confirmed that food temperatures were not within the required range, with soup, milk, tea, and ham sandwich all served at improper temperatures. The Dietary Manager was unsure how to maintain hot food temperatures during service, and beverages were not kept on ice as required.
The facility failed to ensure safe serving of hot beverages, resulting in a third-degree burn for a resident. Additionally, the facility did not adequately implement fall prevention interventions for residents at risk, leading to multiple falls and injuries. Furthermore, residents were unsafely transported in wheelchairs without foot pedals, causing their feet to drag on the floor.
A resident with a history of joint pain and surgical amputation experienced unmanaged pain due to the facility's failure to routinely assess pain and offer PRN medication. Despite being on a pain management program, the resident was not informed about available PRN medication and was not offered it when in pain. Staff interviews revealed a lack of awareness and adherence to pain management protocols, with no documentation of pain scores or PRN medication administration.
A resident with mental illness exhibited inappropriate behaviors, including entering another resident's room without pants and making threatening gestures. The facility failed to implement meaningful interventions or update the care plan to address these behaviors, contributing to ongoing issues. Staff interviews revealed inadequate monitoring and response to the resident's actions.
The facility failed to maintain a clean and homelike environment, with observations of unemptied urinals, poor room maintenance, and a shortage of linens. The DON acknowledged the need for regular urinal checks, but this was not consistently done. Maintenance issues included missing paint, holes, and exposed drywall, while the exterior showed signs of neglect. The facility also faced a linen shortage, impacting resident care.
The facility failed to ensure consistent documentation of residents' code status and proper CPR certification among staff. Multiple residents had discrepancies in their code status across various records, leading to potential confusion in emergencies. Additionally, several shifts lacked staff with valid CPR certifications, and the facility did not have policies to address these issues.
The facility employed an unqualified Activity Director who lacked necessary certifications and training, affecting all 67 residents. The director admitted to having no formal training and was the sole member of the activity department, with no resource person available. The Administrator, new to the facility, was unaware of the director's certification status.
The facility failed to provide adequate nursing staff, resulting in insufficient care for residents, including infrequent showers and delayed response to call lights. A resident reported going without a shower for extended periods, while another did not receive restorative therapy due to the absence of a restorative aide. The facility also lacked consistent RN coverage, relying on agency staff who often did not show up, leading to unmet resident needs.
The facility failed to ensure that CNAs, CMTs, LPNs, and RNs demonstrated competencies in essential care areas as outlined in their facility assessment. Training records for two CNAs showed no evidence of education or competencies in the past year, with only new hire training documented. Interviews revealed confusion and lack of responsibility for tracking and implementing training, with no training schedule or documentation available. The facility's attempt to implement a computer software training system was incomplete, and changes in nursing administration contributed to the lack of documentation.
The facility did not maintain the required RN coverage of at least eight consecutive hours a day, seven days a week, potentially affecting all 67 residents. The facility's assessment highlighted the need for such coverage, but reviews of payroll and staffing sheets showed several days in March, April, and May 2024 without RN hours. The interim DON confirmed reliance on agency RNs for weekends, with instances of no-shows.
The facility failed to ensure the Dietary Manager had the necessary certification and skills to manage food and nutrition services. The DM, hired without the required Certified Dietary Manager certification, lacked training and relevant experience. Interviews with staff, including the Registered Dietitian and Director of Nursing, confirmed the absence of certification. The Administrator was unaware of the DM's certification status, despite expecting compliance with federal requirements.
The facility failed to maintain sanitary conditions in its food service operations, with unlabeled food items, unclean equipment, and improper hand hygiene observed. Staff did not adhere to cleaning schedules, and the ice machine lacked an air gap. The Dietary Manager and Administrator were unaware of these issues, indicating a lack of oversight.
The facility failed to use resources effectively, resulting in numerous deficiencies, including lack of infection control logs, inadequate staff training, and reliance on agency staff. There were inconsistencies in medical records, unsanitary dietary services, and medication errors. The facility also failed to provide adequate care for mobility and range of motion, maintain a homelike environment, and ensure resident rights. Additionally, there was insufficient staffing, lack of oversight for administrative tasks, and failure to conduct thorough investigations of abuse allegations.
The facility did not have a current Quality Assurance and Performance Improvement (QAPI) plan or recent meeting minutes, failing to monitor and evaluate system problems. The Interim Administrator, who began in May, confirmed the absence of a QAPI policy and recent activities, with the last meeting minutes dated January 2023. Staff interviews indicated no recent QAPI committee meetings, and only an outdated outline was found.
The facility failed to implement an effective QAA committee, lacking a QA/QAPI policy and recent meeting minutes. The Interim Administrator, who started recently, found no recent QAPI meetings or active Process Improvement Plans. Staff interviews confirmed the absence of recent QAPI activities, despite expectations for a program with quarterly process improvement activities.
The facility did not maintain an active QAPI committee with required members and quarterly meetings. The Interim Administrator, who started recently, found no QAPI policy or recent meeting minutes, with the last notes dated over a year ago. No staff reported being part of a QAPI committee, and the Interim Administrator had not attended any QAPI meetings since starting.
The facility failed to follow infection control protocols, including Enhanced Barrier Precautions for a resident with a catheter, proper sanitization of glucometers during blood glucose monitoring, and maintenance of oxygen and nebulizer equipment. Additionally, the facility lacked a comprehensive water management plan and did not adhere to tuberculosis testing requirements for residents and new employees.
The facility failed to ensure the interim DON, acting as the infection preventionist, completed the required specialized training in infection prevention and control. Although partial module certifications were provided, a full program completion certificate was not available. The MDS coordinator, who had completed the certification, was not involved in the IPCP program at the facility.
The facility failed to provide mandatory training for all staff on its QAPI program, as revealed through interviews and record reviews. The facility's assessment and new employee training documentation did not include QAPI training. Interviews with staff showed a lack of clarity and responsibility for training oversight, with the Director of Nursing unaware of facility-wide training tracking and the RN Training Coordinator not conducting CNA education. The Interim Director of Nursing confirmed the absence of a training schedule, contributing to the deficiency.
The facility failed to maintain an effective infection prevention and control training program, as evidenced by the absence of documented training and competencies for CNAs hired in 2017 and 2023. Despite the facility's assessment requiring infection control education for all nursing staff, new employee training records lacked this component. Interviews revealed confusion over training responsibilities, with no established training schedule or system in place.
The facility failed to provide the required 12 hours of annual in-service education for CNAs, with no evidence of training or competencies documented for two CNAs. Interviews revealed confusion over responsibility for training, with no clear tracking or schedule in place. The facility's assessment lacked dementia and abuse prevention training.
The facility failed to provide comprehensive behavioral health training for all staff, as required by its assessment. Training was limited to nursing staff, excluding others, and new employee training lacked behavioral health components. Interviews revealed confusion over training responsibilities, with key staff unaware of facility-wide training efforts. The facility was attempting to implement a software training system but had no schedule in place.
The facility failed to address and respond to Resident Council concerns, as evidenced by recurring issues in food quality, laundry, and maintenance without documented follow-up. Residents reported dissatisfaction with dietary issues, medication management, and housekeeping. Interviews revealed that department supervisors did not consistently provide responses, and meeting minutes were not shared with residents.
The facility failed to ensure residents could voice grievances without fear of reprisal, as some residents experienced negative staff responses after filing complaints. Additionally, several residents were unaware of the grievance process, and the Social Services Director could not locate the grievance book, indicating poor record-keeping and communication.
The facility failed to complete required significant change in status assessments (SCSA) for three residents after notable changes in their conditions. These changes included increased dependency, cognitive improvements, and new medical needs, which were not documented in updated MDS assessments. The acting MDS coordinator, working part-time, was unaware of the residents' needs, leading to this oversight.
The facility failed to create comprehensive care plans for three residents, leading to deficiencies in addressing their individual needs. A resident's care plan did not reflect their DNR status or refusal of care, while another's plan lacked interventions for cognitive loss and diabetes. Additionally, a third resident's plan omitted details on transfer assistance and oxygen therapy. Staff interviews revealed issues with care plan updates due to staffing and communication problems.
The facility failed to update care plans for three residents, leading to deficiencies in care. A resident experienced cognitive decline and medication changes without care plan updates. Another resident had multiple falls due to cognitive impairment, with no care plan revisions for fall risk. A third resident's care plan was not updated after a fall causing injuries and missing hearing aids, impacting communication. Staff confusion over care plan responsibilities contributed to these issues.
The facility failed to adhere to professional standards of practice in medication administration and physician order compliance. Medications were left at the bedside without orders for two residents, necessary lab tests were not conducted for a resident, and another resident received oxygen therapy without a physician's order. Additionally, a resident missed several doses of Victoza due to unavailability and authorization issues.
The facility failed to provide adequate ADL assistance and hygiene care for four residents, leading to unshaven whiskers, improper perineal care, and infrequent showers. Residents with impaired cognition and mobility did not receive necessary grooming and hygiene support, as staff did not follow care plans or provide comprehensive personal care.
The facility failed to provide an adequate activity program for residents, particularly those with dementia, due to a lack of scheduled evening and dementia-specific activities. Observations showed residents with severe cognitive impairments had no involvement in activities, despite care plans indicating preferences. The new, untrained Activity Director struggled to balance responsibilities, leading to frequent cancellations and lack of engagement. The DON acknowledged the absence of specific policies and was unsure of evening and weekend offerings.
The facility failed to provide timely podiatry care for three residents, including two with diabetes, resulting in long and uncomfortable toenails. Despite orders and requests for podiatry consultations, residents had not seen a podiatrist in a long time. Staff interviews revealed issues with obtaining podiatry services and staffing challenges, contributing to the deficiency.
Failure to Protect Two Residents From Verbal Abuse by Housekeeper
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from verbal abuse by a staff member, specifically a housekeeper. The facility’s abuse policy states that each resident will be free from abuse, including verbal and mental abuse, and that no abuse or harm of any type will be tolerated. Despite this, on 03/30/26, a housekeeper yelled, screamed, and cursed at two residents while in their shared room. The Assistant Director of Nursing (ADON) heard shouting and cursing, went to the room, and observed the housekeeper shouting obscenities at one of the residents. One resident involved had Alzheimer’s disease, required substantial to maximal assistance with dressing, and needed partial to moderate assistance with bed mobility and was dependent on staff for transfers. The resident’s care plan documented assistance needs with activities of daily living and mobility due to weakness and cognitive impairment. This resident reported that the housekeeper told him/her to “shut up” and used profanity, including the words “fuck,” “damn,” and “shit,” which made the resident feel bad. Multiple staff witnesses, including CNAs and the ADON, described the housekeeper being very close to this resident, yelling, and using phrases such as “Shut the fuck up bitch. I’m trying to do my job,” and “Shut the fuck up,” while the resident was crying and shouting in the room. The second resident involved had a serious mental illness, dependency needs for emotional and physical care, a history of domestic violence in prior marriages, a mood disorder with depression and anxiety, a diagnosis of major depressive disorder with a prior suicide attempt, poor coping skills, a history of trauma, and moderate cognitive impairment. This resident stated that the housekeeper began yelling at the first resident when the first resident was calling for help, and when the second resident told the housekeeper not to talk that way, the housekeeper cursed at him/her, called him/her a “bitch,” and said “damn you.” The second resident reported feeling upset that the housekeeper “picked on” him/her because he/she could not defend himself/herself. The housekeeper’s own written statement confirmed that he/she became increasingly angry at the first resident’s shouting, “snapped,” and screamed and cursed at the resident, corroborating the accounts of verbal abuse toward the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a registered nurse (RN) eight consecutive hours a day, seven days a week. The facility census was 85, and the facility assessment updated 01/09/26 identified RN coverage eight hours per day as a resource needed to provide competent support and care for the resident population every day and during emergencies. The Administrator stated during interview that the facility did not have a policy directly addressing RN coverage. Review of the CMS [NAME] report for Quarter 1, 2026 showed the facility did not meet the eight-hour per day RN requirement on multiple days between 10/19/25 and 01/29/26. Review of RN time sheet punches and schedules from 10/19/25 through 4/14/26 showed no RN coverage on numerous dates in October, November, and December 2025 and January and February 2026, with partial RN coverage on 01/29/26 for 5.28 hours, 03/8/26 for one hour, and 04/02/26 for 7.18 hours. During interviews, the Staffing Coordinator said she notified the DON and Administrator when an RN was not scheduled so they could contact corporate to fill shifts. The DON stated there had not been an RN in the building eight hours each day in the last six to eight months, and the Administrator acknowledged awareness of the RN coverage issue identified on the PBJ report.
Unsafe food storage, poor hand hygiene, and unsanitary kitchen conditions
Penalty
Summary
Staff failed to store food in accordance with professional standards in the dietary department. During the initial tour, an open bag of tater tots and an open bag of breaded fish were found unsealed in the reach-in freezers. In the dry storage room, a half-full gallon bottle of soy sauce labeled to refrigerate after opening was stored unrefrigerated on the shelf, and two boxes containing 35-pound bottles of frying shortening were stored on the floor. Facility policies required food to be tightly sealed, stored at least six inches above the floor, and protected from contamination. Staff also failed to follow proper hand hygiene, glove use, and sanitary food handling during lunch meal service. One cook used bare hands to touch the eating surfaces of bowls and plates, serving utensil handles, meal tickets, cooler door handles, a personal cell phone, shirt, and face, opened and drank from a personal beverage container in the food preparation area, and then handled bread with bare hands without washing hands. Another cook used gloved hands to touch cooler and microwave door handles, handled cheese, removed gloves and put on new gloves without washing hands, removed cooked chicken from the bone and placed it on residents’ plates, picked up a hamburger bun from the floor with gloved hands, and later used bare hands to adjust a stove knob and open a freezer door. A dietary aide picked up a meal ticket from the floor and returned it to the serving counter, turned off the faucet with clean hands after washing, touched and discarded trash without washing hands, and carried clean glasses to the serving area. The dietary department also had sanitation and equipment maintenance issues. The ice machine had dried white drips on the exterior and interior surfaces and a moderate accumulation of moist light-brown and pink residue on the plastic above the ice storage area. The kitchen floor had a heavy accumulation of dark gray residue and food debris under the stove, griddle, fryer, and toaster table, along with moderate brown residue throughout the kitchen, especially in high-traffic areas. In addition, the ice machine drains did not have sufficient air gaps: one drain line was propped above a floor drain with a metal rod and partially blocked by a towel, and another drain line was inserted into a drain pipe connected to a utility sink drain. The Maintenance Supervisor stated he was unaware the drains lacked air gaps.
Failure to Maintain Safe, Clean, and Orderly Environment and Housekeeping Standards
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, including adequate housekeeping and maintenance services. Surveyors observed an occupied resident room with a hole in the drywall under the PTAC unit and visible white spackle on the wall, indicating incomplete repair. In another occupied room, dirt and debris were repeatedly observed on a resident’s bed sheets over multiple days, and the resident stated they wanted staff to change the sheets. On one hallway, surveyors noted a strong urine odor, black scuff marks along the corridor, and a sticky floor, and on another hallway, a strong urine odor was repeatedly noted on several days. In an additional occupied resident room, surveyors observed piles of trash and food on the floor, including an open can of food with a dirty spoon, dirty napkins/Kleenex, food pieces, and food wrappers along the wall and under the bed. Food pieces and stains were also present on the resident’s bedding and mattress. Another occupied room had a persistent urine smell and visible puddles of yellow liquid on the fall mat, floor, and under the bed, which were observed as dried or fresh at different times over two days. These conditions showed that spills and soiled areas were not cleaned promptly as outlined in the facility’s floor-cleaning policy. Further observations over two days revealed multiple maintenance and clutter issues throughout resident rooms and common areas. Several rooms had missing cove base trim, chipped floor tiles, holes in drywall, loose or missing wardrobe handles, cracked windows, and missing shower heads in bathrooms. Some resident rooms contained large areas of accumulated clothes, papers, decorations, boxes, trash, food, and beverages stacked on tables, floors, and refrigerators, leaving no clear pathways around beds or between beds and walls. The soiled utility room had a non-functioning light and missing floor tile, and the lobby guest bathroom had discolored flooring and rust stains on the sink and drain. The Maintenance Director reported that staff encouraged residents to keep clutter-free spaces and that he relied on a binder at the nurses’ station and verbal reports to learn of maintenance issues, and the Administrator stated she expected residents to have a safe, clean, orderly, and comfortable environment.
Failure to Deliver Resident Mail on Regular USPS Delivery Days
Penalty
Summary
The facility failed to ensure residents received mail on regular USPS delivery days, including Saturdays, as required by its Resident Rights policy stating residents have a right to communicate freely and have access to people and services inside and outside the facility. During a group interview, two residents said residents did not receive mail on Saturdays, and one resident stated the Business Office Manager went to the post office to get the mail Monday through Friday. The Administrator later stated facility staff did not deliver mail to residents on Saturdays when the BOM was not the manager on duty, and the BOM was only present as manager on duty on weekends about every six weeks.
Medications Not Administered as Ordered
Penalty
Summary
The facility failed to administer medications as ordered for multiple residents, and the record showed repeated instances where ordered medications were documented as unavailable during medication passes. For Resident #7, physician orders included doxycycline, lidocaine patches, torsemide, potassium chloride, and Trulicity, but the MAR showed several doses were not given because the medications were unavailable. The record also showed no documentation that staff administered medications from the E-kit when available and no documentation that the pharmacy was notified when medications were not available. The resident stated the facility frequently ran out of medications. For Resident #68, ordered medications including bupropion, Protonix, spironolactone, Celebrex, and duloxetine were documented as unavailable on multiple dates across February, March, and April 2026. The E-kit contained substitute or matching medications for several of these orders, but the record showed no documentation that staff administered the medications from the E-kit when the resident’s medications were unavailable. The record also showed no documentation that the pharmacy was notified. The resident stated the facility often ran out of scheduled medications. For Resident #37, ordered medications including pantoprazole, pravastatin, levothyroxine, lidocaine patches, metoprolol succinate, gabapentin, amlodipine, and Eliquis were documented as unavailable on 03/08/26, and levothyroxine was again documented as unavailable on 03/09/26. The E-kit contained several of the ordered medications, but there was no documentation that staff administered them from the E-kit or notified the pharmacy. For Resident #44, pantoprazole, atorvastatin, lisinopril, and later carbidopa-levodopa were documented as unavailable, with no documentation of E-kit administration or pharmacy notification. For Resident #75, weekly semaglutide injections were documented as not administered because the medication was unavailable, and the resident stated the facility had run out of the medication and had not yet received it. For Resident #73, cefpodoxime for UTI was documented as not administered during a medication pass because it was unavailable, and the resident stated staff told him/her they were out of the antibiotic.
Failure to Provide Needed ADL Assistance and Hygiene Care
Penalty
Summary
The facility failed to ensure residents who needed assistance with ADLs received the necessary care and services to maintain good grooming and personal hygiene. In a review of 18 sampled residents, the deficiency involved Residents #60 and #62, and also Residents #31 and #45, who required staff assistance with bathing, dressing, toileting, and hygiene. The facility’s undated ADL policy addressed assisting residents to achieve maximum function, but it did not address bathing/showering, dressing, or clothing changes, and no other related policy was provided upon request. Resident #45 had a history of stroke and was described by a family member as unable to maintain proper hygiene and perform ADLs since the stroke. Shower records showed multiple missed or undocumented showers over several weeks, including periods of six to ten days between showers and several dates with no documentation that staff offered, provided, or refused a shower. During repeated observations, the resident had body odor, disheveled and greasy hair, debris in the hair, white flaky skin on clothing, dried food on pants, and wore the same shirt and pants across multiple days. The resident stated staff help was needed to get in and out of the shower and that clothes needed to be changed daily, while a CNA stated the resident was independent with hygiene and clothing changes and only needed encouragement. Resident #31 was dependent on staff for toileting hygiene and personal hygiene and was incontinent of bowel and bladder. During observation, the resident was incontinent of urine and feces, had a very strong urine smell in the room, and staff performed only partial pericare. The CNA cleaned the frontal and rectal areas but did not clean the buttocks and thighs that were in contact with the urine-saturated pad, then replaced the pad and gown. Resident #62 had similar needs for ADL assistance and incontinence care. During observation, the resident was incontinent of urine and liquid feces, had a strong urine odor in the room, and staff performed frontal and rectal pericare but did not clean the hips or upper buttocks that were in contact with the soiled brief before replacing it. The CNA stated the hips were not visibly wet, but also acknowledged all wet or soiled skin should be cleaned during pericare. Resident #60 was severely cognitively impaired, dependent on staff for showering/bathing and personal hygiene, and always incontinent of bowel and bladder. Shower records showed repeated refusals and multiple dates with no documentation that a shower was offered or refused, including a 10-day gap between documented showers and a later period with no shower or partial bath documented for 25 days. On observation, the resident had disheveled hair, body odor, urine odor in the room, and the roommate reported ongoing concern about the resident not receiving showers and smelling of urine and feces. The roommate said they wore multiple masks while sleeping because of the odors. Staff interviews indicated the resident refused care often, and the DON stated staff should clean all soiled areas during pericare and offer partial baths and continued encouragement when residents refuse showers or clothing changes.
NAs Worked Beyond Training Timeframe Without CNA Completion
Penalty
Summary
The facility failed to ensure that three nurse aides, NA J, NA I, and NA K, completed a CNA training program within four months of hire. The Administrator stated the facility did not have a policy directly addressing the use of NAs and the timeframe to become certified. Review of employee records showed NA J was hired on 08/20/25, NA I on 09/25/25, and NA K on 10/02/25, and none of their files contained documentation showing completion of CNA training within four months of hire. The DON stated that an NA had four months to complete the CNA training program and identified these three NAs as having worked longer than four months without completing training. Facility schedules and staffing sheets showed the three NAs were still working as NAs in April 2026 and were assigned to resident halls. NA J was observed assisting another staff member transfer Resident #62 from bed to wheelchair and was assigned to resident halls E and D. NA I was assigned to resident halls A and E and was observed providing incontinence care for Resident #7 and transferring the resident with a mechanical lift; during interview, NA I said he/she had worked as an NA for eight months, had just completed CNA class, and was waiting to take the certification test. NA K was scheduled and assigned to work as an NA after returning from extended leave, and the Administrator stated NA K had not been added back to the class. The Administrator also stated NA J was supposed to take the test but the test shut off, and NA I had completed classes but had not scheduled the test yet.
Missing CNA Performance Evaluations and Training Review Process
Penalty
Summary
The facility failed to complete annual performance reviews for three CNAs and failed to develop a process to identify weaknesses and provide regular in-service education based on those reviews. The facility policy stated that employee evaluations should be completed 90 days after hire and annually on or near the anniversary date, and the facility assessment stated that competency assessments, performance reviews, observed abilities, and training were completed based on assessment and observation results. However, review of the employee files for CNA D, CNA E, and CNA F showed no documentation of annual performance evaluations. During interviews, the Administrator said she believed the DON or ADON completed annual CNA performance reviews and that staff conducted in-services related to required elements and any identified areas as needed. The DON stated she did not complete formal performance evaluations or reviews for CNAs employed for 90 days or for 12 months or longer, and she had not formally identified any weaknesses to determine what education should be completed. The ADON stated she had not completed any CNA performance evaluations or tracked staff education and had not been told she was responsible for any aspect of CNA performance evaluations.
Expired Medications Found in Carts and Storage Areas
Penalty
Summary
The facility failed to ensure that medications and biologicals stored on the CMT cart for halls B/E/F, in the CMT medication room, in the stock medication room, and on the nurse medication/treatment cart for hall B/D/E were not expired and were stored in an orderly manner. Surveyors observed sticky residue in multiple drawers of the CMT cart, and staff personal items, including keys, were stored with eye drops in the top drawer. The cart also contained an opened stock bottle of Vitamin E with an expiration date of 8/25 and an opened bottle of diphenhydramine/lidocaine/aluminum hydroxide/magnesium hydroxide/simethicone labeled for a resident with an expiration date of 02/20/26. In the CMT medication room and over-the-counter stock/wound care storage room, surveyors found multiple expired items, including an opened bottle of Omega-3 with an expiration date of 03/2026, two opened containers and five unopened containers of Reguloid daily fiber with an expiration date of 02/2026, an opened and an unopened bottle of Lactulose labeled for a resident with an expiration date of 08/31/25, an opened bottle of glucosamine and chondroitin with an expiration date of 03/2025, and six unopened bottles of oyster shell calcium and vitamin D with an expiration date of 07/2025. On the nurse medication/treatment cart for hall B/D/E, surveyors observed an opened bottle of nitroglycerin labeled for a resident with an expiration date of 12/2025, opened and unopened heparin vials labeled for a resident with an expiration date of 03/31/26, an opened in-use Lantus pen that was not dated when opened, an opened stock bottle of acetaminophen 650 mg with an expiration date of 06/2025, an opened stock bottle of melatonin with a white pill intermixed, an opened stock bottle of naproxen sodium with an expiration date of 03/2025, an opened stock bottle of acetaminophen 500 mg with an unclear expiration date, and an opened stock bottle of acetaminophen 325 mg with no expiration date. During interviews, CMT and LPN staff stated that anyone who used the medication carts was responsible for checking for expired medications and keeping the carts clean, but neither was sure who specifically was responsible for expired medications or the exact process for handling them. The DON stated that the DON, ADON, all nursing staff who pass medications, and the pharmacists were responsible for checking medication carts and storage rooms for expired medications, and the consultant pharmacist stated she performed monthly spot checks but did not check every medication in the medication rooms or carts and did not check the stock medication room for expired medications. She stated it was ultimately the facility's responsibility to ensure there were no expired medications in the medication room, medication carts, or stock medication room.
Infection Control and EBP Failures During Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control practices during personal care and incontinence care for multiple residents. Review of the facility’s policies showed that enhanced barrier precautions (EBP) required gown and glove use for high-contact care activities such as hygiene, toileting, changing briefs, and transferring residents, and that gloves were to be changed between residents and between dirty and clean tasks, with hand hygiene performed before care and after glove removal. The report identified failures involving Residents #8, #9, #31, #62, #34, and #7 during direct observation and record review. For Resident #9, who was dependent on staff for toileting and personal hygiene and was always incontinent of bowel and bladder, staff provided incontinence care while wearing gloves but did not perform hand hygiene before donning gloves, did not change gloves or perform hand hygiene between dirty and clean tasks, touched the room doorknob and clean linen cart with contaminated gloves, and carried soiled linens and trash before later pushing another resident in a wheelchair without hand hygiene. For Resident #31, who was incontinent of bowel and bladder and dependent on staff for toileting hygiene and personal hygiene, a CNA performed pericare, handled a saturated pad, then placed a clean pad and gown on the resident and handed the resident items without changing gloves or washing hands, and later removed gloves and covered the resident without hand hygiene. For Resident #62, who was dependent on staff for toileting hygiene and always incontinent of bowel and bladder, a CNA performed pericare, then handled a clean brief and repositioned the resident without changing gloves or washing hands. For Resident #8, who was dependent on staff for toileting and personal hygiene and was incontinent of bladder, staff entered the room wearing gloves without observed hand hygiene, removed a urine-saturated brief, provided perineal care, then continued care and handled soiled linens before performing hand hygiene only after leaving the room. For Resident #34, who had an open wound to the left lower leg and a stage III pressure ulcer present on admission, EBP signage was posted on the door, but staff did not consistently wear gowns during direct care; one RN provided incontinence care and changed a urine-soiled sheet while wearing gloves only, and the ADON entered the room wearing gloves but no gown while assisting with dressing and handling items in the room. For Resident #7, who had an unhealed pressure ulcer and an open area to the right lower extremity and was on antibiotics for cellulitis, staff entered the room wearing gloves but no gown and provided pericare, dressing, and a mechanical-lift transfer despite the EBP sign directing gown and glove use for high-contact care.
Failure to Preserve Resident Dignity During Toileting
Penalty
Summary
The facility failed to treat one resident with dignity and respect when staff told the resident to urinate and defecate in his/her incontinence brief. Resident #8 had moderately impaired cognition, was dependent on staff for toileting hygiene, and was always incontinent of bowel and bladder. The resident’s care plan stated that he/she required staff assistance with ADLs, including toileting, and that he/she was incontinent of bowel and bladder. During interview, the resident said staff used to take him/her to the bathroom in the hall to have a bowel movement, but now staff wanted him/her to use a bed pan or incontinence brief. The resident stated that when staff asked him/her to go in the brief, he/she was left wet or dirty for long periods and was not checked or changed frequently, and that he/she preferred to use the toilet because it was easier to have a bowel movement sitting up. A CNA said the resident required a hoyer lift for transfers and staff sometimes reminded the resident to use the brief because he/she could not walk and became distracted. An LPN said the resident preferred to sit to have a bowel movement and told the resident, "You can go to the bathroom in your brief. You have a brief on." The DON stated she expected staff to treat residents with dignity and respect and that she should not tell the resident to have a bowel movement in the brief or on a bed pan if the resident preferred and was capable of using the toilet.
Failure to Notify Physician and Resident Representative of Change in Condition
Penalty
Summary
The facility failed to follow its policy for notifying the physician and the resident’s representative when a resident had a change in condition. The resident had hypotension, moderately impaired cognition, occasional pain, and was independent with walking and transfers on the quarterly MDS. The care plan directed staff to monitor for deterioration in status and report it to the physician. The physician order required blood pressure monitoring and midodrine for hypotension. The resident’s blood pressures were documented as low on multiple occasions, including 96/50, 96/49, 86/43, and 88/66, with midodrine administered as ordered. On the evening of 02/24/26, an LPN documented that the resident’s friend reported concern about the resident’s decline, shortness of breath, increased pain, inability to swallow, and a temperature that could not be checked. The LPN documented vital signs of BP 128/94, pulse 102, respirations 24, and oxygen saturation 84% on room air, and oxygen was started at 2 liters. The record did not show documentation that the physician or the resident’s representative was notified at that time, and there was no documentation that the day shift nurse had attempted to contact the physician as stated in the note. Later documentation showed further decline. The resident’s oxygen saturation dropped to 87% when talking, and at midnight the resident’s family representative called stating the resident could not get up. Staff found the resident unable to stand as before, bent forward, pale, with oxygen saturation 81%, and asking for his/her parent. The note stated medical group was notified, but it was not clear who was contacted. The record did not show documentation that the resident’s representative was notified of the change in condition. On the morning of 02/25/26, a CMT documented a blood pressure of 53/32, but there was no documentation that the charge nurse or physician was notified. The charge nurse later stated the CMT did not report the low blood pressure, and the resident’s family representative stated staff did not notify him/her of the decline.
Failure to Provide and Plan for Fluid Assistance
Penalty
Summary
The facility failed to implement a hydration program for a resident who required extensive assistance with drinking and failed to include a plan of care addressing the resident’s need for help with fluid intake. The resident’s admission MDS showed the resident was cognitively intact, had moderately impaired vision, and was independent with eating. However, the care plan did not include the type of assistance needed for fluid intake, even though the resident’s comprehensive nutrition assessment later documented extensive assistance with eating/drinking, a total fluid requirement of 1540 mL, and that staff were to anticipate needs. During multiple observations, the resident’s lips and oral mucosa were dry, the resident repeatedly requested water, and the water pitcher was placed on the bedside table but not within reach. On several occasions, staff entered the room or provided care to the roommate without offering the resident fluids. The resident’s family member stated the resident liked to drink a great deal of water, could not take drinks without assistance, and expected staff to offer fluids frequently. Staff interviews confirmed the resident needed assistance with fluids, could not use the call light to request help, and should be offered water every time staff entered the room or more frequently when the resident was calling out for water.
Failure to Identify and Document Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not implemented for one resident with a diagnosis of PTSD. The resident’s PASRR/MI Level II evaluation documented major depressive disorder, anxiety, PTSD, childhood molestation, hopelessness, sadness, anxiety, and prior suicidal thoughts, and it identified a need for monitoring of behavioral symptoms and trauma-informed services and tools of choice or other positive behavioral support services. The resident’s psychiatric mental status exam later showed depression, anxiety, poor sleep, homelessness, hip pain, and statements that he/she sometimes felt suicidal without a plan and felt worthless. The resident’s quarterly MDS listed anxiety, depression, and PTSD, and the care plan addressed risk related to antipsychotic medication, monitoring behavior and medication response, assessing effectiveness, and using non-pharmacological measures such as reducing noise/stimulation, validation therapy, and light exercise. However, the care plan did not document the resident’s PTSD triggers or interventions to prevent further re-traumatization related to the PTSD diagnosis. During interviews, the resident described childhood abuse and molestation, depression, loneliness, and staying in the room except to smoke. Staff interviews showed the LPN was unsure about PTSD history and unaware of an assessment for residents with PTSD or past trauma, the MDS/Care Plan Coordinator said PTSD history and PASRR information should be included in the care plan, Social Services said she arranged psychiatric care but did not complete a trauma assessment, and the DON stated the admission nurse should assess for trauma and that PASRR information and PTSD should be addressed on the care plan.
Failure to Identify and Address Dementia-Related Behaviors and Provide Staff Training
Penalty
Summary
The facility failed to provide appropriate care and services to maintain the highest practical well-being for a resident with vascular dementia. Staff did not identify or document triggers that led to the resident's aggression and combativeness, nor did they implement or document non-pharmacological interventions to address these behaviors. During an incident, staff continued to provide incontinence care and transferred the resident using a sit-to-stand lift while the resident was actively combative, resulting in the resident sustaining skin tears. The care plan was not updated to reflect the resident's behavioral responses or to provide individualized interventions related to dementia care. Multiple staff interviews revealed that several CNAs and LPNs had not received dementia care training upon hire and lacked direction on how to manage the resident's aggressive behaviors. Some staff were unaware of how to access care plans, and others relied on verbal reports to learn about resident care needs. Staff also reported that the resident was only aggressive with certain staff members, particularly those of the same gender, but this information was not communicated to facility leadership or reflected in the care plan. The psychiatric nurse practitioner was not informed of the resident's behavioral issues, and the care plan coordinator acknowledged that the care plan should have been updated after the incident. The facility did not provide a dementia care policy when requested, and there was no evidence that staff had received or understood dementia care training. The lack of communication, training, and individualized care planning contributed to the failure to address the resident's behavioral symptoms and ensure staff were equipped to manage dementia-related behaviors safely and effectively.
Deficiencies in Resident Care and Hygiene
Penalty
Summary
The facility failed to provide necessary care and services for several residents, leading to deficiencies in maintaining comfortable positioning, nail care, and bathing. Resident #4, who was admitted post-stroke with flaccid hemiplegia, was observed in an uncomfortable position in bed with legs hanging off the foot of the bed and was not repositioned by staff despite expressing discomfort. The resident was also left with a towel to clean up urine spills, indicating inadequate incontinence care. Resident #10, who required setup assistance for personal hygiene, was found with brown debris under the fingernails, which the resident was unaware of and upset about. This indicates a lack of attention to personal hygiene needs by the staff. Additionally, the facility's policy on nail care, especially for diabetic residents, was not adhered to, as there was no evidence of licensed nurses cutting the resident's fingernails. Residents #1, #5, and #14 did not receive showers as per their care plans, which specified twice-weekly showers. The records showed significant gaps between showers, and interviews with residents and staff confirmed that showers were often missed due to staffing issues. Resident #5's roommate noted that showers were infrequent, and Resident #14 reported not receiving showers twice a week. Staff interviews revealed that when residents refused showers, there was no consistent follow-up to ensure they received care, contributing to the deficiency in maintaining hygiene standards.
Staffing Shortages Lead to Inadequate Resident Care
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, particularly in the area of bathing. The facility's assessment indicated that with an average census of 60 residents, 112 certified nurse aide (CNA) hours per day were required. However, a review of the facility's daily staffing sheets from late December to mid-January showed consistent shortfalls in CNA hours, with deficits ranging from 7 to 44 hours per day. This staffing inadequacy directly impacted the care provided to residents, as evidenced by missed showers and inadequate personal hygiene. Three residents were specifically noted to have been affected by the staffing shortages. One resident, who required moderate assistance with showering, did not receive showers twice a week as scheduled, with gaps of up to 11 days between showers. Another resident, who preferred showers to bed baths, was only offered showers sporadically, with refusals noted but also significant gaps between offered showers. A third resident, who required supervision for bathing, also experienced long intervals between showers, sometimes up to nine days. Interviews with staff, including nurse aides and licensed practical nurses, confirmed the staffing issues, with reports of missed showers and difficulty in providing basic care such as hair brushing and incontinence care. The Director of Nursing and other administrative staff acknowledged challenges in filling open slots on the nursing schedule and were unaware of the specific staffing requirements outlined in the facility assessment. The administrator expected sufficient staffing to provide quality care but was uncertain if the responsible staff knew the required hours per discipline.
Medication Tampering and Documentation Failures in LTC Facility
Penalty
Summary
The facility failed to maintain a safe and effective medication system, as evidenced by several incidents involving tampered medications and improper documentation of narcotic counts. Morphine prescribed for two residents was found to have unusual smells, indicating tampering, and a card of oxycodone was missing from the facility's emergency medication kit. Additionally, an Ozempic insulin pen for another resident was tampered with and replaced with a different type of insulin. These incidents highlight significant lapses in medication security and monitoring. The facility's policies for storing and handling medications, particularly controlled substances, were not adequately followed. Controlled substances were not consistently stored under double lock and key, and the required narcotic counts at shift changes were not properly documented. Interviews with staff revealed that medication counts were often not conducted due to the absence of available personnel to perform the task together, leading to discrepancies in the controlled substance shift change log. The facility's failure to audit medication carts and the Stat Safe emergency medication kit contributed to the deficiencies. The consultant pharmacist discovered the missing oxycodone during a routine visit, and it was noted that a nurse could access the Stat Safe without a witness. The lack of oversight and adherence to policies for medication administration and documentation resulted in multiple instances of medication tampering and missing narcotics, compromising resident safety.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food items at a safe and appetizing temperature, as observed during a survey. The facility's policy requires hot foods to be served at no less than 120 degrees Fahrenheit and cold foods at no greater than 40 degrees Fahrenheit. However, during meal service, residents reported receiving cold meals, and observations confirmed that food temperatures were not maintained within the required range. Specifically, a test tray showed soup at 118 degrees Fahrenheit, milk at 62 degrees Fahrenheit, tea at 60 degrees Fahrenheit, and ham on a sandwich at 52 degrees Fahrenheit. These temperatures were below the facility's standards for hot foods and above the standards for cold foods. Interviews with residents revealed consistent complaints about receiving cold meals, particularly when meals were served in their rooms. The Dietary Manager acknowledged the issue, noting that the soup was initially at 165 degrees Fahrenheit before service but was unsure how to maintain the temperature during service. Additionally, beverages were not kept on ice as required, contributing to the improper temperatures. The Administrator confirmed that beverages should be kept on ice and meals should be served in a timely manner to ensure proper temperatures.
Deficiencies in Hot Beverage Service, Fall Prevention, and Wheelchair Transport
Penalty
Summary
The facility failed to ensure the safe serving of hot beverages, resulting in a third-degree burn for a resident. The resident, who was cognitively intact but had limited range of motion, was served hot water in a large Styrofoam cup, which was placed out of reach. As the resident attempted to pull the overbed table closer, the cup tipped over, spilling hot water onto the resident's leg. The facility did not have a policy for hot liquid service, and staff training did not include instructions on placing trays or allowing drinks to cool before serving. The facility also failed to implement and modify fall prevention interventions for residents at risk of falls. One resident with a history of falls and moderate cognitive impairment experienced multiple falls, resulting in injuries such as a dislocated shoulder and lacerations. Despite these incidents, the resident's care plan was not updated to address the fall risk adequately. Another resident with severe cognitive impairment and a history of falls was not provided with a care plan that addressed their fall risk, leading to multiple falls and injuries. Additionally, the facility did not safely transport residents in wheelchairs, as staff pushed residents without foot pedals, causing their feet to drag on the floor. This practice was observed with multiple residents, and staff were unaware of the location of the foot pedals. The facility's policy on wheelchair use did not address the importance of using foot pedals during transport, contributing to the unsafe transportation of residents.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide adequate pain management for a resident with a history of joint pain, surgical amputation, and phantom leg pain. The resident was on a pain management program that included scheduled and PRN opioids, but the facility did not routinely assess the resident's pain as ordered. The resident frequently experienced pain that interfered with daily activities and expressed agitation and difficulty sleeping due to pain. Despite having PRN pain medication available, the resident was not informed of this option and was not offered additional medication when complaining of pain. Interviews with the resident revealed that their pain was never controlled, and they were unaware of the availability of PRN medication. Observations showed the resident in distress, rocking back and forth in their wheelchair, and expressing frustration about their unmanaged pain. The facility's medication administration record (MAR) lacked documentation of PRN medication administration and pain scores, indicating a failure to follow physician orders for pain assessment every shift. Staff interviews highlighted a lack of awareness and adherence to pain management protocols. Certified Medication Technicians (CMTs) responsible for the resident's care did not document pain scores or offer PRN medication, as they believed the resident was simply agitated and did not request it. The Director of Nursing (DON) acknowledged the expectation for staff to follow physician orders and assess pain, but was unaware of the resident's ongoing pain issues and inability to sleep.
Failure to Provide Appropriate Behavioral Interventions for Resident with Mental Illness
Penalty
Summary
The facility failed to provide appropriate person-centered and individualized treatment and services to a resident with mental illness, resulting in multiple incidents of inappropriate behavior. The resident, who had a history of schizoaffective disorder, major depressive disorder, anxiety disorder, and a history of trauma, exhibited behaviors such as entering another resident's room without pants, lighting a cigarette indoors, and making threatening gestures towards other residents. Despite these behaviors, the facility did not implement meaningful interventions or ensure the resident received services to address these behaviors. The resident's care plan was not adequately updated to address ongoing inappropriate sexual behaviors and aggressive actions towards peers. The facility's interventions were insufficient, as evidenced by the resident's continued inappropriate actions, including touching other residents inappropriately and attempting to choke a roommate. The facility's lack of a comprehensive behavior management policy and failure to implement non-pharmacological interventions contributed to the deficiency. Interviews with staff revealed that the resident's behaviors were often triggered by urinary tract infections, yet the facility's response was limited to encouraging fluid intake. The facility did not consistently monitor the resident's interactions with peers, and staff were not always present to redirect the resident during negative behaviors. The facility's failure to provide a structured environment and consistent routines, as recommended in the resident's PASRR II assessment, further contributed to the deficiency.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple observations of poor housekeeping and maintenance practices. In several resident rooms, urinals were not emptied or replaced as per physician orders, leading to unpleasant odors. The Director of Nursing acknowledged that urinals should be checked and emptied regularly by staff, but this was not consistently done. Additionally, the facility lacked a homelike environment policy, and the housekeeping department was short-staffed, contributing to the inadequate cleanliness and maintenance of resident rooms. Numerous observations revealed significant maintenance issues throughout the facility. Resident rooms had walls with missing paint, holes, and exposed drywall, while bathroom fixtures were stained and in disrepair. The facility's exterior also showed signs of neglect, with rotted trim boards, missing paint, and loose siding. The maintenance director admitted to being aware of some issues but was unable to address them due to budget constraints and lack of resources. The housekeeping supervisor noted that vents were cleaned monthly, but the buffer machine needed for floor maintenance was broken, further hindering cleaning efforts. The facility also faced a shortage of linens, impacting the ability to provide adequate resident care. Linen carts and closets were often empty or contained insufficient supplies, forcing residents to wait for bed changes or use their own linens. The laundry supervisor reported a decrease in available linens, suspecting that agency staff might be discarding them. Despite notifying the previous administrator about the shortage, no action was taken to address the issue. The current administrator acknowledged the lack of a linen policy and was unaware of any requests for additional linens from the supplier.
Inconsistent Code Status Documentation and CPR Certification Deficiencies
Penalty
Summary
The facility failed to ensure systems were in place to clearly document residents' code status and communicate this information to direct care staff. This deficiency was identified for multiple residents, where inconsistencies were found between the residents' face sheets, care plans, physician order sheets (POS), paper charts, and the facility's 24-hour daily nursing reports. For instance, one resident's face sheet did not indicate a code status, while their care plan and POS showed a full code status, yet the 24-hour daily nursing report indicated a DNR status. Such discrepancies were prevalent across several residents, leading to potential confusion about whether to perform CPR in emergencies. The facility also failed to ensure that a staff member with the required CPR certification was scheduled for each shift. The survey revealed that several shifts lacked staff with valid CPR certifications, and some staff members' CPR certifications did not meet the requirements for basic life support (BLS) for healthcare providers. Interviews with staff members highlighted a lack of clarity and consistency in identifying residents' code status, with some relying on outdated or incorrect documentation. Additionally, the facility did not have policies regarding staff CPR certification, scheduling for CPR coverage, or code status documentation. The Director of Operations confirmed the absence of such policies, and the Director of Nursing acknowledged the inconsistencies in code status documentation and the lack of verification of agency staff CPR credentials. This lack of policy and oversight contributed to the deficiencies observed during the survey.
Unqualified Activity Director Lacks Certification and Training
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, affecting all 67 residents. The current Activity Director had not completed an approved activity professional training program and lacked both state certification and certification in therapeutic recreation or activities. The facility was unable to provide job title responsibilities and qualifications for the Activity Director, only providing a job description for an assistant activity director. The employee list confirmed that the department head was the Activity Director, yet her file showed no relevant certifications. Interviews revealed further deficiencies in the activity program. The Activity Director admitted to having no formal training in activities and split her time between activities and resident transportation. She was the sole member of the activity department and had no resource person to assist her. She also expressed a lack of knowledge regarding appropriate activities for residents with dementia. The Director of Nursing indicated that the administrator was responsible for ensuring staff certifications. However, the Administrator, who was new to the facility, was unaware of the Activity Director's certification status and expected a certified director to oversee and train her until certification was obtained.
Staffing Shortages and Inadequate Care in LTC Facility
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of its residents, as evidenced by the lack of routine showers and timely response to call lights for certain residents. Specifically, Resident #61 did not receive regular showers, leading to poor personal hygiene and body odor. The resident expressed dissatisfaction with the infrequency of showers and the lack of staff to change bed sheets. Additionally, Resident #41 reported delays in receiving assistance, including waiting an hour for help and not receiving restorative therapy due to the absence of a restorative aide. The facility also did not maintain the required staffing levels, including the absence of a Registered Nurse (RN) for eight consecutive hours a day, seven days a week. The facility's staffing records showed multiple days without RN coverage, and the Director of Nursing (DON) confirmed that the facility relied heavily on agency staff, who often did not show up for work. This staffing shortage affected the delivery of care, as residents reported delays in receiving medications and assistance with activities of daily living. Furthermore, the facility's restorative nursing program was discontinued after the restorative aide left, leaving residents without necessary therapy. The therapy director and DON confirmed that the program was halted due to the lack of trained staff. The facility's failure to maintain adequate staffing and provide necessary care and services as outlined in the facility assessment contributed to the deficiencies observed during the survey.
Failure to Ensure Staff Competency and Training
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies to care for residents, as outlined in their facility assessment. The assessment, updated on 5/20/24, specified that all Certified Nurse Assistants (CNAs), Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to demonstrate competencies in various areas such as activities of daily living, mobility, fall prevention, bowel and bladder care, skin integrity, mental health, medication and pain management, infection control, management of medical conditions, therapy, special care needs, nutrition, and person-centered care. However, the facility did not provide evidence of education, testing, or return demonstrations for these competencies. The report highlighted specific deficiencies in the training records of two CNAs. CNA C, hired on 12/5/17, and CNA PP, hired on 4/17/23, both lacked documentation of education hours or competencies in the past year. The only training documented for both was their new hire training, which did not include any competencies. Interviews with the Interim Director of Nursing, Social Service Director (SSD), RN Training Coordinator/MDS Coordinator, and Business Office Manager revealed a lack of clarity and responsibility regarding the tracking and implementation of training and competencies for CNAs and other staff. The Interim Director of Nursing admitted that the facility was attempting to implement a computer software training system, but it had not been accomplished. There was no training schedule in place, and the documentation of training and competencies was either missing or could not be located. The facility had undergone changes in nursing administration, which contributed to the confusion and lack of documentation. The report indicates a systemic failure in maintaining and verifying staff competencies, which is crucial for ensuring the well-being of residents.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, which had the potential to affect all 67 residents. The facility's assessment, updated on May 20, 2024, indicated the necessity of RN coverage for eight hours daily. However, a review of the facility's RN payroll and agency staffing sheets revealed multiple instances in March, April, and May 2024 where there was no evidence of RN hours, specifically on March 4, 9, 10, and 31, April 19, and May 18, with insufficient hours on April 5. During an interview, the interim Director of Nursing stated she was the only full-time RN, and the facility relied on agency RNs for weekends, but there were occasions when agency RNs did not show up.
Dietary Manager Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager (DM) possessed the necessary competencies and skills to fulfill the responsibilities of the food and nutrition services department. The DM, hired on January 23, 2023, lacked the required certification as a Certified Dietary Manager, a federal requirement for long-term care facilities. Additionally, there was no evidence of certification as a certified food service manager, national certification for food service management, or documentation of an associate's or higher degree in food service management or hospitality. The DM also did not have two or more years of experience in the position of director of food and nutrition services in a nursing facility setting. The only certification present was a State Food Safety Food Protection Manager Certification, which does not meet the dietary manager certification requirements. Interviews with facility staff revealed that the DM had not received any training related to the position and had only attended a food safety course. The Registered Dietitian, who visits the facility monthly, confirmed that the DM was not certified. The Director of Nursing acknowledged the lack of certification, stating that it was the administrator's responsibility to ensure staff certifications. The Administrator expressed an expectation for the DM to be certified and, if not, to be supervised by a certified Dietary Manager or Dietitian until certification was obtained. However, the Administrator admitted to not being aware of the DM's certification status due to his short tenure at the facility.
Sanitation and Hygiene Deficiencies in Food Service Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in its food service operations, as observed during a survey. Staff did not label and date opened food items in the kitchen refrigerator, including sandwiches and pudding, which is against the facility's food storage guidelines. Additionally, the ice machine was not properly cleaned, with scaly material and slime observed, and lacked an appropriate air gap at the drain, which is necessary for sanitary conditions. The Maintenance Director was unaware of the missing air gap and the Dietary staff were behind on checking items for labeling and dating. The kitchen and food preparation areas were found to be in unsanitary conditions, with slime and debris in the steam table, oil and debris on the sneeze guard, and a buildup of oily material on various kitchen surfaces and equipment. The cleaning schedules were not adhered to, as evidenced by the presence of dust, debris, and oily material on kitchen hoods, fire suppression systems, and other surfaces. Dietary staff admitted to not completing cleaning tasks due to time constraints, and the Dietary Manager was unaware of the extent of the cleanliness issues due to a recent absence. Improper hand hygiene and glove use were also observed, with staff failing to wash hands before putting on gloves and using the same gloves for multiple tasks. Staff entered the kitchen without hairnets and handled food without washing hands, which is against the facility's handwashing and glove use guidelines. The Dietary Manager and Administrator were not fully aware of these issues, indicating a lack of oversight and adherence to sanitary practices in the facility's food service operations.
Facility Fails to Use Resources Effectively, Leading to Multiple Deficiencies
Penalty
Summary
The administration of the facility failed to effectively use its resources to ensure the highest practicable well-being of its residents. Observations during the survey period revealed numerous deficiencies, including the absence of infection control logs, lack of yearly staff education on dementia care, abuse, and neglect, and failure to provide required training hours for certified nursing assistants. The facility also lacked an organized Quality Assurance and Performance Program (QAPI) and relied entirely on agency staff for licensed nursing positions, with no permanent licensed nursing staff hired. Additionally, there were inconsistencies in residents' cardiopulmonary resuscitation status across medical records, unsanitary dietary services, and medication administration errors. Further deficiencies included inadequate management of foot care, failure to prevent decline in mobility and range of motion, inconsistent protective oversight, and insufficient supplies such as linens. The facility did not consistently provide assistance with activities of daily living, follow infection control measures, or offer an activities program that met the needs of all residents. There was a lack of proper certification for key staff roles, failure to ensure resident rights, and grievances were not being addressed. The facility also failed to provide oversight for various administrative tasks, such as completing Advance Beneficiary Notices and notifying residents about trust account balances. The physical environment was not maintained, and there was insufficient staffing to meet residents' needs. Additionally, the facility did not conduct thorough investigations of abuse allegations or ensure timely and accurate assessments. Pharmacy reviews were not being received or followed up on, and the facility had experienced significant turnover, relying heavily on agency staffing.
Lack of QAPI Plan and Implementation
Penalty
Summary
The facility failed to establish and implement a Quality Assurance and Performance Improvement (QAPI) plan to monitor and evaluate system problems, as evidenced by the absence of a current QAPI policy or recent meeting minutes. The facility, with a census of 67, did not provide a QAPI policy when requested by the state agency. The last available QAPI meeting minutes were dated January 2023, and no current, facility-specific QAPI plan was found in the provided binder. The Interim Administrator, who started on May 7, 2024, confirmed that the facility lacked a QAPI policy, recent minutes, or completed QAPI information. Interviews with current staff revealed that no one recalled recent QAPI committee meetings, and the Interim Administrator only found an outline of what to do, which he was unsure was current. He expected the facility to have a QAPI program with process improvement activities meeting quarterly with appropriate team members.
Failure to Implement Effective QAA Committee
Penalty
Summary
The facility staff failed to implement an effective Quality Assessment and Assurance (QAA) committee to address and resolve identified concerns. The facility, with a census of 67, did not provide a Quality Assurance (QA)/QAPI policy when requested. A binder labeled QAPI, reviewed on May 23, 2024, contained meeting minutes last dated January 2023. The Interim Administrator, who began on May 7, 2024, confirmed that the facility lacked a QAPI policy and recent meeting minutes. Interviews with current staff revealed no recent QAPI meetings or active Process Improvement Plans. The Interim Administrator expected the facility to have a QA/QAPI program with quarterly process improvement activities involving appropriate team members.
Lack of Active QAPI Committee and Meetings
Penalty
Summary
The facility failed to maintain an active Quality Assurance and Process Improvement (QAPI) committee with the required members and quarterly meetings. The facility, with a census of 67, did not provide documentation of a QAPI policy or recent meeting minutes. The last available QAPI meeting notes were dated over a year ago. The Interim Administrator, who started on 5/7/24, confirmed that no QAPI policy or recent minutes were available and that no staff reported being part of a QAPI committee. The Interim Administrator expected the QAPI program to include the Administrator, Director of Nursing, several floor staff, department heads, medical director, pharmacist, and dietitian, meeting at least quarterly. However, he had not participated in any QAPI meetings since his tenure began.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols for multiple residents, leading to several deficiencies. For Resident #20, who had an indwelling urinary catheter, staff did not follow Enhanced Barrier Precautions (EBP), as they were unaware of what EBP entailed and did not use gowns during care. This resident had a history of urinary tract infections and returned from the hospital with antibiotics, yet the staff did not implement the necessary precautions to prevent further infections. Additionally, the facility did not follow proper infection control practices during blood glucose monitoring for several residents. The staff failed to sanitize the glucometer appropriately and did not place it on a clean surface after use. This oversight occurred repeatedly across different residents, indicating a systemic issue with the procedure for blood glucose monitoring. The facility also neglected to maintain proper infection control regarding oxygen and nebulizer equipment. Oxygen tubing was not changed as ordered, and nebulizer equipment was not cleaned according to facility policy. Furthermore, the facility did not have a comprehensive water management plan to prevent Legionella, and there were lapses in tuberculosis testing for both residents and new employees, with some tests not being administered or documented correctly.
Inadequate Training for Infection Preventionist
Penalty
Summary
The facility failed to ensure that the designated infection preventionist (IP) completed the required specialized training in infection prevention and control. The interim Director of Nursing (DON) was serving as the IP after the departure of the previous DON and assistant director of nursing (ADON). Although the interim DON claimed to have completed the Infection Prevention Control Program (IPCP), the facility was unable to provide a certificate of completion for the entire program, only partial module certifications were available. This deficiency affected all 67 residents in the facility. Additionally, the facility's policy required the selection of an Antibiotic Stewardship Champion (ASC) who would be responsible for implementing and maintaining the antibiotic stewardship program, with certification through the CDC. However, the MDS coordinator, who had completed the IPCP certification, was only employed part-time for MDS assessments and had not been involved in the IPCP program at the facility. The MDS coordinator provided her certificate to the facility for potential future assistance, but no direct involvement in the IPCP was noted at the time of the survey.
Failure to Provide Mandatory QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training for all staff on its Quality Assurance and Performance Improvement (QAPI) program. This deficiency was identified through interviews and record reviews, revealing that the facility did not include QAPI training in its new employee training or ongoing staff education. The facility's assessment, updated on 5/20/24, outlined various staff education and competencies but did not address QAPI training. Additionally, the new employee training documentation lacked any mention of QAPI training, focusing instead on topics like resident rights, abuse prevention, and company policies. Interviews with facility staff highlighted a lack of clarity and responsibility regarding training oversight. The Director of Nursing was unaware of any facility-wide training tracking beyond new hire training. The Social Service Director, who previously tracked CNA and NA training, no longer did so, and the RN Training Coordinator/MDS Coordinator stated she did not conduct CNA education or competencies. Furthermore, the Business Office Manager confirmed the absence of QAPI training records for specific employees. The Interim Director of Nursing acknowledged the facility's attempt to implement a computer software training system, which had not yet been accomplished, and confirmed the absence of a training schedule. This lack of structured training and oversight contributed to the facility's failure to ensure all staff received mandatory QAPI training, as required.
Deficiency in Infection Control Training Program
Penalty
Summary
The facility failed to maintain an effective infection prevention and control training program for its staff, as evidenced by the lack of documented training and competencies in the employee education files of two Certified Nurse Assistants (CNAs) hired in 2017 and 2023. The facility's assessment indicated that all CNAs, Certified Medication Technicians (CMTs), Licensed Practical Nurses (LPNs), and Registered Nurses (RNs) were required to undergo education and return demonstrations to assess their abilities in infection prevention and control. However, the new employee training records reviewed did not include infection control training, despite the facility's stated requirements. Interviews with various staff members revealed a lack of clarity and responsibility regarding the tracking and implementation of infection control training. The Director of Nursing was unaware of who was responsible for facility-wide training beyond new hires, while the Social Service Director and RN Training Coordinator/MDS Coordinator both indicated they did not track or conduct CNA training or competencies. Additionally, the facility was in the process of implementing a computer software training system, but this had not yet been accomplished, and there was no established training schedule in place.
Deficiency in CNA Training and Competency Documentation
Penalty
Summary
The facility failed to ensure that Certified Nurse Assistants (CNAs) received the required 12 hours of in-service education annually. This deficiency was identified through interviews and record reviews, which revealed that two CNAs, hired on different dates, did not have any documented evidence of education hours or competencies in the past year. The facility's assessment, updated in May 2024, outlined various staff education and competencies but did not address dementia training or annual abuse and neglect prevention training. Interviews with facility staff highlighted a lack of clarity and responsibility regarding the tracking and provision of CNA training. The Director of Nursing initially indicated that the Social Service Director was responsible for tracking training hours and competencies, but the Social Service Director stated that the RN Training Coordinator was handling CNA training. However, the RN Training Coordinator confirmed that she did not conduct any CNA education or competencies, nor did she perform annual training for CNAs. Further interviews revealed that the facility was attempting to implement a computer software training system, but this had not been accomplished. The Interim Director of Nursing mentioned that there was no training schedule in place and that while some training documentation was completed earlier in the year, changes in nursing administration led to uncertainty about the current status of training records and staff attendance.
Deficiency in Behavioral Health Training for Facility Staff
Penalty
Summary
The facility failed to maintain a comprehensive training program for all staff, specifically lacking in behavioral health care and services training. The facility's assessment, updated in May 2024, outlined the need for staff education in managing mental health and behavioral issues, including psychiatric symptoms, cognitive impairments, and other psychiatric diagnoses. However, the training was only identified for nursing staff, excluding other facility staff. The new employee training program also did not include behavioral health training, which was a requirement according to the facility assessment. Interviews with various staff members, including the Director of Nursing, Social Service Director, and RN Training Coordinator, revealed a lack of clarity and responsibility regarding the tracking and implementation of training programs. The Director of Nursing was unaware of any facility-wide training beyond new hire training, and the Social Service Director no longer tracked CNA training. The RN Training Coordinator confirmed that she did not conduct CNA education or competencies, nor did she handle annual training for all employees. The Business Office Manager confirmed the hire dates of CNAs but did not have additional training information. The Interim Director of Nursing acknowledged the absence of a training schedule and the ongoing attempt to implement a computer software training system.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to consistently address and respond to concerns brought forth by the Resident Council, as evidenced by the lack of documentation and follow-up on issues raised during council meetings. The facility's grievance protocol, which outlines the responsibilities of the Social Services Director (SSD) and the administrator in handling grievances, was not effectively implemented. The Resident Council Meeting Minutes from February, March, and April 2024 highlighted recurring issues such as inadequate food quality, unresolved laundry problems, and maintenance concerns, with no documented follow-up or resolution. Interviews with residents and staff revealed that department supervisors did not consistently provide responses to the Resident Council's questions or recommendations, and meeting minutes were not shared with the residents. Residents expressed dissatisfaction with various aspects of their care, including dietary issues, medication management, and housekeeping. Specific grievances included bland and improperly cooked food, missing laundry items, and insufficient housekeeping staff. Additionally, maintenance issues such as broken beds and wheelchairs, and the need for air conditioner filter replacements were reported. Despite these ongoing concerns, the facility did not maintain a consistent process for addressing and resolving grievances, as the Activities Director did not follow up for responses from department supervisors, and the administrator's expectations for timely responses were not met.
Failure to Ensure Safe Grievance Process
Penalty
Summary
The facility failed to ensure that residents could voice grievances without fear of discrimination or reprisal. Two residents expressed concerns about the negative response from staff after filing grievances. One resident reported that staff made derogatory comments after a grievance was filed, and another resident expressed fear of retaliation, indicating a lack of a safe environment for voicing concerns. Additionally, the facility did not adequately inform residents about the grievance process. Several residents were unaware of how to file a grievance or that they could file directly with the state agency. This lack of information suggests that the facility did not effectively communicate the grievance procedures to its residents, which is a critical component of ensuring residents' rights are upheld. The Social Services Director, responsible for managing grievances, was unaware of certain grievances and could not locate the grievance book, which was found damaged and unreadable. This indicates a failure in maintaining proper records and oversight of the grievance process, further contributing to the deficiency in handling resident grievances appropriately.
Failure to Complete Significant Change Assessments
Penalty
Summary
The facility failed to complete a significant change in status assessment (SCSA) Minimum Data Set (MDS) for three residents within the required 14-day period after a significant change in their condition was identified. This deficiency was observed in a review of 24 sampled residents. The facility did not perform the necessary assessments to document changes in the residents' physical or mental conditions, which impacted multiple areas of their health status and required an interdisciplinary review and revision of their care plans. For Resident #54, the facility did not complete an SCSA despite significant changes in the resident's condition, including a decline in cognitive and physical abilities, the need for oxygen therapy, and a shift to comfort care only. The resident, who previously exhibited independence in certain activities, became dependent on staff for all care and was placed on oxygen therapy. These changes were not reflected in an updated MDS, indicating a failure to reassess and adjust the care plan accordingly. Resident #42 experienced a significant increase in cognitive ability, a decrease in pain, and changes in mobility and restraint use, yet the facility did not complete an SCSA to document these improvements. Similarly, Resident #52 showed increased dependency in activities of daily living, a rise in incontinence and falls, and new diagnoses, but the facility failed to conduct an SCSA. The acting MDS coordinator, who was only present part-time, admitted to not being fully aware of the residents' needs and not completing the necessary assessments, contributing to the oversight.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop person-centered comprehensive care plans for three residents, leading to deficiencies in meeting their individual needs. For Resident #20, the care plan did not reflect the resident's preferred Do Not Resuscitate (DNR) status, despite it being documented in the resident's out-of-hospital DNR form. Additionally, the care plan lacked documentation of the resident's repeated refusals of catheter and peri-care, which were noted in multiple progress notes. Interviews with staff revealed that the resident often refused care from certain staff members, yet this was not addressed in the care plan. Resident #68's care plan was found lacking in addressing the resident's cognitive loss/dementia and diabetes, despite these conditions being documented in the resident's medical records and physician orders. The resident's admission and quarterly Minimum Data Set (MDS) assessments indicated severe cognitive impairment and diabetes, yet the care plan did not include any problems, goals, or interventions related to these diagnoses. This oversight suggests a failure to incorporate critical health information into the care planning process. For Resident #4, the care plan did not include necessary details on how the resident was to transfer, despite requiring substantial assistance for transfers as indicated in the MDS. Furthermore, the care plan did not document the resident's need for oxygen therapy or the discontinuation of restorative nursing services, which were noted in the physician orders. Interviews with facility staff revealed a lack of clarity and responsibility in updating care plans, with the Director of Nursing acknowledging that care plans were not being updated due to staffing issues and lack of communication.
Failure to Update Care Plans for Residents
Penalty
Summary
The facility failed to update the comprehensive care plans for three residents, leading to deficiencies in their care. Resident #17 experienced a significant decline in cognitive function, increased assistance needs, and changes in medication, including the addition of an antidepressant and pain management drugs. Despite these changes, the resident's care plan was not updated to reflect the new cognitive status, medication regimen, or the removal of an indwelling urinary catheter. Observations showed the resident's condition had changed, yet the care plan remained outdated. Resident #52 had multiple falls, some resulting in injuries, due to severe cognitive impairment and attempts to assist a family member who was also a resident. The care plan did not address the resident's fall risk or the need for increased supervision and assistance. Despite several falls and changes in the resident's condition, including increased assistance needs and the use of a walker, the care plan was not revised to include these critical interventions. Resident #42's care plan was not updated after improvements in transfer, ambulation, continence, and cognition. The resident experienced a fall resulting in a dislocated shoulder and facial lacerations, yet the care plan did not reflect these injuries or the need for increased pain management. Additionally, the resident's missing hearing aids were not addressed in the care plan, impacting communication with staff. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for updating care plans, contributing to the deficiencies.
Medication Administration and Physician Order Compliance Deficiencies
Penalty
Summary
The facility failed to ensure that medications were administered according to professional standards of practice, as evidenced by several incidents involving multiple residents. For Resident #38, medications were left at the bedside without a physician's order permitting self-administration. The resident had various medications, including an inhaler and pain medication, left unattended, which the resident claimed to use as needed. The Certified Medication Technician (CMT) acknowledged that medications should not be left at the bedside unless ordered by a physician, yet the resident's medications were found unattended. Resident #59 also had medications left at the bedside without the appropriate order. The resident was unsure about the medication left and when it was brought to them. The Licensed Practical Nurse (LPN) and CMT both confirmed that the resident should not have medications left at the bedside, yet the medication was found and later taken by the resident without supervision. This indicates a lapse in following the facility's medication administration policy. Additionally, the facility failed to obtain necessary laboratory tests and maintain medication availability. Resident #1 did not have a required Dilantin level drawn, and the Director of Nursing (DON) could not explain how the order was missed. Resident #25 was on oxygen therapy without a physician's order, and Resident #45 experienced multiple days without receiving the prescribed Victoza due to unavailability and issues with prior authorization. These incidents highlight a pattern of non-compliance with physician orders and facility policies, leading to potential risks for the residents involved.
Inadequate ADL Assistance and Hygiene Care for Residents
Penalty
Summary
The facility failed to provide adequate care and assistance for activities of daily living (ADLs) to four residents who were unable to perform these tasks independently. Resident #4, with severely impaired cognition and dependent on staff for personal hygiene, was observed with unshaven whiskers despite expressing a preference for a clean-shaven appearance. The resident's care plan indicated a need for assistance with ADLs due to dementia progression, yet staff did not meet these needs as evidenced by the resident's unkempt appearance. Resident #26, who was incontinent of bowel and bladder and at high risk for urinary tract infections, did not receive proper perineal care. Observations showed that CNAs failed to clean all necessary areas during incontinence care, leaving the resident's skin in contact with urine and feces. The care plan required assistance with toileting and hygiene, but the staff did not adequately perform these tasks, compromising the resident's hygiene and comfort. Resident #28, with moderately impaired cognition and limited mobility, did not receive comprehensive personal care. The CNA did not clean all areas during perineal care, and the resident was left with unkempt hair and dried matter around the eyes. Additionally, Resident #61, who required assistance with bathing and personal hygiene, went extended periods without showers, leading to body odor and long facial hair. The facility's policies lacked specific guidelines on the frequency of showers and personal grooming, contributing to the deficiencies observed.
Inadequate Activity Program for Dementia Residents
Penalty
Summary
The facility failed to design an activity program that met the needs, interests, and well-being of its residents, particularly those with dementia. Observations and interviews revealed that there were no scheduled evening activities or activities specifically tailored for dementia residents. The activity calendar showed limited weekend activities, primarily consisting of bingo and devotionals, with no evidence of one-on-one activities or engagement for residents with cognitive impairments. Resident #22, diagnosed with dementia and severely impaired cognitive skills, was observed to have no involvement in activities despite a care plan that encouraged socialization and participation in favorite activities. Similarly, Resident #44, also with severe cognitive impairment, expressed the importance of religious services and music but had no documented activity assessments or participation. Resident #52, with a diagnosis of dementia, had preferences for reading, music, and outdoor activities, yet there was no evidence of activity engagement or assessments in their medical record. Interviews with staff and residents highlighted systemic issues in the activity program. The Activity Director, who was new and untrained, struggled to balance her responsibilities between activities and transportation, resulting in frequent cancellations and lack of enthusiasm. The Director of Nursing acknowledged the lack of specific policies for activities and was unsure of the evening and weekend offerings. The facility's failure to provide adequate activities for dementia residents and ensure consistent programming contributed to the deficiency.
Failure to Provide Timely Podiatry Care
Penalty
Summary
The facility failed to provide appropriate foot care for three residents, including two with diabetes, in a sample of 24 residents. Resident #36, who has congestive heart failure, end-stage kidney disease, and diabetes, had orders from a dialysis clinic to have their toenails trimmed, which were not followed. Observations showed that the resident's toenails were long, uneven, and causing discomfort. Despite multiple reminders from the dialysis clinic, the resident had not seen a podiatrist in a long time. Resident #9, diagnosed with heart failure and requiring assistance with personal hygiene, had an order for a podiatry consult that was not fulfilled. The resident expressed a desire to see a podiatrist, indicating it had been a long time since their last visit. Similarly, Resident #34, who is diabetic, had not seen a podiatrist for over a year despite having an order for a podiatry evaluation. The resident expressed a need to see a podiatrist due to their diabetic condition. Interviews with facility staff revealed systemic issues in obtaining podiatry services. CNA W stated that CNAs were not allowed to clip toenails for diabetic residents, and a list for the podiatrist had been started six weeks prior without a visit occurring. LPN R mentioned difficulties due to thick toenails and staffing issues, while the social services director and the Director of Nursing acknowledged problems with securing a foot care provider, noting that a new podiatrist had been contracted but had not yet seen the residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 83 citations issued within 25 miles in the last 12 months — 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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Troy
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Troy Manor | 0.4 mi | ★★★★★ | 0 | 0 |
| Silex Community Care | 11.3 mi | — | 0 | 0 |
| Elsberry Missouri Health Care Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Warrenton Manor | 14.3 mi | ★★★★★ | 7 | 0 |
| Cottages Of Lake St Louis | 17.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.