Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Neighborhoods Rehabilitation And Skilled Nursing B during CMS and state inspections, most recent first.
Failure to issue emergency discharge notice: A resident was sent to the hospital for uncontrolled pain and then told the facility would not accept the resident back because the acuity of care was higher than anticipated. The record contained no documentation of an emergency discharge notice, and the DON and Administrator stated the resident’s needs could not be met and no written discharge was issued.
Surveyors found multiple opened and undated eye drops, nasal sprays, and insulin vials on several medication carts and in a medication refrigerator, along with expired or potentially expired items. CMTs and an LPN said they were responsible for dating opened medications and checking expiration, but admitted the items were not dated or had been overlooked. The DON and administrator stated opened medications were considered expired after 28 days and that unit staff were responsible for reviewing carts for undated and expired medications.
Dietary staff failed to keep waste containers covered when not in use, performed hand hygiene incorrectly during food prep and service, served hot foods from steam tables at temperatures below required levels, and did not wear required hair restraints, including facial hair restraints. Observations showed uncovered refuse containers in multiple kitchen areas, improper handwashing after glove removal and after contact with raw food and trash, hot foods held and served at temperatures below 140 dF, and staff preparing and serving food without proper hair restraints.
EBP was not followed during wound and catheter care for two residents, including one with an indwelling catheter and pressure injuries and another with a surgical wound and wound infection. Staff did not wear gowns as indicated, and one resident’s care involved repeated glove changes without hand hygiene between them. The facility also lacked documentation of required two-step PPD testing for eight employees, with staff unsure who was responsible for tracking the second step.
Resident funds were managed without written authorization and several discharged residents’ balances were not refunded timely. The BOM admitted that resident trust accounts were opened and maintained without the required written consent from residents or responsible parties, and one resident’s private pay credit balance was held in the facility’s operating account after discharge because the facility was waiting on insurance payment. Other discharged residents still had trust account balances long after discharge or death, and the BOM could not provide documentation showing the withdrawals or refunds were properly accounted for.
Failure to Individualize Dementia Care Plans: Staff did not develop person-centered care plans for three residents with dementia on a secured unit. The records showed each resident had documented activity preferences and behavioral concerns such as anxiety, agitation, wandering, hallucinations, cueing needs, and refusal of care, but the care plans did not include the secured unit placement, preferred activities, or specific behavioral interventions. Observations also showed one resident becoming agitated during a transfer attempt, another remaining in bed with eyes closed, and a third speaking to self at the lunch table.
Failure to update care plans for falls and pressure wounds: The facility did not review or revise care plans for three residents after documented falls, including residents with cognitive impairment, stroke, Parkinson's disease, and dementia. A resident with a neck brace and forehead laceration also had no care plan direction for the fall-related injuries. In addition, a resident with severe cognitive impairment, hospice services, and multiple pressure injuries had a care plan that omitted wounds on the left upper arm and tailbone while listing wounds that were not observed.
Incomplete Orders for Catheters and Dialysis: Staff failed to obtain and document complete physician orders for two residents with indwelling catheters and two residents receiving dialysis. The orders lacked key details such as catheter indication, size, and bulb size, and dialysis orders lacked the indication, clinic location, and other required information. An LPN and the DON stated these details should be included in the orders, but the records did not contain them.
Facility staff did not transcribe a physician's wound care order for a resident and failed to complete weekly skin assessments for three residents, despite standing orders and documented risk for skin breakdown. Staff interviews confirmed that required documentation and follow-through on physician orders and assessments were not consistently performed.
A resident who required two-person assistance for bed mobility and had enablers on both sides of the bed was not monitored for over four hours, contrary to facility policy requiring checks at least every two hours. The resident was found entrapped between the bedrail and mattress, unresponsive, and later pronounced dead. Both the CNA and LPN failed to perform the required monitoring and care as outlined in the resident's care plan.
A resident with recent hospitalization and significant medical changes was not reassessed for bed rail use as required by facility policy. Staff failed to document an updated bed rail assessment after the resident's return, and the resident was later found entrapped between the bed rail and mattress, unresponsive and subsequently pronounced deceased. Interviews confirmed the lack of reassessment and documentation following the significant change in condition.
Staff failed to transcribe and implement updated wound care orders for two residents with pressure ulcers, resulting in the continued use of outdated treatment protocols and improper wound care. Observations and interviews revealed that new orders from a wound clinic were not entered into the system, and wound care was not performed as prescribed, with staff citing oversight and unclear responsibilities for updating orders. The DON and administrator were unaware of these lapses, highlighting a breakdown in communication and adherence to policy.
Staff failed to follow infection control protocols during wound care for a resident with multiple wounds, including not performing hand hygiene, not changing gloves between tasks, not using gowns as required by Enhanced Barrier Precautions (EBP), and not ensuring PPE was available or signage was posted. The resident's care plan and physician orders lacked EBP instructions, and contaminated items were placed on uncleaned surfaces, increasing the risk of cross-contamination.
A resident with severe cognitive impairment and multiple diagnoses was found unresponsive and without a pulse. Staff failed to initiate CPR, despite a full code order, due to an RN's mistaken belief that the resident was a DNR because hospice was being considered. The RN did not verify code status in the medical record, and no hospice order was present. Interviews confirmed the resident was a full code and not on hospice, and the failure to perform CPR was contrary to facility policy and physician expectations.
Staff did not report to DHSS when a resident with severe cognitive impairment and a full code order was found unresponsive and did not receive CPR. The nurse on duty assumed the resident was DNR based on secondhand information and did not verify code status, resulting in no resuscitation. Facility leadership did not consider the incident neglect and did not report it as required by policy.
The facility failed to store medications safely, with expired medical supplies and medications found in multiple medication rooms and a cart. Staff interviews revealed a lack of a written process for checking expired medications, and uncertainty about audit documentation. The presence of expired items suggests ineffective implementation of storage processes.
The facility failed to ensure timely responses to residents' call lights, with reports showing repeated activations without prompt staff response. Residents expressed concerns about delays, especially at night, and staff interviews revealed challenges due to staffing shortages. The facility's leadership provided inconsistent information on expected response times, highlighting a systemic issue in addressing residents' needs.
A resident with schizophrenia and other mental health diagnoses did not receive their prescribed antipsychotic medication, Aristada, as required due to issues with medication delivery and documentation. The facility failed to document the administration of the medication, notify the physician, or monitor for adverse effects, despite policies requiring these actions. Interviews revealed that the medication was not received due to a lack of signature, leading to its return to the post office and outside hospital.
Failure to Issue Emergency Discharge Notice
Penalty
Summary
Facility staff failed to provide an appropriate emergency discharge notice for Resident #1 when the resident was discharged to the hospital and then not allowed to return to the facility. The resident’s face sheet showed admission to the facility and discharge to the local hospital on 5/20/26, and the progress notes documented that the resident was discharged back to the hospital at 11:48 A.M. for uncontrolled pain. Review of the resident’s medical record did not contain documentation of an emergency discharge notice issued to the resident. During interviews, the DON stated the facility was not informed of the full acuity of care and believed it could not meet the resident’s needs, and the Administrator stated the resident’s acuity was much higher than anticipated, the resident was sent to the hospital, and the hospital social worker was told the resident would not be permitted back because of the level of care needed; the Administrator also stated no written discharge was issued.
Undated and Expired Medications Found on Multiple Carts
Penalty
Summary
Facility staff failed to label eye drops and nasal sprays in accordance with accepted professional principles and failed to destroy expired medications in three medication carts and one medication room. During observation, surveyors found opened and undated bottles of Atropine eye drops and multiple opened and undated bottles of artificial tears on one medication cart. On another cart, surveyors observed opened and undated artificial tears, an opened bottle of artificial tears dated 11/28/25, an opened and undated bottle of Lantoprost eye drops, and two opened and undated bottles of fluticasone nasal spray. On a third cart, surveyors observed opened and undated bottles of Olopatadine eye drops, azelastine eye drops, three opened and undated bottles of normal saline nasal spray, and an opened and undated bottle of deep sea normal saline nasal spray. Surveyors also observed the refrigerator on one unit containing opened and undated vials of Lantus insulin, Aspartate insulin, and Humalog insulin, with the manufacturer expiration date on one vial listed as 12/09/25. Staff interviews showed CMTs and an LPN stated they were responsible for dating opened medications and checking for expiration, but acknowledged they had not dated the items or had not noticed they were undated. The DON stated opened medications were considered expired after 28 days and said CMTs were responsible for dating and checking the carts, while the administrator stated CMTs were responsible for weekly review of carts for undated and expired medications and was not sure the weekly checks were being completed on all units.
Dietary Food Safety and Hygiene Deficiencies
Penalty
Summary
Food preparation and service practices were not followed in multiple kitchen areas. Waste containers in the Flat Branch, [NAME] and [NAME], Boonslick, Smithton Village, and [NAME] Station kitchens were observed uncovered and in use or not in use, and the areas did not contain covers for the containers. Dietary aides stated they did not have covers for the waste containers, and one aide said the container had not had a cover for at least two months. The dietary manager and administrator stated kitchen waste containers should be covered when not in use and acknowledged that some lids had broken and replacement lids had been ordered, but they did not know that all of the unit kitchen waste containers lacked covers. Hand hygiene practices were not performed correctly during food preparation and service. One dietary aide cut a raw onion with gloved hands, removed the gloves, and then washed hands by placing soap on the hands and rubbing them together under running water before serving prepared foods. Another dietary aide entered the kitchen, obtained raw eggs, touched the lid of the waste container with a bare hand, put on a hair net, transported prepared food to another kitchen, and later washed hands by rubbing them together under running water with soap, then used the same paper towel to turn off the faucet and dry the hands. The dietary aide stated staff were trained to perform hand hygiene when entering the kitchen, before and after glove use, before handling food, and after touching anything dirty, and that hands should be scrubbed with soap for 30 to 45 seconds and dried with a paper towel before using a different paper towel to turn off the faucet. The dietary manager and administrator also stated staff should perform hand hygiene at those times and should use a different paper towel to turn off the faucet so hands are not recontaminated. Hot foods held in steam tables were observed below the required temperature and were served to residents. In one kitchen, spaghetti noodles measured 124 dF and vegetables measured 130 dF while being served from the steam table, with open spaces around the pans allowing heat to escape. In another kitchen, spaghetti noodles measured 120 dF, spaghetti sauce measured 130 dF, and vegetables measured 118 dF; the food temperature log showed the noodles at 107 dF, the sauce at 168 dF, and the vegetables at 135 dF. A dietary aide stated the noodles were covered to let them heat up on the steam table and that the food was served anyway because it was as close as it was going to get to the right temperature without running late. On another observation, sausage, ground sausage, and peppered white gravy on a steam table measured 119 dF, 130 dF, and 125 dF, respectively, and were left uncovered while the aide stated the food would be allowed to heat up on the steam table and later prepared to serve it even though it had not reached 140 dF. Dietary staff also failed to wear required hair restraints. A staff member with facial hair prepared food in the main kitchen without a facial hair restraint. Another dietary aide with head and facial hair pushed a cart of prepared food, obtained raw eggs, put on a hair net only after entering the kitchen, transported prepared food to another kitchen, placed the food into the steam table, and served it without a facial hair restraint. A third dietary aide with facial hair served food to residents without a facial hair restraint. The dietary manager and administrator stated dietary staff are trained to wear hair restraints, including facial hair restraints, and that anyone around food should wear them.
EBP, Hand Hygiene, and Employee TB Testing Failures
Penalty
Summary
The facility failed to provide Enhanced Barrier Precautions (EBP) during wound care and catheter care for Resident #5, who had severe cognitive impairment, was dependent on staff for toileting and dressing, had an indwelling catheter, and had a Stage 3 pressure ulcer and a deep tissue pressure injury. The resident’s care plan identified the catheter and risk for skin breakdown, but it did not include direction for EBP or the sacral wound. During observation, CNA H and LPN I entered the room, applied gloves, and provided hygiene, catheter care, and wound care without wearing gowns. Both staff members removed gloves and put on clean gloves multiple times without performing hand hygiene between glove changes. CNA H stated he/she had been taught about EBP but did not think about it with this resident, and LPN I stated he/she did not know what EBP was and did not believe the resident required it. The facility also failed to provide EBP during wound care for Resident #15, whose admission MDS identified cognitive impairment and diagnoses including orthopedic condition, wound infection, surgical joint repair, and surgical wound care. The physician order required daily wound care to the left upper arm with cleansing, soaked gauze, dressing pad, kerlix, and ACE wraps. Observation showed the resident’s door did not have EBP signage and gowns were not available on the PPE cart. During wound care, LPN A applied the kerlix wrap, removed his/her gown, and then wrapped the arm with an ACE bandage, stating he/she was not going to be in contact with other residents so he/she did not need the gown. The resident stated staff had never worn gowns during wound care prior to that day. LPN A stated EBP was used for residents with infection or catheter depending on the reason for the catheter, and said PICC lines did not require EBP. The facility also failed to ensure two-step PPD testing was completed for eight employees. Review of employee files for Housekeeper J, CMT K, CNA L, Housekeeper M, DA N, LPN O, SSD, and ABOM showed each had documentation of only a first PPD skin test and read, with no second PPD administered one to three weeks later as required by facility policy. Interviews showed the ABOM believed another nurse was responsible for employee TB testing, LPN P said he/she administered and read the initial test but did not know who ensured the second step was given or tracked, and the DON stated the Flat Branch nurse was responsible and was aware the facility was out of compliance.
Resident Funds Managed Without Authorization and Not Refunded Timely
Penalty
Summary
The facility failed to obtain written authorization before managing the personal funds of four residents in the resident trust account. The facility policy required written authorization from the resident or the resident’s designee, guardian, or conservator before the facility could hold, safeguard, manage, and account for resident funds. The admission agreement also stated that written authorization was required for the facility to manage personal funds. Despite this, the Business Office Manager (BOM) acknowledged that written authorization was not obtained and said he/she did not know it was required. For one resident, the guardian had documented that the facility was not authorized to place the resident’s personal funds in the facility’s possession, yet the facility opened and maintained an individual resident trust account with deposits and withdrawals, leaving a balance of $231.62. For another resident, the admission agreement showed no authorization to place funds in the facility’s possession, but the facility opened a resident trust account with a balance of $300.01. Two additional residents also had resident trust accounts opened and maintained without written authorization, including one account opened with $221 and another with $150, both of which remained in the facility’s resident trust account at the time of review. The facility also failed to maintain a full, complete, and separate accounting of resident funds and failed to refund funds timely for discharged residents. One discharged resident had a private pay credit balance of $2,576 that the facility held in its operating account after discharge because it was waiting for insurance payment, despite no written authorization to do so. Several discharged residents still had balances in the resident trust account long after discharge or death, including balances of $221, $150, $3,192.91, and $172.86. The BOM stated that some funds had been sent to state unclaimed property or were being held because the resident still owed the facility money, but no documentation was available to show the withdrawals or refunds were properly accounted for in the resident trust records. The administrator stated that resident personal funds should be refunded within 30 days of discharge and should not be held without written authorization.
Failure to Individualize Dementia Care Plans
Penalty
Summary
Facility staff failed to develop and implement person-centered care plans for three residents on a secured memory care unit, including behavioral interventions and activity preferences. The facility’s Dementia Care, Activity, and Comprehensive Care Plans policies stated that individualized, non-pharmacological approaches, meaningful activities, and care plans addressing services needed to attain or maintain the resident’s highest practicable well-being were to be used and monitored. However, the care plans for the sampled residents did not include the residents’ secured unit placement, activity preferences, or specific interventions for behaviors documented in the record. Resident #2’s MDS showed cognitive impairment, dementia, and preferences for music, going outside when weather was nice, religious activities, books or magazines, favorite activities, and group activities. Nursing notes documented confusion, verbal cueing needs, restlessness, agitation, and anxiety. The care plan dated 11/03/25 did not address the resident’s need for the secured memory care unit, activity preferences, or behavioral interventions for anxiety. During observation, the resident became restless in the television room, attempted to self-transfer from a wheelchair to a regular chair, became agitated when unsuccessful, struck the wheelchair armrest, and then had the wheelchair unlocked by an unknown staff member so the resident could self-propel around the sitting area. Resident #5’s MDS showed severe cognitive impairment, dementia, and preferences for music, groups of people, favorite activities, and religious activities. Nursing notes documented agitation during an assessment, but the care plan dated 12/21/25 did not address the secured memory care unit, activity preferences, or behavioral interventions. Resident #9’s MDS showed cognitive impairment, dementia, and preferences for music, religious activities, books or magazines, and favorite activities. Nursing notes documented wandering at night, spitting food, yelling out, chronic confusion, disorganized thinking, cueing needs, refusal of care, hallucinations, and increased behaviors when without hearing aids. The care plan dated 11/04/25 did not include direction for wandering, spitting food, cueing, hallucinations, or use of hearing aids to ease behavioral episodes. Observations showed Resident #5 in bed with eyes closed and Resident #9 in a wheelchair at the lunch table speaking to self and later in bed with eyes closed.
Failure to Update Care Plans for Falls and Pressure Wounds
Penalty
Summary
The facility failed to develop, review, and revise comprehensive care plans for residents with falls and pressure ulcers. The comprehensive care plan policy stated the plan would include measurable objectives and timeframes to meet resident needs identified in the comprehensive assessment, with objectives used to monitor progress and alternative interventions documented as needed. Review of records showed Resident #2 had a significant change assessment dated 11/07/25 identifying cognitive impairment, impaired functional cognition, impaired range of motion, dependence for sit-to-stand transfers, no falls since the prior assessment, and a stroke diagnosis, but nurses' notes later documented two falls on 01/15/26 and the care plan dated 11/29/25 did not show review of those falls. Resident #6 had an annual assessment dated 12/01/25 showing cognitive intactness, progressive neurological disorder, Parkinson's disease, no falls since admission, and substantial to maximal assistance needs, yet the resident was observed wearing a neck brace with a forehead laceration and stated he/she fell and hit his/her head on a bedside table and broke his/her neck on 12/17/25; the care plan dated 11/25/25 did not document review of the fall or direction for the laceration or neck brace. Resident #9's admission assessment showed cognitive impairment, impaired range of motion to one upper extremity, dependence for sit-to-stand transfers, a history of falls prior to admission, and a diagnosis of dementia, but nurses' notes documented falls on 01/17/26 and 01/19/26 and the care plan dated 11/04/25 did not show review of those falls. Resident #5's significant change assessment showed severe cognitive impairment, a Stage III pressure wound, a deep tissue pressure injury, a surgical wound, hospice services, and diagnoses of dementia and anemia, but the care plan dated 12/21/25 only addressed a Stage III wound to the right heel and a surgical wound to the right thigh and did not include the pressure ulcers on the left upper arm or tailbone. Observation on 01/23/26 showed a Stage II wound to the left upper arm and a Stage IV wound to the tailbone, and no wound to the right heel or right thigh. The MDS nurse and DON stated care plans should be updated for changes in condition, falls, treatments, acute illnesses, and specialized equipment, and reviewed after each fall.
Incomplete Orders for Catheters and Dialysis
Penalty
Summary
Facility staff failed to provide services that met professional standards when they did not document and obtain complete physician orders for indwelling urinary catheters for two residents. For one resident with cognitive impairment, dementia, and an indwelling catheter, the physician order sheet included catheter care, emptying the drainage bag, and changing the drainage bag, but did not include the catheter size, bulb size, or indication for the catheter. The care plan also did not contain direction or guidance for the catheter indication, size, or bulb size. The resident was observed in a wheelchair with the catheter drainage bag hanging from the wheelchair. A second resident, who was severely cognitively impaired, on hospice services, had an indwelling catheter, a stage III pressure injury, and was dependent on staff for bed mobility, also had catheter care orders but no order for catheter size, bulb size, or indication. The care plan did not contain direction or guidance for catheter size or bulb size. The resident was observed in bed with the catheter drainage bag hooked to the side of the bed. During interview, an LPN stated residents with indwelling catheters should have an order that includes why the resident has the catheter and the size and care of the catheter, and that it is the responsibility of the nurse who obtained the order to put it into the chart. The DON stated nurses are responsible to obtain an order for urinary catheters and that the order should include the reason for use, size, and bulb size. Facility staff also failed to document and obtain complete physician orders for dialysis for two residents receiving dialysis. One resident with ESRD and cognitive intactness had orders for dialysis-related monitoring and weights, but the physician order sheet did not include the days of the week, location of the clinic, or indication for dialysis. Another resident admitted to the facility had a baseline care plan showing dialysis every Monday, Wednesday, and Friday, and the physician order sheet included dialysis assessment, chair time, and fistula care, but did not contain the indication for dialysis, location of the clinic, or name and phone number of the nephrologist. Staff interviews showed nurses were relying on shift reports or the resident to know dialysis details, and the DON stated residents who undergo dialysis should have orders that include the reason, days of week, and location of services.
Failure to Transcribe Physician Orders and Complete Weekly Skin Assessments
Penalty
Summary
Facility staff failed to meet professional standards of practice by not transcribing physician's orders for one resident and not completing weekly skin assessments for three residents. For one resident with severe cognitive impairment and at risk for skin breakdown, a wound consultant ordered a hydrocolloid sheet to be applied weekly and as needed, but this order was not transcribed into the resident's Physician Order Sheet (POS) or Treatment Administration Record (TAR). The wound care nurse and charge nurse both acknowledged that the process for entering new wound care orders was not followed, and the wound care nurse did not verify that the orders were entered as required. Additionally, weekly skin assessments were not documented as completed for three residents who were all assessed as being at risk for skin breakdown and requiring assistance with activities of daily living. Review of the residents' records showed multiple missed weekly skin assessments over several months, despite standing physician orders for these assessments to be completed by licensed staff on specific days. Interviews with staff, including the DON, wound care nurse, and administrator, confirmed that the responsibility for entering new orders and completing weekly skin assessments was not consistently fulfilled. Staff interviews revealed a lack of clarity and follow-through regarding the process for transcribing and verifying physician orders, particularly those from the wound consultant. The facility's policy required all physician orders to be carried out as ordered and entered into the electronic medical record, but this was not done. The DON, wound care nurse, and administrator all stated that if something is not documented, it is considered not done, and acknowledged that the required documentation and follow-up were missing in these cases.
Failure to Perform Required Resident Rounds Resulting in Entrapment and Death
Penalty
Summary
Facility staff failed to monitor a resident at least every two hours as required by facility policy and based on the resident's needs. The resident, who was moderately cognitively intact and required two staff for bed mobility and transfers, was not checked between 11:00 P.M. and 3:10 A.M. Staff interviews and record reviews confirmed that the assigned CNA did not observe the resident during this period, and the LPN responsible for the resident's IV medication also did not return to the room to disconnect the IV as required. The resident had a physician's order for enablers (grab bars) on both sides of the bed and required significant assistance for mobility and transfers. The resident's baseline care plan indicated the need for a mechanical lift and two staff for bed mobility, transfers, and toileting. Despite these needs, staff did not assess or document the use of bed rails or grab bars, and the resident was left unattended for over four hours during the night shift. At approximately 3:10 A.M., the resident was found entrapped between the bedrail and mattress, face down and unresponsive. Staff had to forcefully remove the resident's head from between the rail and mattress. CPR was initiated, and emergency services were called, but the resident was pronounced dead. The investigation confirmed that the required two-hour checks were not performed, and both the CNA and LPN failed to monitor the resident as per policy and the resident's care plan.
Failure to Reassess Bed Rail Use After Significant Change in Condition Resulting in Resident Entrapment and Death
Penalty
Summary
Facility staff failed to reassess the use of bed rails for a resident following a significant change in condition, as required by facility policy. The resident, who had a history of weakness, recent hospitalization for a severe infection, and delirium, was readmitted to the facility with new medical interventions including a PICC line and a closed drain. Despite these changes, there was no documented updated assessment to determine the appropriateness and safety of continued bed rail use after the resident's return from the hospital. The facility's policy required reassessment of bed rail use after significant changes in a resident's status, as well as ongoing monitoring and proper documentation. However, interviews and record reviews revealed that neither nursing nor maintenance staff could provide documentation of a post-hospitalization bed rail assessment. The assistant administrator stated that routine checks were performed but could not confirm if the check occurred before or after the resident's return, nor if the resident was present in the bed at the time. Nursing staff were unclear about the resident's change in status and the requirements for reassessment. The deficiency resulted in a fatal incident where the resident was found entrapped between the bed rail and mattress, unresponsive and later pronounced deceased. Staff interviews confirmed that the resident's head was trapped between the rail and mattress, and that the required reassessment and documentation of bed rail appropriateness following the significant change in condition had not been completed.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
Facility staff failed to meet professional standards of quality by not transcribing and implementing wound care orders for two residents with pressure ulcers. For one resident, staff did not update the physician order sheet (POS) with new wound care instructions received from the wound clinic, resulting in the continued use of outdated treatment protocols. The wound nurse confirmed that the orders were not updated in the system because the nurse who received the new orders did not enter them, and the responsibility for updating orders was not clearly followed. Documentation on the Treatment Administration Record (TAR) showed treatments were administered according to the old orders, not the updated ones from the wound clinic. For another resident, the plan of care did not address the resident's wounds, and staff failed to document new wound care orders, including specific cleansing and dressing instructions. During observation, an LPN did not use the correct cleansing agents or dressings as prescribed in the new orders, instead using wound cleanser and foam dressings not specified in the orders. The LPN admitted to not updating the orders in the system and not following the prescribed wound care protocol, citing oversight as the reason for the errors. Interviews with staff, including the wound nurse, LPN, DON, and administrator, revealed a lack of clarity and consistency in the process for updating and implementing new physician orders. Staff acknowledged that it is the responsibility of the nurse receiving the orders to enter them promptly, but this was not consistently done. The DON and administrator were not aware that orders were not being updated or that wound care was not being performed as prescribed, indicating a breakdown in communication and adherence to facility policy.
Failure to Implement Infection Control and Enhanced Barrier Precautions During Wound Care
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols during wound care for a resident with multiple wounds. Observations revealed that an LPN did not perform hand hygiene or apply gloves before handling wound care supplies, did not clean scissors before use, and placed supplies directly on the treatment cart without a barrier. During wound care, the LPN did not use a gown, failed to change gloves and perform hand hygiene between tasks and wounds, and placed soiled items on the resident's bed and bedside table without cleaning these surfaces afterward. The LPN also used the same gloves for multiple tasks and wounds, increasing the risk of cross-contamination. The facility's policies on hand hygiene and Enhanced Barrier Precautions (EBP) require staff to perform hand hygiene before and after glove use, treat each wound individually, and use gowns and gloves for residents with chronic wounds. However, the resident's plan of care and physician orders did not include directions for EBP, and there was no signage or PPE available near the resident's room to alert staff or facilitate compliance with EBP. Interviews with the LPN, DON, and Administrator confirmed that staff were aware of the correct procedures but failed to implement them during the observed wound care. The resident involved was cognitively intact, at risk for pressure ulcers, and had multiple documented wounds requiring ongoing wound care. Despite these risk factors, the facility did not ensure that staff followed established infection control practices or that EBP protocols were implemented and communicated to staff. The lack of proper hand hygiene, glove changes, use of PPE, and environmental cleaning during wound care constituted a failure to prevent potential cross-contamination and infection.
Failure to Initiate CPR for Full Code Resident Due to Staff Miscommunication and Assumptions
Penalty
Summary
Facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) for a resident who had a signed full code physician order. The resident, who had severe cognitive impairment and diagnoses including dementia, Alzheimer's disease, non-traumatic brain disorder, coronary artery disease, and heart failure, was found unresponsive during a medication pass. Staff documented that the resident did not have a pulse and confirmed the resident had expired, but did not attempt CPR. The investigation revealed that the registered nurse (RN) on duty did not verify the resident's code status and assumed the resident was a Do Not Resuscitate (DNR) because the resident was reportedly going on hospice, although there was no hospice order in the record. The RN admitted to being confused, not knowing what to do, and not checking the resident's code status in the medical record, despite knowing where to find this information. The certified medication technician who gave the report to the RN stated that the resident's family was considering hospice, but the resident was not on hospice at the time. Interviews with facility leadership and the resident's durable power of attorney confirmed that the resident was a full code and not on hospice. The physician also stated that staff are expected to follow the resident's code status and perform CPR as ordered, regardless of hospice consideration. The failure to verify code status and initiate CPR was a direct violation of facility policy and the resident's documented wishes.
Failure to Report Neglect After Staff Did Not Initiate CPR for Full Code Resident
Penalty
Summary
Facility staff failed to report to the Department of Health and Senior Services (DHSS) an incident of neglect involving a resident with a full code status. The resident, who had severe cognitive impairment and diagnoses including dementia, Alzheimer's, non-traumatic brain disorder, coronary artery disease, and heart failure, was found unresponsive without a pulse. Despite a physician order and care plan indicating full code status, the registered nurse on duty did not initiate CPR. The nurse assumed the resident was a DNR based on a report from a medication technician and did not verify the resident's code status in the medical record or facility documentation. The facility's policy required immediate reporting of suspected neglect to the state agency, but the incident was not reported. The Director of Nursing and the administrator both stated they did not believe the incident constituted neglect and therefore did not report it to DHSS. The nurse involved admitted to confusion and not checking the resident's code status, resulting in no resuscitation efforts being made for a resident who was documented as full code.
Medication Storage Deficiency Due to Expired Supplies
Penalty
Summary
The facility failed to store medications safely and effectively, as evidenced by expired medical supplies and medications found in multiple medication rooms and a medication cart. Observations revealed expired medical tubing, syringes, antiseptic bottles, and Nitroglycerin tablets in various locations within the facility. Interviews with staff, including a Certified Medication Technician (CMT) and Licensed Practical Nurses (LPNs), indicated a lack of a written process for checking medication carts for expired medications. Staff were expected to conduct weekly audits, but there was uncertainty about how these audits were documented. Further interviews revealed that there were no destruction logs for non-narcotic medications, and expired medications were either destroyed using a drug buster or placed in the main medication room for management to handle. The Director of Nursing and the Administrator confirmed that the pharmacy reviews medication storage for expired items, and medication technicians are supposed to check for expired medications weekly. However, the presence of expired medications suggests that these processes were not effectively implemented or followed.
Delayed Response to Call Lights in LTC Facility
Penalty
Summary
The facility staff failed to ensure that residents' call lights were answered in a timely manner, as evidenced by multiple instances where call lights were activated numerous times without a prompt response. The electronic call light report for several rooms showed that call lights were activated repeatedly, often nine times, before automatically shutting off after 45 minutes without a response. In some cases, responses were delayed by 30 to 40 minutes, indicating a significant delay in addressing residents' needs. Interviews with residents revealed dissatisfaction with the timeliness of call light responses, with some residents reporting that call lights were not answered for extended periods, especially at night. One resident expressed concern about the risk to resident well-being due to the lack of timely assistance, stating that they had to scream to get help when the call light did not work. The Resident Council members agreed with this sentiment, highlighting a broader issue of inadequate response times. Staff interviews provided further insight into the problem, with some CNAs acknowledging that call lights should be answered within a few minutes but admitting that it was challenging to meet this standard due to staffing shortages. The Assistant Director of Nursing and the Director of Nursing provided conflicting information about the expected response times, with some suggesting a 5-minute response time and others indicating it could take up to 30 minutes. The Administrator acknowledged that if a call light was announced nine times, it meant it was never answered, underscoring the facility's failure to meet its own standards for timely response to residents' needs.
Medication Management and Documentation Deficiency
Penalty
Summary
The report identifies a deficiency in the facility's medication management and documentation processes, specifically concerning a resident with a diagnosis of schizophrenia, bipolar depression, anxiety, and depression. The resident was prescribed Aristada, an antipsychotic medication, to be administered intramuscularly every four weeks. However, the facility failed to document the administration of this medication on multiple occasions, as evidenced by the Medication Administration Record (MAR) and progress notes. The MAR lacked documentation of the medication being administered, and progress notes indicated that the medication was unavailable and awaiting delivery, without evidence of physician notification or monitoring for adverse effects. The facility's policies on medication errors, reordering, and documentation require timely acquisition and administration of medications, as well as accurate documentation of any errors or omissions. Despite these policies, the facility did not follow up adequately when the medication was unavailable, nor did they document any adverse effects or notify the physician as required. Interviews with staff revealed that the medication was shipped but not received due to a lack of signature, resulting in the medication being returned to the post office and subsequently to the outside hospital. This lack of proper documentation and follow-up led to the resident not receiving the medication as prescribed. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed the issues with medication delivery and documentation. The LPN acknowledged the absence of documentation regarding adverse effects and physician notification, while the DON explained the challenges in obtaining the medication from an outside hospital. The facility's failure to ensure timely administration and proper documentation of the resident's medication represents a breach of professional standards of care, as outlined in their policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Columbia
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bluffs, The | 0.2 mi | ★★★★★ | 18 | 0 |
| Lenoir Health Care Center | 0.7 mi | ★★★★★ | 0 | 0 |
| Columbia Manor Health & Rehabilitation | 1 mi | ★★★★★ | 6 | 0 |
| South Hampton Rehabilitation & Health Care Center | 2.8 mi | ★★★★★ | 9 | 0 |
| Columbia Post Acute | 2.9 mi | ★★★★★ | 2 | 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.