Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at New Mark Rehab And Healthcare Center during CMS and state inspections, most recent first.
The facility failed to maintain a safe, comfortable environment when both boilers malfunctioned, causing indoor temperatures to drop below the facility’s stated 71–81°F range. Several residents with conditions such as CHF, multiple sclerosis, dementia, chronic respiratory failure, and depression reported very cold rooms and described needing to wear coats, mittens, gloves, sweaters, and extra blankets indoors to stay warm. Some residents were offered moves to warmer rooms, but others were not offered relocation or extra blankets, despite the facility’s extreme weather policy requiring comfort measures during cold conditions. Observations confirmed cool rooms, non-functioning or inadequately heating room units, and residents bundled in outerwear and blankets while in bed or in their rooms.
A resident with multiple cardiac, cognitive, and functional diagnoses was moved from the facility to another SNF within the same company without a physician discharge order, required discharge notice, or completed discharge documentation in the medical record. The facility’s policy required advance written notice of transfer/discharge, including reasons, effective date, destination details, appeal rights, and Ombudsman information, to be provided to the resident and their representative, and for discharge planning and documentation to be maintained. Instead, staff communicated discharge plans with a family member who was not the resident’s DPOA, while the designated DPOA reported not being notified of the discharge, not receiving any discharge paperwork or notice, and not being contacted by or signing admission paperwork for the receiving facility. The DON stated that staff were expected to notify and obtain agreement from the DPOA or provide a 30‑day notice, and the Administrator acknowledged that no discharge notice was completed because staff believed the move to another SNF was a transfer rather than a discharge.
Licensed staff and the SSD failed to document critical clinical information and to administer or properly document medications as ordered. A resident with ESRD on hemodialysis, diabetes, CHF, atrial fibrillation, chronic infected wounds, and intact cognition had a critical potassium level reported from an outside clinic; the clinic ordered hospital transfer, the resident refused, and an NP ordered high-dose oral KCl and STAT labs, yet none of these events, refusals, code status changes, or missed dialysis/IV antibiotic treatments were documented in the clinical record. On a separate day, three other residents had multiple medications and nutritional supplements marked on the MAR with a code directing staff to see progress notes, but the notes did not explain why medications were not given, and some doses were not documented as administered at all. Staffing issues contributed when a CMT called off, an RN unfamiliar with LTC med passes attempted to cover while managing other clinical duties, and many scheduled medications were not administered or explained in the record.
A facility failed to report an alleged incident of sexual abuse between two residents to law enforcement and the state survey agency within the required timeframe, despite its own policy and federal regulations. The incident involved a resident with severe cognitive impairment and another resident with a history of inappropriate sexual behavior. Staff and family were aware of the allegation, but administration decided not to report it after reviewing camera footage and assessments, and the hospice agency was not notified by the facility.
A facility failed to follow its abuse prevention policy by not conducting a documented investigation or notifying authorities after an allegation that a resident with severe cognitive impairment was sexually abused by another resident with a history of inappropriate sexual behavior. Despite staff and family reports of the incident and the facility's own policy requirements, the Administrator determined the allegation was unsubstantiated without a formal investigation or external reporting.
A resident with severe cognitive impairment and behavioral symptoms repeatedly screamed and yelled in shared areas while staff only offered water, repositioning, and later moved the resident out of the dining room. Staff said the resident yelled often and that other residents were upset by it, while two residents reported the constant yelling bothered and depressed them. The DON and Administrator acknowledged that residents had a right to dignity and respect.
Failure to Provide Timely Incontinence Care and ADL Assistance: Several dependent residents with cognitive impairment and bowel/bladder incontinence were observed being taken to activities and meals without toileting, repositioning, or changing. One resident was later found with a saturated brief and foul body odor, another had urine-soaked clothing and wheelchair, and others were noted with strong urine odor while staff stated they had not provided care because they were busy with other residents.
Delayed incontinent care and failure to promptly identify/report skin breakdown led to a resident with dementia, Parkinson’s disease, and bowel/bladder incontinence developing an open area on the right buttock. The resident was left in a saturated brief for an extended period, was not offered toileting or repositioning, and was later found with foul odor, red/inflamed skin, and a painful open area with drainage. Staff said they had not changed the resident since the morning, were too busy, and were not aware of the wound.
A resident with a surgical wound and multiple health conditions had a wound vac dressing left unchanged for an extended period due to missing physician orders and unclear staff responsibilities. When the dressing was finally removed, it was severely adhered to the wound, causing significant bleeding and requiring hospital transfer. Staff interviews confirmed a lack of documentation and confusion about wound care procedures.
A resident with severe cognitive impairment and a history of wandering exited the secure memory care unit, was found in the parking lot with a head laceration, and required hospital evaluation. Staff were aware of the resident's exit-seeking behaviors but did not prevent the elopement, resulting in injury.
A resident with complex medical and behavioral needs was transferred to a hospital after an incident of aggression, but facility staff failed to provide the required written discharge notice, bed hold policy, and information on appeal rights to the resident or their representative. There was no evidence of involvement of the resident or representative in discharge planning, and communication among staff and with the hospital was lacking, resulting in confusion and harm to the resident.
A resident with a history of behavioral issues and neurocognitive disorders physically assaulted another resident with dementia, resulting in multiple injuries including facial scratches, bruising, and emotional distress. Staff discovered the incident after hearing screaming, and the facility's policies requiring intervention and abuse prevention were not effectively implemented to prevent the altercation.
During a recent survey, multiple food safety and hygiene protocol deficiencies were observed. Stored food items in the walk-in freezer and refrigerator were found undated and exposed to potential contamination. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating but noted a lack of awareness among maintenance staff regarding vent cleanliness. Furthermore, a dietary staff member was observed not wearing a beard restraint while handling food, contrary to facility policy. The staff member cited discomfort as the reason for removing the restraint, indicating a gap in adherence to established hygiene guidelines. These deficiencies could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
The facility failed to inform a resident and/or their representative of the risks and benefits of a physician-ordered antipsychotic medication. The resident, who had moderate cognitive impairment, was not aware of the purpose of the medication, and no consent was documented. The Unit Manager confirmed the lack of consent, and the facility did not provide a relevant policy.
The facility failed to maintain a clean and comfortable environment for a resident, who was observed to have a build-up of dirt and grime, dust, and ants in the room. Despite the resident's cognitive intactness, the room's condition remained poor over multiple observations. The Administrator was unaware of the ant issue, and the Activity Director acknowledged that spring cleaning had not started and there was no care plan addressing the resident's wishes and the need for room cleaning.
A resident with cognitive impairments bit another resident after the latter reached for a blanket, despite staff being aware of the aggressive behaviors and having interventions in place. The biting incident resulted in a bruise but no broken skin. Staff separated the residents and placed the aggressor on 15-minute checks.
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the SSA within the required timeframes. A resident with dementia was found with a bruise, and another resident was involved in an altercation, both of which were not reported promptly as per facility policy.
The facility failed to investigate an injury of unknown origin and a resident-to-resident altercation involving two residents. One resident was found with a bruise below her eye, and another was hit on the arm by another resident. No investigations were conducted as required by the facility's policy.
The facility failed to update the care plans for two residents. One resident with PTSD did not have a care plan addressing this condition, and another resident using a specialized wheelchair did not have this equipment included in their care plan. These oversights could lead to inappropriate care and services.
The facility failed to provide appropriate support for a resident's head and leg while in a wheelchair and delayed obtaining a dermatology appointment for another resident with excessive itching. These deficiencies were confirmed through observations, staff interviews, and record reviews.
A resident with a history of stroke and cerebral palsy did not receive appropriate services to maintain or improve her range of motion (ROM). Despite having functional limitations, the resident did not receive any restorative therapy or exercises, and the only intervention was the placement of a washcloth in her contracted hand. Staff confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program.
The facility failed to properly store a resident's nebulizer tubing and pipe, leaving them uncovered on a bedside table. This oversight was confirmed by an LPN and placed the resident, who had COPD and required frequent nebulizer treatments, at risk for infection.
The facility failed to complete an AIMS assessment for a resident on antipsychotic medication and did not have a stop date or diagnosis for a PRN psychotropic medication for another resident. These oversights placed the residents at risk for unrecognized side effects and diminished quality of life.
The facility failed to remove an expired insulin pen from a medication cart, leading to its use on a resident with high blood sugar. The RN confirmed the pen was expired, and the DON stated that expired pens should be removed. The facility's policy and manufacturer's guidelines were not followed.
The facility failed to maintain the reach-in refrigerator in the kitchen, which had been leaking for at least six months, affecting 98 of the 99 residents who consume food from the kitchen. Despite being noted in the Maintenance Repair Log in August 2023, the issue was not repaired, and the maintenance staff was only notified about the leak recently.
Failure to Maintain Comfortable Indoor Temperatures During Heating System Malfunction
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, comfortable, and homelike environment when the heating system could not sustain comfortable temperatures for residents. The facility had a policy titled “Extreme Weather” dated 08/25/23, which stated that during extreme cold weather the facility would provide extra blankets to residents who desired them, obtain additional warm clothing for residents with insufficient warm clothing, provide additional warm beverages, and have staff assess residents for comfort and take additional measures as necessary. The policy also required the Maintenance Department to maintain a log of facility temperatures and document measures taken if temperatures fell below 71°F or above 81°F. Despite this policy, the heating system malfunctioned, and the facility did not consistently implement measures such as relocation or provision of extra blankets for all affected residents. One resident with lymphedema, repeated falls, asthma, depression, atrial fibrillation, and bilateral knee osteoarthritis, and with intact cognition per a BIMS score of 15, reported that it was very cold in the facility on a Sunday. This resident stated that the room was very cold, requiring extra blankets and a coat, and that staff later offered and completed a move to a warmer room on a different hall. The resident reported that no one had followed up about when they could return to the original room and that it was still too cold in the facility, requiring continued use of a coat and blanket while outside the room. Another resident with multiple sclerosis, dementia, cognitive communication deficit, and bipolar disorder, with moderately impaired cognition (BIMS score 12), reported that their room was very cold, that staff asked them to move rooms but they declined due to concern about leaving belongings unattended, and that they had to wear a coat, mittens, and an extra blanket to keep warm. Observation confirmed the room was very cool, the resident was in bed wearing a coat and mittens, and the in-room heating unit was not blowing air and had a blank control panel screen that did not respond to the on/off switch or temperature buttons. A third resident with polyneuropathy, type 2 diabetes mellitus, chronic respiratory failure, weakness, and major depressive disorder, and intact cognition (BIMS score 14), stated that it had gotten “pretty cold” in the room. This resident reported that staff did not offer another room to move to temporarily or offer additional blankets, and that they would have moved to sleep in a warmer room. The resident said the heating unit was working but did not blow very warm air, and that maintenance had checked it that morning without explaining what was done. Observation showed this resident wearing a coat, gloves, and blankets. A fourth resident with CHF, alcohol-induced persisting dementia, tachycardia, seizures, major depressive disorder, and GAD, and moderately impaired cognition (BIMS score 12), reported that the room was very cold overnight, that the heating unit felt like it was blowing cool air, and that they had to wear a sweater, coat, and gloves to stay warm. This resident stated that staff did not offer a move to a warmer room or extra blankets and that they would have moved temporarily if given the choice. A CMT reported working on the Sunday when the building became very cold, especially on one hall, due to a problem with the heating system. The CMT stated that some residents in affected rooms were offered moves to warmer rooms, two residents agreed to move, and two chose to stay, but the CMT did not know why all affected residents were not offered room changes. The Maintenance Director reported that one of the two boilers stopped working over the weekend and that while technicians were working on it, the second boiler also stopped working. The Maintenance Director acknowledged that temperatures in the facility became cool on that Sunday and again on the day of the survey, and noted that one resident room temperature had been 68°F that morning. The Maintenance Director stated they had been resetting individual heating units in resident rooms and that temperatures were returning to normal. The DON and Administrator both stated expectations that the facility temperature remain within 71–81°F, that residents should not need to wear mittens inside, and that residents should be relocated to warmer areas and offered extra blankets if rooms were too cold. Despite these stated expectations and the written policy, multiple residents experienced cold rooms, wore coats, gloves, and blankets indoors, and some were not offered relocation or additional blankets, demonstrating the failure to provide a safe and comfortable environment during the heating system failure.
Failure to Provide Required Discharge Notice and Documentation for a Resident Transferred to Another SNF
Penalty
Summary
The deficiency involves the facility’s failure to provide a required discharge notice, follow appropriate discharge procedures, and complete discharge documentation for a resident who was moved to another skilled nursing facility. The facility had a written Transfer and Discharge policy requiring that residents be transferred or discharged only under specific conditions, based on a physician order (unless leaving against medical advice), and that reasonable advance notice—typically 30 days—be given to the resident and their representative, with certain exceptions. The policy also required that a written notice of proposed transfer/discharge be provided to the resident and their representative, containing the reason for discharge, effective date, destination information, appeal rights, and Ombudsman contact information, and that a copy be sent to the State Long Term Care Ombudsman for facility-initiated discharges. Documentation related to discharge, including a discharge summary and post-discharge plan, was to be maintained in the medical record. The resident at issue was admitted from a hospital and later discharged to another skilled nursing facility within the same company. The resident had multiple diagnoses, including fluid overload, atrial fibrillation, cognitive communication deficit, repeated falls, lack of coordination, dementia with behavioral disturbance, heart disease, and urinary incontinence. An admission MDS showed adequate hearing, clear speech, ability to make self-understood and understand others, and a BIMS score of 10 indicating moderately impaired cognition, with no behaviors noted during that assessment. The comprehensive care plan included interventions for smoking-related lung function, ADLs, behaviors related to inappropriate sexual comments, communication, cardiac status, edema/fluid overload, cognition related to dementia, fall risk, mood problems related to new long-term care admission, nutrition, skin integrity, and bladder incontinence. The resident had a Durable Power of Attorney (DPOA) document naming a family member (Family Member A) as the Power of Attorney for financial, contractual, medical, legal, and personal matters. Despite these requirements and the identified DPOA, the facility did not obtain or document a physician order to discharge the resident to another skilled nursing facility, and the electronic medical record lacked a discharge notice, discharge summary, discharge care plan, or physician orders related to the discharge and admission to the receiving facility. Progress notes showed that on one date the Social Services Designee spoke with a family member who was not the DPOA to update them on the resident’s discharge progress, and later the Admissions Director documented that the resident would discharge to another skilled facility within the company on a specified day and time, with transport arranged, personal effects sent with the resident and family, and current documentation and discharge order to be sent. However, the DPOA (Family Member A) reported not being notified of the discharge, not receiving any discharge paperwork or discharge notice, and not being contacted by or signing admission paperwork for the receiving facility, and stated they would not have chosen that facility. The DON stated an expectation that staff notify the DPOA/representative, obtain approval or give a 30‑day notice, and ensure the accepting facility could meet the resident’s needs. The Administrator acknowledged that a discharge notice was not completed because staff believed the move to another skilled nursing facility was a transfer rather than a discharge, even though social services was responsible for discharge planning documentation and providing discharge notices as required by regulation. There was no indication in the record that, once the failure to provide a discharge notice was identified, the facility subsequently administered a discharge notice to the resident or the resident’s representative. The lack of required notice, absence of a physician discharge order, and missing discharge documentation in the medical record, combined with communication directed to a non‑DPOA family member instead of the designated DPOA, formed the basis of the deficiency identified by surveyors.
Failure to Document Critical Clinical Events and Administer Medications as Ordered
Penalty
Summary
The deficiency involves failures by licensed nursing staff and the social services designee (SSD) to document critical changes in a resident’s condition and treatment, as well as failures by nursing staff to administer and/or document medications as ordered for multiple residents. One resident with intact cognition, end-stage renal disease on hemodialysis three times weekly, insulin-dependent diabetes, chronic infected wounds with osteomyelitis, prior lower extremity amputation, atrial fibrillation, and congestive heart failure had a critical potassium level reported from an outpatient clinic. The clinic physician ordered that the resident be sent to the emergency room for treatment. RN A was notified of the critical lab and the order to send the resident to the hospital, spoke with the resident who refused transfer, and then contacted the facility nurse practitioner, who ordered an immediate 80 mEq dose of oral potassium and a STAT repeat potassium level. None of these events, including the resident’s refusal of hospital transfer, the new treatment plan, the STAT lab order, or the subsequent STAT lab results and provider notification, were documented in the resident’s clinical record. For this same resident, the SSD completed a change in code status to Do Not Resuscitate (DNR) but did not document this interaction or other extensive contacts with the resident in the clinical record, instead keeping notes in a separate notebook. The SSD recalled the resident expressing a wish to change to DNR status after discussions with dialysis nurses, and a new DNR was completed, but there was no corresponding documentation in the facility chart. Additionally, there was no documentation that the dialysis clinic or physician were notified when the resident refused a scheduled hemodialysis treatment, which also included IV antibiotic therapy, nor was the missed dialysis/antibiotic treatment documented as such. Nursing progress notes around the time of the critical potassium result and subsequent events contained only limited entries (e.g., repositioning, offering water, and the time the resident was found without respirations and pulse), with no record of the critical lab, treatment decisions, refusals, or communication with outside providers. The deficiency also includes failures to administer and/or document medications as ordered for three other residents. For one resident with multiple cardiac and nutritional medications, the MAR showed that on a specific date all ordered medications and supplements were marked with a code "9" (indicating to see progress notes), but the progress notes contained no explanation for why the medications were not administered. For another resident with numerous psychotropic, cardiac, pain, GI, and nutritional orders, the MAR likewise showed all medications and supplements coded "9" on a specific date, with no corresponding documentation in the progress notes explaining the omissions; in addition, gabapentin, buspirone, and Med Pass were not documented as administered at scheduled times. A third resident had ordered diltiazem three times daily and a nutritional supplement four times daily; on a specific date, both were coded "9" on the MAR, and a progress note explicitly stated that neither the medication nor the supplement had been administered. Staff interviews further clarified the circumstances leading to the missed medications. The staffing coordinator reported that on the day in question a Certified Medication Technician (CMT) called in for the 100 halls, and despite attempts to find in-house or agency coverage, no replacement was obtained until 2:00 p.m. RN B, who had never previously passed medications in LTC, was instructed to begin passing medications while coverage was sought. RN B reported difficulty with medication administration, including not knowing which medications required crushing or mixing with food, and being simultaneously responsible for a resident with a medical emergency, wound care, and monitoring residents for falls or altercations. RN B acknowledged that some medications were passed but not all, and that when the CMT arrived at 2:00 p.m., the CMT declined to administer the overdue medications and told RN B to document them as not administered. RN B stated that if medications were not passed, he or she should have documented in the progress notes why they were not administered, but this was not done.
Failure to Timely Report Alleged Sexual Abuse to Authorities
Penalty
Summary
The facility failed to follow its own abuse prevention policy and federal and state regulations by not reporting an alleged incident of sexual abuse involving a resident to law enforcement and the state survey agency within the required two-hour timeframe. The policy clearly mandates immediate reporting of suspected abuse, including sexual abuse, to the appropriate authorities, but this was not done in this case. The incident involved one resident allegedly attempting to put their hands down another resident's pants in a common area, as witnessed by staff and other residents. The resident who was the alleged victim had significant cognitive impairment, including diagnoses of senile degeneration of the brain, dementia with agitation, and major depressive disorder. The resident required assistance with activities of daily living and exhibited behaviors such as yelling and agitation. The alleged perpetrator also had cognitive deficits and a history of making inappropriate sexual comments, and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy, the incident was not reported to the state survey agency, law enforcement, or the hospice agency caring for the resident. Interviews revealed that staff were aware of the incident and that the family of the alleged victim was notified. However, the facility's administration determined, after reviewing camera footage and conducting assessments, that the incident did not occur as initially reported and therefore did not report it to authorities. The hospice agency only became aware of the incident after being informed by the resident's family, not by the facility. The failure to report the allegation as required constitutes the deficiency.
Failure to Investigate and Report Alleged Sexual Abuse
Penalty
Summary
The facility failed to follow its abuse prevention policy and did not ensure that an alleged incident of sexual abuse involving a resident was properly investigated. According to the facility's policy, all allegations of abuse, including sexual abuse, must be promptly and thoroughly investigated, with appropriate notifications made to authorities and documentation of all investigative steps. However, when an allegation was made that one resident put their hands down another resident's pants in a common area, the facility did not conduct a documented investigation as required by policy. The Administrator relied on a review of camera footage, which was later stated to be unavailable, and determined the allegation was unsubstantiated without further inquiry or reporting to the state survey agency or law enforcement. The resident involved in the alleged incident had significant cognitive impairment, as evidenced by a BIMS score of zero and diagnoses including dementia with agitation, senile degeneration of the brain, and major depressive disorder. The resident was also receiving hospice services and required assistance with activities of daily living. The alleged perpetrator had a history of making inappropriate sexual comments and was placed on one-to-one supervision following the incident. Despite these factors and the facility's policy requiring investigation and reporting, the Administrator did not initiate a formal investigation or notify external authorities. Interviews with staff and the resident's family revealed inconsistencies in the facility's response. The family was informed by nursing staff that the incident had been witnessed by others and that an assessment found no injuries or signs of distress. However, the Administrator later stated there was no camera footage and that the incident did not warrant reporting or further investigation. The lack of a documented investigation and failure to follow established protocols resulted in a deficiency related to the facility's handling of abuse allegations.
Failure to Protect Residents from Disruptive Yelling
Penalty
Summary
The facility failed to treat residents with dignity and respect when staff allowed a resident with severe cognitive impairment and behavioral symptoms, including screaming, yelling, and crying out, to remain in common areas where the behavior disturbed others. The resident’s MDS showed dependence on staff for ADLs and diagnoses including Parkinson’s disease, diabetes, and anxiety. The care plan identified the resident as being at risk for mood problems related to anxiety and depression and directed staff to assist with positive coping skills and maintain a stable mood state. During observation, the resident cried out and yelled in the assisted dining room while seated in a wheelchair, and staff repositioned the resident, offered water, and later wheeled the resident out of the dining room after continued yelling. Interviews showed staff were aware the resident yelled often and that the behavior upset other residents. An NA stated the resident had been moved to the hall in hopes it would help the yelling, and that other residents became upset when the resident yelled. A CNA said staff tried offering food, drink, and repositioning, but had not been given specific instructions for how to care for the resident. Two other residents reported that the constant yelling bothered and depressed them, and one said the yelling happened in front of staff who knew about it. The DON and Administrator stated they expected staff to address the needs of the resident and acknowledged that the other residents had a right to be treated with dignity and respect.
Failure to Provide Timely Incontinence Care and ADL Assistance
Penalty
Summary
The facility failed to provide timely incontinence care and basic ADL assistance for four residents who were dependent on staff for toileting and personal hygiene. The report states that Resident #10 had severe cognitive impairment, was incontinent of bowel and bladder, and required total assistance with toileting and perineal care. During continuous observation, the resident was left in a wheelchair for extended periods without toileting or repositioning and was later found with a foul body odor. When staff finally assisted the resident to the room, the incontinent brief was saturated and hanging to mid-thigh, with copious fluid dripping from it, and the resident’s skin was cleansed after the brief was removed. Resident #1 was also described as severely cognitively impaired, incontinent of bowel and bladder, and dependent on staff for toileting and personal hygiene. During observation, the resident was taken to activities and back without being toileted or changed. Later, the resident had a strong smell of urine, the wheelchair seat was wet and smelled of urine, the resident’s pants were wet in the groin area, and the brief was saturated with urine and had a strong odor. Staff stated the resident should have been provided incontinent care and repositioned at least every two hours, but they had not done so because they were busy helping other residents. Resident #4 had mild cognitive impairment, was totally dependent on staff for toileting, dependent on staff for showers, and always incontinent of bowel and bladder. During observation, the resident was taken to the dining room and back to the TV area without toileting or changing, and later had a strong smell of urine while sitting in the dining room. Resident #3 had severe cognitive impairment, was substantially assisted with toileting, and was incontinent of bowel and bladder. The resident was also observed being taken to activities and returned without toileting or changing, and staff did not offer toileting during the observation period. Interviews with NA A, CNA A, LPN B, the DON, and the Administrator reflected that dependent incontinent residents were expected to be checked and changed at least every two hours, but staff reported they had not provided the care because they were busy with other residents.
Delayed Incontinent Care and Unreported Buttock Skin Breakdown
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when a resident with dementia, heart failure, Parkinson’s disease, bowel and bladder incontinence, and dependence on staff for ADLs developed an open area on the right buttock after not receiving timely incontinent care. The resident’s MDS showed significant cognitive loss, incontinence, and risk for pressure ulcers, and the care plan directed staff to keep the skin clean and dry and provide full assistance with toileting and perineal care. On observation, the resident was seated in a wheelchair in the TV room and later taken to the dining room without being offered toileting or repositioning. The resident remained in the dining room for an extended period and later was observed in the TV room with a foul body odor. When the resident was assisted to the room, the incontinent brief was saturated and hung to mid-thigh, with copious fluid dripping from it. After cleansing, the resident had a pencil eraser-sized open area to the right buttock with pink-tinged drainage and surrounding redness and inflammation, and the resident stated the area hurt when it was wiped. Staff interviews showed the resident had not been changed or cleaned since the morning, and one NA stated there was not enough staff to provide care to all residents and that he/she was not able to change the resident’s brief as needed. A CNA stated he/she had not provided care since the morning because he/she was busy and did not have time to assist the resident. The LPN said he/she was not aware of the open area and could not evaluate the resident because the resident was in the dining room, and also stated the resident had a history of open areas and wounds. The DON and Administrator stated incontinent residents should be checked and changed at least every two hours and as needed, and open areas should be reported immediately.
Failure to Obtain and Follow Wound Vac Dressing Orders Resulting in Harm
Penalty
Summary
The facility failed to ensure that appropriate wound dressing orders were obtained and followed for a resident with a left below-the-knee amputation and multiple comorbidities, including Parkinson's Disease and peripheral vascular disease. The resident had a negative pressure wound therapy (wound vac) applied to the surgical site, but there were no documented physician orders for wound vac changes between September 9 and September 16. During this period, the wound vac dressing remained in place for ten days without being changed, contrary to standard practice and the facility's own wound management policy, which requires treatment per physician order and regular skin assessments. When staff attempted to change the wound vac dressing, they found the sponge severely adhered to the wound, resulting in significant bleeding and pain for the resident. The lack of documentation regarding dressing changes and absence of a wound nurse contributed to confusion among staff about wound care responsibilities and supply ordering. The incident led to the resident being transferred to the hospital due to excessive bleeding. Interviews with clinical staff and providers confirmed that the dressing was not changed as expected and that there were no clear orders or documentation guiding wound care during the period in question.
Failure to Prevent Elopement and Injury in Cognitively Impaired Resident
Penalty
Summary
A resident with a history of traumatic brain injury, subdural hemorrhage, dementia with behavioral disturbances, and other significant medical conditions eloped from the facility's secure memory care unit. The resident was known to have severely impaired cognition, required substantial assistance with activities of daily living, and had a documented risk for elopement and wandering. On the day of the incident, the resident was observed to be agitated, demanding to go home, and was last seen at the nurse's station before propelling a wheelchair down the hallway, transferring out of the wheelchair, and exiting through a door that sounded an alarm. Shortly after, the resident was found in the facility parking lot by visitors, sitting on the ground with a laceration to the forehead. Staff responded, brought the resident back inside, and the resident was subsequently sent to the emergency room for evaluation due to the head injury and history of anticoagulant use. The resident returned later with sutures to the forehead and additional bruising, but imaging was negative for further injury. Interviews with staff and practitioners confirmed that the resident was known for frequent wandering and exit-seeking behaviors, and staff were expected to monitor the resident and respond to door alarms. The deficiency occurred due to the facility's failure to provide adequate supervision and prevent the resident from eloping, despite the resident's known risks and behaviors. The resident was able to leave the secure unit, exit the building, and sustain an injury before being found and assisted by staff.
Failure to Provide Required Discharge Notice and Documentation
Penalty
Summary
A deficiency occurred when facility staff failed to provide an appropriate discharge for a resident with complex medical and behavioral needs. The resident, who had diagnoses including congestive heart failure, neurocognitive disorder with Lewy bodies, repeated falls, dementia, and was on hospice care, was transferred to a hospital following an incident of severe agitation and aggression. Staff attempted de-escalation techniques, but after the resident struck a staff member and exhibited exit-seeking behavior, the DON called 911 for a hospital transfer. The family was notified of the transfer for medical evaluation, but there was no clear communication that the resident would not be accepted back to the facility. The facility did not provide the required written notice of discharge, which should have included the date and location of discharge, a statement of appeal rights, and contact information for the State Long Term Care Ombudsman. Documentation of the bed hold policy was not found in the electronic records, and the family confirmed they did not receive a copy of the bed hold policy, notice of proposed transfer/discharge, or information regarding appeal rights. The resident's DPOA was not notified of the transfer or discharge, and there was no evidence of the resident or representative's involvement in the development of a discharge plan addressing the resident's needs. Interviews with facility staff revealed confusion and lack of coordination regarding the discharge process. The Social Services Director had little involvement and was notified after the transfer occurred, while the Admissions Coordinator was unaware that the resident would not return to the facility. The DON and LPN involved in the transfer did not communicate the final discharge decision to the family or DPOA. The hospital staff were also not informed that the resident would not be returning, and the hospital was not equipped to provide long-term care. As a result, the resident experienced confusion, physical and psychosocial harm due to the lack of appropriate planning and notification.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse when one resident physically assaulted another, resulting in multiple injuries. Specifically, a resident with a history of behavioral problems, including hitting and pulling peers' hair, and diagnoses such as frontal temporal neurocognitive disorder, dementia, depression, and Pick's disease, hit and restrained another resident. The assaulted resident, who had Alzheimer's disease and dementia, sustained a scratch to the left cheek, redness to the right eye, an abrasion to the right eyebrow, and redness and bruises to the right forearm and bicep. The incident occurred in a resident room and was discovered by staff after hearing screaming; staff did not witness the altercation but found the injured resident visibly shaken and crying. The care plan for the resident who initiated the altercation noted a behavior problem and directed staff to intervene as necessary to protect others, but the incident still occurred. Both residents involved had significant cognitive impairments, and the resident who was assaulted had a history of trauma and poor safety awareness. The facility's Abuse Prevention and Prohibition Program outlined a zero-tolerance policy for abuse and required staff to prevent abuse and monitor resident behaviors that could lead to conflict. Despite these policies, the altercation resulted in physical harm, and the injuries were confirmed by the DON and Administrator as fitting the definition of physical abuse according to facility policy.
Food Safety and Hygiene Protocol Deficiencies Identified
Penalty
Summary
The facility failed to ensure compliance with food safety standards during a survey conducted on 04/08/24. Observations revealed multiple instances of stored food items being undated and exposed to potential contamination in the walk-in freezer and refrigerator. Additionally, air vents in the kitchen were visibly dirty, posing a risk of contaminating food with dust particles. The Dietary Director acknowledged the importance of proper labeling and dating of food items but noted a lack of awareness among maintenance staff regarding the cleanliness of the vents. Furthermore, during the same survey, a dietary staff member was observed not wearing a beard restraint while handling food on the serving line, contrary to facility policy requiring staff to wear appropriate hair restraints at all times. The staff member admitted to removing the restraint due to discomfort, highlighting a gap in adherence to established guidelines for preventing hair contamination in food preparation areas. These deficiencies in food storage practices and staff compliance with hygiene protocols could potentially impact the health and safety of the 98 residents consuming food prepared in the facility's kitchen.
Failure to Inform Resident of Medication Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident and/or their representative was informed of the risks and benefits of a physician-ordered antipsychotic medication. Specifically, Resident 78, who was admitted with Alzheimer's disease and major depressive disorder, was prescribed Abilify 5 mg at bedtime. The resident's electronic medical record did not document that the resident or her representative was informed of the risks and benefits prior to initiating the new medication order. This oversight was confirmed during an interview with the Unit Manager, who acknowledged that no consent was obtained for the use of the medication. Resident 78 had a Brief Interview of Mental Status score indicating moderate cognitive impairment and was administered the antipsychotic medication daily. During an interview, the resident stated she was not aware of what Abilify was for, despite being administered the medication. The facility did not provide a policy regarding the documentation of informed consent for medication use, highlighting a significant lapse in ensuring residents are fully informed about their treatments.
Failure to Maintain Clean and Comfortable Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment for Resident 67, who was observed to have a heavy build-up of dirt and grime in the sliding door track, dirt and dust under the bed, and small black ants in the room. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the room's condition remained poor over multiple observations. The resident and a family member both noted the presence of ants and the need for better cleaning. The facility's Administrator was unaware of the ant issue, and the Activity Director, who oversees housekeeping, acknowledged that spring cleaning had not yet started and there was no care plan addressing the resident's wishes and the need for room cleaning. During interviews, the Administrator mentioned that exterminators visit every other week and weekly in late spring and summer. The Activity Director stated that they had not begun spring cleaning tasks such as steam cleaning and moving furniture. The lack of a care plan to balance the resident's preferences with the need for cleanliness contributed to the ongoing issue. The facility's failure to address the cleanliness and pest control in Resident 67's room led to the deficiency noted in the report.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, bit Resident 51 on the arm after Resident 51 reached for a blanket that Resident 96 was using. Both residents have significant cognitive impairments, with their respective care plans noting aggressive and socially inappropriate behaviors. Despite interventions to monitor and manage these behaviors, the incident occurred, resulting in a bruise on Resident 51's arm, although the skin was not broken. Interviews with staff revealed that Resident 96 was known to be uncooperative with care, often becoming combative when staff attempted to take something away from her. Staff had been using strategies such as offering sweets and drinks to redirect her, but these were not always effective. On the day of the incident, Resident 96 was lying on a couch in the common area, a place she preferred to stay during the day. When Resident 51 reached for the blanket, Resident 96 reacted by biting her. Staff immediately separated the residents and placed Resident 96 on 15-minute checks. Further interviews indicated that staff were aware of Resident 96's unpredictable behavior and had been trying to keep a close eye on her. The Director of Nursing mentioned that Resident 96 had been sent out for psychiatric evaluation following the incident. The facility's policy on abuse and neglect emphasizes the residents' right to be free from all forms of abuse and outlines procedures for reporting and addressing such incidents. However, the measures in place were insufficient to prevent the incident from occurring, highlighting a deficiency in protecting residents from abuse by other residents.
Failure to Report Injury and Altercation Timely
Penalty
Summary
The facility failed to report an injury of unknown origin and a resident-to-resident altercation to the State Survey Agency (SSA) within the required timeframes. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a bruise below her left eye on 10/24/23. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON also did not recall the incident and confirmed it was not reported to the SSA as required. Additionally, an altercation occurred on 03/20/24 where Resident 96 was hit by another resident. This incident was reported to the unit manager but not to the DON until the following morning. The DON was unaware that such incidents needed to be reported within two hours if they did not result in major injury. The incident was eventually reported to the SSA on 03/22/24. The facility's policy mandates reporting all incidents of potential abuse, neglect, exploitation, or potential crimes against residents within prescribed timeframes, but this was not adhered to in these cases.
Failure to Investigate Injury and Altercation
Penalty
Summary
The facility failed to conduct thorough investigations for an injury of unknown origin and a resident-to-resident altercation involving two residents. Resident 96, who has diagnoses including frontotemporal neurocognitive disorder, dementia, impulse disorder, and delusional disorder, was found with a small purplish bruise below her left eye while sitting in the TV area. The resident was unable to explain how the bruise occurred and denied pain. The Licensed Practical Nurse (LPN) who discovered the bruise did not remember reporting it to the Director of Nursing (DON) or completing a report. The DON confirmed that no investigation was conducted to determine the cause of the bruise. Resident 51, diagnosed with Alzheimer's and dementia, was involved in an altercation where another resident was observed hitting her on the right arm. The incident was reported to the unit manager by an LPN, but the DON confirmed that no investigation or witness statements were collected. The facility's policy mandates thorough investigations for all allegations, observations, or suspected cases of abuse, neglect, misappropriation of property, exploitation, or injuries of unknown sources, which was not followed in these cases.
Failure to Update Care Plans for PTSD and Specialized Wheelchair
Penalty
Summary
The facility failed to revise the care plan for two residents, leading to deficiencies in their care. Resident 66, who was admitted with a diagnosis of PTSD, did not have an updated care plan addressing this condition. Despite showing symptoms of depression and expressing feelings of tiredness and lack of interest in activities, the care plan for Resident 66 did not include any interventions related to PTSD. The Social Services Director was unaware of the PTSD diagnosis and had not written a care plan for it, indicating a lapse in communication and documentation within the facility's care planning process. Resident 55, who has Alzheimer's disease and dementia, was observed using a specialized wheelchair provided by hospice for four to six months. However, the care plan for Resident 55 was not updated to reflect the use of this specialized wheelchair. The Unit Manager confirmed that the care plan had not been revised to include this critical piece of equipment. This oversight in updating the care plan could lead to inappropriate care and services for Resident 55, who is dependent on staff for all activities of daily living and has severe cognitive impairment.
Failure to Provide Appropriate Care and Timely Medical Appointments
Penalty
Summary
The facility failed to ensure that two residents received care and treatment in accordance with professional standards of practice. Resident 55, who has Alzheimer's disease and is severely cognitively impaired, was observed in a specialized wheelchair without proper support. The headrest was angled away from her head, and her left leg was dangling without the support of a leg pedal. Staff interviews revealed that the headrest and leg pedal were not consistently utilized, and there was confusion about whose responsibility it was to ensure these supports were in place. The Rehabilitation Director confirmed that the headrest and leg pedal should be used at all times when the resident is in the wheelchair. Resident 67, who is cognitively intact and has a history of Guillain-Barre syndrome and pruritus, complained of excessive itching and believed she was being bitten by bugs. Despite her requests to see a dermatologist, no appointment was made. Observations and interviews revealed that the resident had reddened and scabbed areas on her skin, and her complaints were documented in the medical record. However, the Assistant Director of Nursing and the Social Service Director were unaware of her request for a dermatology appointment, and no orders for such an appointment were obtained. The facility's failure to provide appropriate support for Resident 55's head and leg while in the wheelchair and the delay in obtaining a dermatology appointment for Resident 67 highlight deficiencies in adhering to professional standards of care. These lapses were confirmed through observations, staff interviews, and record reviews, indicating a need for improved communication and adherence to care plans within the facility.
Failure to Provide Appropriate ROM Services
Penalty
Summary
The facility failed to ensure that a resident with a history of stroke and cerebral palsy received appropriate services to maintain or improve her range of motion (ROM). The resident, who was cognitively intact, had functional limitations in ROM on one side for both the upper and lower extremities. Despite this, the resident did not receive any restorative therapy or exercises to prevent a decline in her contractures. The only intervention documented was the placement of a washcloth in her contracted right hand, which was insufficient to address her needs. Interviews with the resident and staff revealed that the resident did not receive any exercises for her hand and foot, and there was no restorative program in place for her. The Assistant Director of Nursing (ADON) and the MDS Coordinator both confirmed that the resident had not been assessed for restorative exercises, and there was no designated nurse responsible for the restorative program. The facility's policy indicated that residents with potential for decline should be referred to the restorative nurse aid (RNA) program, but this was not done for the resident in question.
Failure to Properly Store Respiratory Equipment
Penalty
Summary
The facility failed to ensure that a resident received respiratory care consistent with professional standards of practice. Specifically, the facility did not place the resident's nebulizer tubing and pipe into a covered bag to minimize the spread of pathogens. This deficiency was observed during a survey, where the nebulizer machine and its components were found on the bedside table without a barrier or bag. The resident, who had been admitted with diagnoses including heart failure and chronic obstructive pulmonary disease (COPD), was at risk for infection due to this oversight. The resident's medical records indicated a need for nebulizer treatments four times a day and the use of oxygen at night. Despite these requirements, the facility did not follow proper storage protocols for the respiratory equipment. An interview with an LPN confirmed that nebulizer masks and pipes should be bagged when not in use, but this was not done for the resident in question. The facility was unable to provide a policy for storing respiratory equipment when requested by the surveyors.
Failure to Complete AIMS Assessment and Properly Document PRN Psychotropic Medication
Penalty
Summary
The facility failed to complete an Abnormal Involuntary Movement Scale (AIMS) assessment for a resident (R78) who was administered antipsychotic medication, Abilify, for Alzheimer's disease, dementia, and major depressive disorder. The AIMS assessment was not performed upon initiating the medication but was delayed by 57 days. The facility's policy required AIMS assessments at admission, readmission, and quarterly if the resident has orders for psychotropic medication. The Unit Manager confirmed that the AIMS assessment was not done at the time the medication was started and could not provide an assessment for the previous quarter before the survey team exited. This failure placed the resident at risk for unrecognized side effects and a diminished quality of life. Additionally, the facility failed to have a stop date and diagnosis for the use of an as-needed (PRN) psychotropic medication, Lorazepam, for another resident (R59) who had a history of stroke and diabetes and was severely impaired in cognition. The Physician Order for Lorazepam was open-ended without a discontinue date and lacked a diagnosis for its use. The Licensed Practical Nurse (LPN) and Consultant Pharmacist were unaware of the need for an end date and proper diagnosis for the medication. The facility's policy required that each resident's drug regimen be free from unnecessary drugs, and PRN orders for psychotropic medications should be limited and necessary. This oversight placed the resident at risk for unrecognized side effects and a diminished quality of life.
Failure to Remove Expired Insulin Pen
Penalty
Summary
The facility failed to ensure an insulin pen was removed from one medication cart after 28 days for one of 18 Kwik pens that were observed for open date and expiration date. During an observation with a Registered Nurse (RN), it was revealed that the Kwik pen for a resident had an open date that was smudged and not legible. The RN confirmed that the Kwik pen was expired and had been used to administer insulin to the resident when their blood sugar was 375. The Director of Nursing (DON) confirmed that the expectation was for expired insulin pens to be removed from the cart and not used. Review of the physician orders in the electronic medical record (EMR) indicated that the resident was to receive four units of Humalog Kwik Pen U-100 insulin if their blood sugar was greater than 300. The manufacturer's guidelines state that opened Humalog prefilled pens must be discarded 28 days after first use. The facility's policy on medication storage also mandates that no outdated or deteriorated drugs be retained for use. Despite these guidelines, the expired insulin pen was not removed, leading to the deficiency.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to ensure the reach-in refrigerator in the kitchen was properly maintained, which had the potential to affect 98 of the 99 residents who consume food from the kitchen. During a tour of the kitchen, it was observed that the refrigerator had a leak resulting in about an inch of water at the bottom, which was almost reaching the rim of a cookie sheet with condiments on it. Several boxes of Jello were visibly wet from the leak, and the water extended onto the floor when the doors were opened. The issue persisted the following day, with a thick slice of cheese wrapped in saran wrap observed submerged in the water. Dietary staff confirmed that the refrigerator had been leaking for at least six months, sometimes causing water to leak onto the floor. The maintenance staff, who had been employed since February 19, 2024, stated that logbooks were kept at each nursing station for items needing attention and were checked daily. However, the maintenance staff was only notified about the refrigerator leak on the day of the interview. The administrator, acting as the maintenance director, confirmed that they had been without a Maintenance Director for a few weeks and were only notified about the leak the previous day. A review of the Maintenance Repair Log revealed that the issue was noted on August 10, 2023, but there was no indication that it had been repaired. The dietary director mentioned that the state had visited in August 2023 and indicated that the refrigerator should be fixed, but it was left as a concern without a violation, leading to the repair notice being written in the log.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 665 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tiffany Springs Rehabilitation & Health Care Cente | 4.6 mi | ★★★★★ | 20 | 0 |
| Linden Woods Village | 5.3 mi | ★★★★★ | 0 | 0 |
| Pleasant Valley Manor Care Center | 7.7 mi | ★★★★★ | 16 | 2 |
| Ignite Medical Resort Kansas City, Llc | 7.8 mi | ★★★★★ | 11 | 0 |
| Avalon View Health And Wellness | 8.2 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.