Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Parkside Manor during CMS and state inspections, most recent first.
Staff failed to protect a cognitively intact, independent resident from sexual abuse when a CNA repeatedly entered the resident’s room when the roommate was absent or asleep, hugged the resident, and kissed the resident on the mouth without the resident’s initiation or encouragement. A housekeeper observed the CNA return to the resident’s room, then saw the CNA and the resident in a full hug with the CNA kissing the resident on the mouth through a partially open door, and reported the incident. The resident later reported that these contacts were inappropriate and made the resident uncomfortable, while the CNA admitted to hugging the resident but denied kissing and believed hugging was not inappropriate, despite the facility’s abuse policy defining sexual abuse as any non-consensual sexual contact and requiring immediate reporting of abuse allegations.
Surveyors found that staff failed to follow infection control practices, including hand hygiene, Enhanced Barrier Precautions (EBP), and oxygen equipment management. During perineal care for a resident on EBP, multiple aides did not wear gowns despite door signage, handled oxygen tubing that had been on the floor, touched shoes and other contaminated surfaces, and then placed a nasal cannula, clean briefs, and personal items without changing gloves or performing hand hygiene. Another resident with a wound and EBP signage received perineal care from a CNA who wore gloves but no gown and later reported not noticing the precautions. For three residents using oxygen, surveyors observed undated nasal cannulas, tubing lying on the floor or without storage bags, missing or unclear physician orders for oxygen and tubing changes, and no documentation of required tubing changes in treatment records, despite facility expectations that tubing be dated, documented, changed if contaminated, and stored properly.
A deficiency was cited for not providing a safe, clean, comfortable, and homelike environment, including failing to ensure that a resident received treatment and supports for daily living in a safe manner.
A resident with a history of anxiety disorder and suicidal ideation expressed not wanting to live, which was overheard by staff and reported to an LPN. The LPN spoke with the resident but did not notify the DON or the resident's physician, nor document the incident, despite facility policy requiring immediate notification and documentation. The DON and administrator confirmed that physician notification was expected but did not occur.
Facility staff did not complete the required admission MDS assessment for a resident within the federally mandated 14-day period. The assessment remained incomplete and unsigned by an RN, and the administrator was unaware of the delay or any additional time for RN signature.
Facility staff did not complete a baseline care plan within 48 hours for a newly admitted resident with a psychiatric history, including recent suicidal ideations. The admitting nurse did not finalize the required documentation, and oversight by the DON and ADON was lacking, resulting in the absence of a person-centered care plan as required by facility protocol.
A resident with a history of anxiety disorder and suicidal ideations expressed suicidal thoughts, but an LPN did not notify the DON or physician as required by policy, nor document the incident at the time. The resident's EHR lacked a care plan for suicidal ideation, and interviews confirmed that key staff were unaware of the incident and diagnosis, resulting in a failure to meet professional standards for suicide threat management.
Staff did not promptly inform a resident's representative when the resident's toilet became unsecured and required a room change, and failed to notify physicians in a timely manner when two residents experienced skin injuries.
An LPN failed to follow physician's orders for water flushes during medication administration for two residents with feeding tubes. One resident with a G-tube received 500 ml of water instead of the prescribed 30 ml before and after medications, while another resident with a PEG tube received 150 ml instead of the ordered 60 ml. The LPN did not verify the orders, leading to a deficiency in professional standards of care.
The facility failed to meet its own staffing requirements on the night shift, as outlined in their Facility Assessment, for a census of 66 residents. From 12/12/24 to 12/17/24, the facility consistently scheduled fewer staff than required, with only one licensed nurse and a maximum of four CNAs, and sometimes only three NAs. Interviews revealed a lack of awareness and misunderstanding of staffing needs, with the administrator and ADON not aligning on the required staffing levels. This resulted in inadequate coverage, particularly in areas like Colonial Hall, compromising resident care and safety.
The facility failed to ensure RN coverage for at least eight consecutive hours daily, as required. The RN staff schedule for October, November, and December 2024 showed multiple days without an RN present for the required hours. The DON, who was the only RN on the schedule, acknowledged the lack of coverage and stated that he/she was salaried and only attended to the facility's needs. The administrator confirmed the deficiency, noting the risk of not having RN expertise available when needed.
The facility failed to ensure that three NAs completed the required training within four months of employment. The facility's policies lacked guidelines for NA qualifications, and employee files for NAs A, C, and E did not show completed training. Interviews revealed that the facility was aware of the certification requirement but faced challenges in finding training locations after losing access to a previous facility.
Facility staff failed to implement Enhanced Barrier Precautions (EBP) for residents requiring them. A resident with a wound did not have an EBP sign or PPE available, and an LPN provided wound care without a gown. Another resident with a PEG tube had an EBP sign but no PPE nearby, and an LPN administered medication without PPE. A resident with a tracheostomy had an EBP sign, but a CNA did not wear a gown during care. The IP and administrator acknowledged these oversights, indicating a systemic failure in EBP policy implementation.
The facility failed to implement an Antibiotic Stewardship Program, lacking protocols and a system to monitor antibiotic use. The Infection Preventionist, responsible for the program, documented usage but did not trend or monitor it, citing other responsibilities. The DON and administrator were unaware of the program's incomplete status.
The facility failed to provide a structured program of daily activities for residents in the Memory Care Unit, as observed in four residents with cognitive impairments. The absence of a current activity calendar and lack of engagement in activities were noted, with residents often found wandering or alone. Staff interviews revealed insufficient staffing and locked access to activity materials, contributing to the deficiency.
Facility staff failed to maintain proper communication with a dialysis clinic for a resident receiving dialysis. The required Dialysis Communication Record was not used, and vital signs and weights were not documented in the resident's chart. Interviews revealed that staff were unaware of the form's use, and the Director of Nursing and administrator did not ensure its implementation.
The facility failed to document collaboration of care with hospice providers for two residents receiving hospice services. Reviews of hospice binders and medical records showed missing plans of care and communication documentation. Interviews with staff, including an LPN, the DON, and the administrator, revealed a lack of awareness and oversight regarding the missing documentation, with the DON acknowledging responsibility but citing recent arrival at the facility as a factor.
Facility staff failed to properly sanitize a glucometer and use a protective barrier for supplies, leading to potential cross-contamination among residents with diabetes. A CMT placed the glucometer directly on the medication cart without a barrier and did not sanitize it between uses. Interviews with staff confirmed the lack of adherence to infection control protocols, highlighting the risk of spreading germs.
Facility staff failed to provide a proper mechanical lift transfer for a resident with moderate cognitive impairment and hemiplegia, resulting in an acute left proximal humeral fracture. Despite the care plan requiring two-person assistance, a CNA performed the transfer alone, leading to the injury. Interviews confirmed that the standard procedure was to use two staff members for safety.
Failure to Protect a Resident From Non-Consensual Sexual Contact by CNA
Penalty
Summary
Facility staff failed to protect a cognitively intact resident from sexual abuse when a CNA engaged in non-consensual physical contact. The resident’s quarterly MDS showed the resident was cognitively intact and care plan indicated independence with ADLs. On the morning in question, a housekeeper observed the CNA go to the nurses’ station from the direction of the resident’s room, look around, then quickly return to the resident’s room. When the housekeeper approached to clean the room, the door was slightly open; after a quiet knock and looking in, the housekeeper saw the CNA and the resident in a full hug, with the CNA kissing the resident on the mouth. The housekeeper then reported this observation to another housekeeper, who in turn reported it to the administrator. The facility’s abuse and neglect policy defined sexual abuse as non-consensual sexual contact of any type with a resident and required immediate reporting of all abuse allegations to the administrator. In a written statement, the CNA acknowledged going to the resident’s room and hugging the resident, claiming it was to comfort the resident, and denied kissing the resident, stating that hugging residents was not considered inappropriate. In contrast, the resident documented and later stated in interviews that the CNA had repeatedly come into the room when the roommate was absent or asleep to hug and kiss the resident, that these actions were not initiated or encouraged by the resident, and that the resident felt uncomfortable and did not want to be kissed. The resident also reported not disclosing these incidents earlier due to concern about how the CNA might treat the resident and the resident’s friends.
Failure to Follow Hand Hygiene, Enhanced Barrier Precautions, and Oxygen Equipment Protocols
Penalty
Summary
Surveyors identified deficiencies in the facility’s infection prevention and control practices related to hand hygiene, use of Enhanced Barrier Precautions (EBP), and management of oxygen equipment. Facility policies on handwashing and hand cleanser directed staff to cleanse hands between resident contacts and after contact with bodily fluids, but did not clearly address hand hygiene frequency or glove changes between dirty and clean tasks. The perineal care policy instructed staff to remove gloves and wash hands after care, but did not specify hand hygiene and glove changes between dirty and clean portions of the procedure. The EBP policy required use of gown and gloves for high-contact resident care activities, including dressing, bathing, transferring, hygiene, changing briefs, and toileting, for residents with MDRO risk or wounds. The oxygen equipment policy required tubing, masks, and cannulas to be replaced monthly and PRN, labeled with date and initials, and stored appropriately. For one resident with severe cognitive impairment, incontinence, and care plan directions for EBP and oxygen use as needed, staff failed to follow hand hygiene and EBP requirements during perineal care. Observations showed the resident’s nasal cannula and oxygen tubing lying on the floor, with no storage bag attached to the concentrator. Staff entered the room, which had EBP signage requiring gown and gloves, but three aides did not wear gowns. One aide picked up oxygen tubing from the floor and placed it on the concentrator; another aide touched the bottom of the resident’s shoes and then placed the oxygen cannula into the resident’s nose with the same soiled gloves. During perineal care, the aide did not perform hand hygiene or change gloves between cleaning the perineal area and placing a clean brief, applying powder, touching the resident’s drawer, fastening the brief, and handling the mechanical lift sling and oxygen tubing. The aide then removed gloves and handed the call light to the resident without hand hygiene. Another aide placed a bag with a soiled brief on the floor, handled the resident’s personal items, and left the room without performing hand hygiene. Interviews with the aides revealed they were unaware the resident was on EBP, did not notice the door signage, and acknowledged missing hand hygiene and glove change opportunities. For a second resident with moderate cognitive impairment, a wound, and a care plan requiring EBP with gown and gloves for high-contact care, staff again failed to follow EBP. The resident’s door displayed EBP signage instructing staff to wear a gown and gloves, but an aide entered to provide perineal care wearing gloves only and no gown. The resident reported having wounds on the buttocks. The aide later stated they did not know the resident had a wound and did not notice the EBP signage until after leaving the room. Facility leadership confirmed that signage is placed on doors for residents on precautions and that staff are educated to use gown, gloves, and mask for residents on EBP. Surveyors also found deficiencies in oxygen equipment management for three residents. For the first resident, physician orders required monthly oxygen tubing changes on Sundays, but the treatment administration records lacked documentation that tubing was changed on the specified dates. The resident’s oxygen tubing was observed on the floor, undated, and without a storage bag on the concentrator. For a third resident, the MDS and physician orders did not indicate oxygen use or orders for tubing changes, yet the resident was observed in bed with a nasal cannula in place, undated tubing, and no storage bag on the concentrator. For a fourth resident, assessments and care plan indicated no routine oxygen use, but there was an order for PRN oxygen at two liters without an order for tubing replacement. This resident was observed wearing an undated nasal cannula, with no documentation of tubing changes in the treatment record and no storage bag on the concentrator. Interviews with nursing staff and administration confirmed that tubing should be labeled with the change date, documented in the TAR, changed if it had been on the floor, and stored in a bag when not in use, but there was no system in place to ensure these tasks were consistently completed.
Failure to Ensure a Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that the facility did not ensure residents received treatment and supports for daily living in a manner that maintained their safety and comfort. Specific details about the actions or inactions leading to this deficiency, as well as information about the residents involved or their medical conditions, are not provided in the report.
Failure to Notify Physician of Resident's Suicidal Ideation
Penalty
Summary
Facility staff failed to notify a resident's physician after the resident expressed suicidal ideation. The resident, who had a history of generalized anxiety disorder and suicidal ideations, was overheard by staff saying on the phone that they did not know if they wanted to live anymore. The staff member reported this to the charge nurse, who then spoke with the resident and suggested hospitalization for emotional support. However, there was no documentation that the resident's physician or responsible party was notified of the incident, as required by facility policy. Further review of the resident's electronic health record revealed the absence of a care plan and no documentation of the incident or any notifications made. Interviews with the LPN and DON confirmed that the physician was not notified, and the incident was not documented at the time. The LPN stated they did not notify the DON or physician because they believed the resident was okay after their conversation. The DON and administrator both indicated that they would expect the physician to be notified in such situations, but this did not occur.
Failure to Complete Admission MDS Assessment Within Required Timeframe
Penalty
Summary
Facility staff failed to complete the federally mandated Minimum Data Set (MDS) admission assessment within the required 14-day timeframe for one resident. Review of the resident's records showed that the admission MDS was not completed or submitted by the due date, as required by the RAI manual and OBRA regulations. Interviews with the DON, MDS Coordinator, and administrator confirmed that the MDS Coordinator was responsible for completing the assessment within 14 days, but the process was delayed, and the assessment was not finalized because it had not been signed by an RN. The administrator was unaware of the incomplete status of the resident's MDS assessment and did not recognize any additional time allowance for RN signature beyond the 14-day requirement.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
Facility staff failed to develop a comprehensive, person-centered baseline care plan to address a resident's medical, nursing, mental, and psychosocial needs within 48 hours of admission. Review of the resident's medical record showed that, despite facility protocols requiring completion and filing of a baseline care plan within 48 hours, no such care plan was present for the resident. The resident was admitted with a psychiatric history, and staff were not aware of a recent diagnosis of suicidal ideations at the time of admission. Interviews with facility staff revealed that the admitting nurse was responsible for completing the baseline care plan upon admission, with oversight from the DON or ADON. The ADON stated that the baseline care plan template was loaded into the electronic health record at admission, but the admitting nurse did not complete it. The DON, who was on vacation during the admission, acknowledged that the baseline care plan was missed and was unaware of the resident's recent suicidal ideations. The administrator confirmed that the expectation was for the admitting nurse to complete the care plan and for the DON or ADON to follow up on any missing documentation.
Failure to Follow Suicide Threat Protocol and Notify Appropriate Staff
Penalty
Summary
Facility staff failed to follow established policy and professional standards when a resident with a history of generalized anxiety disorder and suicidal ideations expressed suicidal thoughts. The resident was overheard by a staff member stating on the phone that they did not know if they wanted to live anymore. The staff member reported this to an LPN, who spoke with the resident, assessed for a suicide plan, and monitored the resident at intervals. However, the LPN did not notify the Director of Nursing (DON) or the resident's physician, as required by facility policy, and did not document the incident at the time it occurred. The resident's electronic health record lacked a care plan addressing suicidal ideation, and there was no documentation of the date and time of the incident, DON notification, or physician notification. Interviews with the LPN, DON, and administrator confirmed that the DON and physician were not notified of the resident's suicidal statements, and that the incident was not documented according to policy. The DON and administrator both stated they were unaware of the resident's suicidal ideations and would have expected to be notified and for the incident to be documented. The physician's office also confirmed there was no record of notification regarding the resident's suicidal comments or emotional distress. These failures resulted in the facility not meeting professional standards of quality for addressing suicide threats.
Failure to Notify Representatives and Physicians of Significant Resident Events
Penalty
Summary
Facility staff failed to notify a resident's representative when the resident's toilet became unsecured from the floor, tipped, and required the resident to be moved to a different room. Additionally, staff did not notify the physicians of two residents in a timely manner when those residents experienced a skin injury. These failures were identified through observation, interview, and record review during the survey, with a facility census of 73 residents. The deficiencies involved lack of timely communication to both resident representatives and physicians regarding significant events affecting the residents, including environmental hazards and changes in medical condition.
Failure to Follow Physician's Orders for Water Flushes
Penalty
Summary
Facility staff failed to maintain professional standards of care by not adhering to physician's orders regarding water flushes during medication administration for two residents with feeding tubes. Resident #38, who was assessed as a nutritional risk with a G-tube, had physician orders to flush the tube with 30 ml of water before and after medication administration. However, an LPN administered medications and flushed the tube with a total of 500 ml of water, exceeding the prescribed amount. Similarly, Resident #12, who had a PEG tube with continuous night feedings, was ordered to have the tube flushed with 60 ml of water before and after medications. The LPN administered medications and flushed the tube with 150 ml of water, again not following the physician's orders. Interviews with the LPN and the Director of Nursing revealed that the LPN was unsure of the correct water flush amounts and did not verify the physician's orders before administering medications. The Director of Nursing and the facility administrator both stated that they expected nurses to follow physician's orders and verify them if unsure. This failure to adhere to physician's orders for water flushes during medication administration was observed and documented by surveyors, indicating a deficiency in maintaining professional standards of care.
Inadequate Night Shift Staffing in LTC Facility
Penalty
Summary
The facility failed to provide adequate nursing staff on the night shift as per their Facility Assessment, which required two licensed nurses and five to eight CNAs for a census of 65-70 residents. The facility's actual staffing during the period from 12/12/24 to 12/17/24 consistently fell short, with only one licensed nurse and a maximum of four CNAs scheduled, and on some nights, only three NAs were present. This staffing level did not meet the documented requirements, and the facility's time-keeping records confirmed that the actual number of staff working was even lower than scheduled, with some shifts having only one licensed nurse and two CNAs. Interviews with the facility's administrator and ADON revealed a lack of awareness and misunderstanding of the staffing requirements. The administrator expected the ADON to schedule at least four CNAs and one licensed nurse, but the ADON believed this met the staffing requirement, despite the Facility Assessment indicating otherwise. Additionally, there were instances where no CNA was assigned to specific areas like Colonial Hall, leading to potential gaps in resident care. The administrator acknowledged the staffing challenges and the inability to consistently meet the required staffing levels, which compromised the safety and care needs of the residents.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. The facility's RN staff schedule for October, November, and December 2024 showed multiple days where there was no RN present for the required hours. Specifically, the facility did not have an RN on duty for eight consecutive hours on numerous dates across these months. The Director of Nursing (DON) confirmed that he/she was the only RN on the schedule and acknowledged the absence of RN coverage on several days. The DON stated that he/she was salaried and only attended to the facility's needs, not specifically to fulfill the RN coverage hours. The administrator also confirmed the lack of RN coverage, stating that the facility currently had only one RN on the schedule. Both the DON and the administrator recognized the risk of not having an RN present for the required hours, which includes the absence of RN knowledge and experience in case of an emergency or when specific nursing expertise is needed. The facility did not have a policy in place for RN coverage, contributing to the deficiency in meeting the regulatory requirement.
Failure to Ensure Timely Certification of Nurse Aides
Penalty
Summary
The facility failed to ensure that three nurse aides (NAs) completed the required nurse aide training program within four months of their employment. The facility's policies did not provide clear guidelines for NA qualifications, and the employee files for NAs A, C, and E lacked documentation of completed training programs. NA C, who was rehired in January 2024, stated that they were informed about the need for certification within 90 days but had not taken any classes due to the unavailability of training at the previous facility. The Assistant Director of Nursing (ADON) acknowledged the issue, citing the lack of available training locations as the reason for the delay. Interviews with the ADON, the administrator, and the Director of Nursing (DON) revealed that the facility was aware of the requirement for NAs to be certified within 120 days of hire. However, they were unable to provide documentation of attempts to enroll the NAs in training programs. The facility previously relied on another facility for training, but this option was no longer available due to a change in ownership. The ADON was tasked with finding an alternative training location, but no progress had been documented at the time of the report.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility staff failed to implement the Enhanced Barrier Precautions (EBP) policy effectively, as evidenced by multiple observations and interviews. Resident #8, who was at risk for skin integrity issues and had a wound, did not have an EBP sign on the door, nor was there personal protective equipment (PPE) in close proximity. Licensed Practical Nurse (LPN) F was observed providing wound care without wearing a gown, contrary to the facility's policy. The infection preventionist (IP) and the administrator acknowledged the oversight, indicating a lack of awareness and adherence to the EBP policy. Resident #12, who had a PEG tube, had an EBP sign on the door, but PPE was not available nearby. LPN G administered medication through the PEG tube without using PPE, and during an interview, expressed uncertainty about the EBP sign's significance. The IP and the administrator confirmed that the resident should have PPE available and that staff should use it when providing care. Resident #18, with a tracheostomy, had an EBP sign on the door, but CNA K did not wear a gown while performing personal hygiene tasks. The Director of Nursing (DON) was unsure if the resident should still be on EBP but expected staff to follow the posted precautions. Resident #38, also with a feeding tube, had similar issues with the absence of PPE and staff not using it during care. The IP and the administrator reiterated the expectation for PPE use, highlighting a systemic failure in implementing the EBP policy across the facility.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility staff failed to implement an Antibiotic Stewardship Program with necessary protocols and a system to monitor and track antibiotic use. The facility, with a census of 66, did not have a policy for Antibiotic Stewardship, and the staff did not track antibiotic trends. The Infection Preventionist, responsible for the program, acknowledged documenting antibiotic usage in the electronic medical record but admitted to not having a system in place to trend and monitor usage. Despite being aware of the program's expectations, the Infection Preventionist had not implemented them, citing additional responsibilities as the Minimum Data Set coordinator and care plan coordinator. The Director of Nursing, new to the facility since August, was unaware of the program's incomplete status, and the administrator, responsible for oversight, was also unaware of the deficiency.
Failure to Provide Adequate Activities in Memory Care Unit
Penalty
Summary
The facility staff failed to provide an ongoing program of daily activities designed to meet the residents' interests for four residents residing in the Memory Care Unit (MCU). The facility did not have a policy for activities, and the activity calendar for November 2024 showed limited activities, primarily an 'activity cart available' on weekends. Observations in December 2024 revealed the absence of a current activity calendar, and residents were often found without engagement in activities, either asleep or wandering the hallways. Resident #1, with severe cognitive impairment, was assessed to enjoy reading, music, group activities, and religious practices. However, the care plan lacked direction for religious activities, and observations showed the resident was not engaged in any activities, often found asleep or alone. Similarly, Resident #55, with moderate cognitive impairment, expressed the importance of music and group activities but was not informed about ongoing activities, missing opportunities like listening to carolers. Residents #67 and #270, both with severe cognitive impairments, were also not provided with activities as per their care plans. Observations showed them wandering the hallways without engagement. Interviews with staff, including the Activities Director (AD) and Certified Nursing Assistants (CNAs), revealed a lack of structured activities, insufficient staffing, and locked access to activity materials. The AD admitted to not assessing residents' specific interests and not participating in the MDS process for activities, contributing to the deficiency in meeting residents' activity needs.
Failure in Dialysis Communication and Documentation
Penalty
Summary
Facility staff failed to maintain a system for ongoing communication with a dialysis clinic for a resident receiving dialysis. The facility's policy required a Dialysis Communication Record to be sent with the resident on each dialysis visit, detailing care concerns, medications, and contact information. The dialysis unit was expected to complete the form with relevant information and return it to the facility. However, the resident's medical record lacked these communication records, and the care plan did not reflect the resident's dialysis treatment. Interviews revealed that staff were not using the designated communication form. Instead, vital signs and weights were written on an index card, which was not retained or documented in the resident's chart. The Director of Nursing and the administrator were unaware that the form was not being used, and the responsibility for ensuring its use was not being fulfilled. This lack of communication and documentation could lead to staff being unaware of the effects of dialysis on the resident.
Lack of Hospice Care Documentation for Residents
Penalty
Summary
The facility failed to document collaboration of care with hospice providers for two residents receiving hospice services. The facility's Nursing Facility Hospice Services Agreement and Patient Hospice Chart Guide outlined the requirements for documentation, including a coordinated plan of care and communication between the facility and hospice providers. However, reviews of the hospice binder and medical records for the two residents revealed the absence of a plan of care and communication documentation, indicating a lack of adherence to the established protocols. Interviews with facility staff, including an LPN, the Director of Nursing, and the administrator, revealed a lack of awareness and oversight regarding the missing documentation. The LPN acknowledged the absence of communication in the hospice binders and mentioned the need to contact the hospice agency for resident care information. The Director of Nursing and the administrator both expressed expectations for the hospice binders to contain up-to-date care plans and communication, but they were unaware of the deficiencies. The Director of Nursing admitted responsibility for ensuring the documentation was complete, but noted their recent arrival at the facility as a factor in the oversight.
Inadequate Glucometer Sanitization and Barrier Use
Penalty
Summary
Facility staff failed to adhere to infection prevention and control protocols concerning the use of glucometers for four residents diagnosed with diabetes. Observations revealed that a Certified Medication Technician (CMT) did not use a protective barrier for the glucometer supplies and failed to properly sanitize the glucometer between uses. The glucometer was placed directly on the medication cart without a barrier, and the CMT only partially cleaned it with an alcohol prep pad before placing it back on the cart. This occurred for four residents, with the CMT admitting to missing the opportunity to sanitize the glucometer due to being distracted by conversation. Interviews with facility staff, including a Licensed Practical Nurse (LPN), the Assistant Director of Nursing (ADON), and the administrator, confirmed that the glucometer is used on multiple residents and should be sanitized between uses with approved disinfecting wipes. However, the CMT was not trained to use a protective barrier under the glucometer, which could lead to potential cross-contamination. The staff acknowledged the potential for spreading disease or germs if the glucometer is not properly sanitized between uses.
Improper Mechanical Lift Transfer Resulting in Resident Injury
Penalty
Summary
Facility staff failed to provide a proper mechanical lift transfer for a resident, resulting in an injury. The resident, who had moderate cognitive impairment, hemiplegia, and was totally dependent on staff for transfers, required a mechanical lift with two-person assistance as per their care plan. However, a CNA performed the transfer alone, during which the resident's arm was not properly positioned, leading to a bruise and inflammation. Subsequent nurse notes indicated the resident's arm was swollen and immobile, and an X-ray confirmed an acute left proximal humeral fracture. The resident was then sent to the hospital for further treatment. Interviews with facility staff, including CNAs, LPNs, the DON, ADON, and the administrator, revealed that the standard procedure was to use two staff members for mechanical lift transfers to ensure safety. Despite this, the CNA involved in the incident admitted to performing the lift alone, which was not in accordance with the facility's policy or the resident's care plan. The DON and other staff members confirmed that the use of two staff members for such transfers was a known and expected practice within the facility.
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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) |
|---|---|---|---|---|
| Villa At Blue Ridge, The | 1.9 mi | ★★★★★ | 11 | 0 |
| Columbia Post Acute | 4 mi | ★★★★★ | 0 | 0 |
| South Hampton Place | 4.7 mi | ★★★★★ | 9 | 0 |
| Columbia Manor Health & Rehabilitation | 4.9 mi | ★★★★★ | 7 | 0 |
| Bluffs, The | 4.9 mi | ★★★★★ | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.