Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Pine Grove Manor during CMS and state inspections, most recent first.
The facility failed to follow physician orders and maintain accurate MAR/TAR documentation for multiple residents. A resident with anxiety and bipolar disorder did not receive a scheduled clonazepam dose even though an LPN documented it as given, and the controlled substance count confirmed the dose was not removed. Another resident with dementia, hemiplegia, and multiple comorbidities had numerous undocumented opportunities for scheduled lorazepam, behavior and side-effect monitoring, assistance with dressing, weekly skin assessments, and topical treatments across MAR, NAR, and TAR records. Two additional residents with diabetes, schizophrenia, and bipolar disorder had physician-ordered weekly skin assessments that were not documented on the ordered shifts, and the EMR assessment tab showed no current assessments corresponding to those orders.
The facility failed to provide adequate ADL care, including toileting, bathing, and grooming, to several residents. A resident who was severely cognitively impaired, incontinent, and fully dependent on staff was found at midday lying in urine-saturated linens with strong urine and body odor and open buttock wounds without dressings after not being checked since early morning, despite staff expectations for two-hour checks. Another cognitively intact resident with multiple comorbidities and incontinence was repeatedly observed with strong body odor, oily uncombed hair, and an unshaven face, reported that a cluttered shower room and lack of staff assistance prevented showers, and stated that poor hygiene worsened depression, while a CNA believed the resident managed hygiene independently. A third resident with severe cognitive impairment and an order for twice-weekly showers missed at least two scheduled showers and was observed with a strong sweat odor. Additionally, a cognitively intact resident dependent on staff for personal hygiene was repeatedly seen with long chin hairs despite expressing a desire for their removal, even though CNAs, LPNs, and leadership acknowledged staff were responsible for assisting with unwanted facial hair removal and grooming preferences.
Surveyors found that the facility did not complete activity assessments or develop care plan interventions for multiple residents with conditions such as dementia, bipolar disorder, stroke, MS, and schizophrenia, despite a policy requiring individualized activity programming. An outdated activity calendar was posted, but no group activities were observed over several days, and several cognitively intact residents reported that there were not enough activities, that they were bored, and that activity staff were insufficient. Some residents described doing nothing all day except for medical appointments or paying out-of-pocket for outings. Records for residents identified as needing 1:1 activities showed they were scheduled on specific days, yet there was no documentation of 1:1 activities being offered or provided, and observations confirmed these residents were not engaged in such activities. The Activity Director stated she had just started employment and had not yet created a current calendar or begun 1:1 activities, while the Administrator and DON stated they expected activities and 1:1 services to be provided and reflected in care plans.
Incomplete and illegible narcotic count documentation was found for two medication carts. Review of narcotic book count sheets showed multiple shifts without documented start-shift or end-of-shift counts, missing nurse signatures, and handwritten counts on the back of the sheet that were illegible. An LPN stated the count is completed by one oncoming nurse and one off-going nurse, and the DON stated the narcotic sheets should be fully completed and not written on the back.
The facility failed to complete required monthly DRRs and failed to document physician responses to pharmacist recommendations for multiple residents. Records showed missing MMRs and unanswered pharmacist communications involving meds such as vitamin D, pantoprazole, famotidine, Jardiance, diclofenac, and tizanidine for residents with conditions including CHF, DM, COPD, dementia, bipolar disorder, schizophrenia, CAD, DVT, and malnutrition. The DON and Administrator stated they expected the physician to review the MMRs weekly and sign off promptly or document a rationale when not following the pharmacist’s recommendation.
Kitchen sanitation and maintenance deficiencies: Surveyors repeatedly observed caked-on stains on the stove and oven, dirty and streaked reach-in cooler and freezer doors, and a kitchen floor with crumbs, dirt, debris, stains, and a raised area by the dishwasher. Cleaning logs were blank, and a metal pan with dirty water was seen under a leaking pipe beneath the sink. The DM said deep cleaning was not being done by staff, and the RD and Administrator acknowledged the equipment, floor, and pipe needed attention.
The facility did not ensure that second-floor bathrooms were routinely cleaned, as required by its housekeeping policy. Surveyors observed multiple bathrooms with brown and yellow matter on toilet seats, strong bowel movement odors, unflushed toilets with urine and toilet paper, and shower floors with dark stains and hair. A cognitively intact resident with MS and insomnia reported that the bathrooms were dirty and not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN and a housekeeper confirmed that housekeeping was responsible for bathroom cleaning, with typically one housekeeper assigned to the floor and bathrooms expected to be cleaned each shift, while the Administrator and DON stated they expected bathrooms to be clean and maintained at least daily and as needed.
The facility failed to follow its own policies requiring that eligible residents be offered pneumococcal and annual influenza vaccines, receive education, and have all offers, consents, refusals, and administrations documented. Record review showed that two residents with COPD and other chronic conditions had no documentation of receiving, being offered, or being educated about the pneumococcal vaccine, and another medically complex resident had no documentation of receiving, being offered, or being educated about the influenza vaccine. The DON/IP acknowledged that all residents should be offered these vaccines if eligible and that all related actions should be recorded in the medical record, which did not occur.
Failure to obtain and transcribe wound dressing orders for a resident with a surgical back incision. The resident had osteomyelitis, diabetes, and surgical aftercare needs, but the admission record did not include dressing change orders and the wound physician's daily treatment instructions were not entered into the chart. Staff observed the dressing was not dated, later found with drainage and redness, and an LPN and the DON acknowledged the orders were not completed as expected.
A resident with severe cognitive impairment, hemiplegia, frequent incontinence, and pressure ulcer risk did not have weekly skin assessments completed, was found saturated in urine after an extended period without care, and developed two new open buttock wounds. Staff observed the wounds without dressings, the TAR showed only one wound treatment order, and nursing interviews confirmed confusion about wound treatment responsibility and that incontinent residents should be checked every two hours.
Two residents with g-tubes had incomplete tube feeding care. Staff did not label the water flush bags, one resident was observed with the HOB not elevated enough during tube feeding, and one resident’s care plan did not address g-tube care. The residents had significant medical histories including malnutrition, dementia, COPD, and other chronic conditions, and the DON stated the HOB should be elevated 30 to 45 degrees and the flush bag should be labeled with key tube-feeding information.
Respiratory care was not provided in accordance with standards for two residents receiving oxygen therapy. One resident with COPD, dementia, and diabetes had oxygen tubing and a nasal cannula repeatedly found on the floor or left uncovered, with the tubing undated and the concentrator dusty; the resident’s order also lacked a tubing-change order. Another resident with multiple diagnoses including COPD and acute respiratory failure had oxygen in use, but the physician orders did not specify the flow rate or whether oxygen was continuous or PRN. Staff stated oxygen tubing should be stored properly, dated, and changed weekly, and that oxygen orders should include the flow rate.
Delayed pain medication administration for two residents occurred when a CMT did not promptly notify the nurse or ADON that the residents were waiting for PRN oxycodone. One resident with osteomyelitis and post-surgical aftercare reported 10/10 pain, and another resident with psychiatric diagnoses and left hip pain reported 8/10 pain; both said staff were late with pain medication all the time. An LPN later gave the medications about two hours after the requests, and the DON stated this delay was unacceptable.
Failure to Post Daily Nurse Staffing Information: The facility did not post the daily nurse staffing sheet in a prominent, readily accessible location for residents and visitors. Observations showed the sheet behind the first-floor nurse’s station was blank and still dated several days earlier. The Administrator said the staffing coordinator was responsible for posting the information, and the staffing coordinator said she had been recording the data in a binder instead of posting it.
Failure to address residents’ behavioral health needs and behaviors. Two residents with depression, grief, anxiety, PTSD, schizophrenia, and other mental health diagnoses did not have their ongoing counseling, psychosocial, and activity needs adequately identified or documented, and one resident with severe cognitive impairment continued to wander into offices and rooms, eat others’ food, and eat from the trash despite a known behavior history. Interviews and observations showed poor hygiene, isolation, lack of meaningful counseling, limited activity engagement, and inconsistent staff awareness of the residents’ needs.
Opened eye drops on a CMT cart were found without an open date or expiration date, including Timolol maleate, Latanoprost, and Brimonidine. The facility policy required opened meds to be dated, and both the CMT and DON stated eye drops should have open and expiration dates to ensure medication efficacy.
A resident experienced a delay of up to nine minutes in receiving rescue breaths and oxygen during CPR because the Ambu bag mask was missing from the crash cart and staff were unable to operate the suction machine. Chest compressions were started promptly, but rescue breaths and suctioning were delayed due to missing supplies and lack of staff knowledge. When EMS arrived, staff stopped CPR before EMS was ready to take over, resulting in a lapse in compressions. The resident, who had severe cognitive impairment and multiple medical conditions, expired as a result.
Staff failed to prime pre-filled insulin pens before administering insulin to two residents with diabetes and other health conditions. In both cases, LPNs administered insulin without following manufacturer guidelines for priming, and the DON confirmed that this step is necessary to ensure accurate dosing. The facility's policy did not address insulin pen use, contributing to these significant medication errors.
A resident with severe cognitive impairment and total dependence on staff was found with their long-sleeve shirt sleeves tied together at the wrists, restricting hand movement and constituting a physical restraint. Staff interviews confirmed the knot was intentional and not accidental, and there was no documentation or care plan directive for restraint use. Facility leadership was unable to determine who was responsible for tying the sleeves.
A resident with multiple chronic conditions and recent cellulitis did not receive prescribed wound care due to failure to transcribe physician orders into the electronic medical record. The resident's wounds were observed without dressings or compression socks, and staff interviews revealed a lack of awareness and responsibility for entering and implementing the wound care orders. The Wound Doctor confirmed that his treatment orders were not followed.
The facility did not maintain safe water temperatures in resident rooms on the North and South halls, with temperatures ranging from 141 to 153 degrees Fahrenheit, exceeding the safe range of 105-120 degrees Fahrenheit. This affected 16 out of 31 sampled residents, posing a risk of scalding and burns. The Maintenance Director adjusted water heater temperatures based on resident complaints about cold water without verifying actual room temperatures. The facility's Safety of Water Temperatures Policy was not effectively implemented. Staff, including the Maintenance Director, DON, and Corporate Regional Nurse, were unaware of the high temperatures and used inappropriate methods for temperature checks. Residents with cognitive impairments and mobility issues were at increased risk.
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed limited variety, primarily focused on bingo and cards. Residents expressed dissatisfaction, and the Activities Director confirmed the lack of a regular activities program. The AD had limited formal training and was the only one responsible for activities, leading to the deficiency identified.
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director had not received formal training and had not started the required state-approved course, despite being enrolled since September 2023. The facility's job description required specific qualifications that the current Activity Director did not meet.
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations showed a gray plastic tube extending from the ice machine into a PVC drain pipe connected to the floor drain without an air gap. The Dietary Manager and Administrator were aware of the requirement but did not ensure compliance.
The facility failed to follow infection control standards during perineal and wound care for several residents. Staff did not perform proper hand hygiene or change gloves appropriately, increasing the risk of cross-contamination and infection. Interviews confirmed that facility policies were not adhered to, leading to these deficiencies.
The facility failed to complete pre and post dialysis assessments and did not maintain an accurate care plan for a resident requiring dialysis services. The dialysis communication forms were often incomplete, and the facility did not consistently document or follow up on the resident's assessments.
Failure to Follow Physician Orders and Accurately Document Medications and Skin Assessments
Penalty
Summary
The facility failed to ensure physician orders were followed and that services met professional standards of quality, as evidenced by multiple documentation and administration errors for several residents. One cognitively intact resident with anxiety, depression, and bipolar disorder had an order for clonazepam 0.5 mg to be given every evening at 4:00 p.m. The March MAR showed clonazepam documented as administered on a specific date at 4:00 p.m., but the controlled drug administration record showed the last actual administration occurred the previous day and that 11 tablets remained. The resident reported not receiving the clonazepam dose on that date, stated they informed night shift staff, and was told the medication was documented as given. Observation of the narcotic box with an LPN confirmed 11 tablets remained, and the LPN stated they thought they had given the dose but must have signed it off in the electronic record without actually administering it. Another resident with dementia, hypertension, hyperlipidemia, dysphagia, seizures, depression, hemiplegia, and major depressive disorder had multiple active orders, including scheduled lorazepam oral concentrate for anxiety every six hours, behavior and side-effect monitoring every shift, assistance with dressing and undressing every shift, weekly skin assessments, and topical anti-itch lotion and barrier cream. Review of the MAR and nurse’s administration record for February showed numerous blank entries where lorazepam doses, behavior observations, side-effect monitoring, and assistance with dressing were ordered but not documented, with missed documentation across dozens of opportunities. The treatment administration record for the same period also contained blank entries for weekly skin assessments and for the ordered topical anti-itch lotion and barrier cream, again with multiple missed documentation opportunities. Similar gaps continued into March, with additional blank entries for lorazepam administration, weekly skin assessments, and topical treatments. Two additional residents with diagnoses including diabetes, hearing loss, schizophrenia, dementia, and bipolar disorder had physician orders for weekly skin assessments on specified shifts. For one cognitively intact resident, the March MAR showed weekly skin assessments ordered on Wednesday night shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab predated those dates. For another resident with moderately impaired cognition, the March MAR showed weekly skin assessments ordered on Monday evening shifts, but the assessments for two specified dates were not documented as completed, and the most recent skin assessment in the EMR assessment tab also predated those dates. In an interview, the Administrator and DON stated they expected weekly skin assessments to be completed and documented in both the assessment tab and MAR when ordered, and that medications should be administered per physician orders with documentation of reasons and physician notification when not administered.
Failure to Provide Adequate ADL, Hygiene, and Grooming Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate activities of daily living (ADL) care, including toileting, bathing, and personal hygiene, to multiple residents. One resident with severe cognitive impairment, hemiplegia, and dependence on staff for toileting, bathing, dressing, and personal hygiene was observed in bed at midday with a strong urine and body odor. When CNAs turned the resident, the brief, two quilted bed pads, and fitted sheet were saturated with urine, and the resident had open wounds on both buttocks without dressings. A CNA reported last checking the resident around 8:00 A.M. and stated they did not want to disturb the resident due to sleep and frequent pain, while nursing staff and the DON stated incontinent residents were expected to be checked and repositioned every two hours. Another resident, cognitively intact but with a history of stroke, dementia, diabetes, kidney failure, Parkinson’s disease, and myasthenia gravis, required partial to moderate assistance with bathing, personal hygiene, and toilet hygiene and was frequently incontinent of bladder and occasionally of stool. This resident was repeatedly observed in bed with strong body odor, uncombed oily hair, and an unshaven face with approximately half an inch of facial hair. The resident reported being willing to walk with a walker to the shower room but described the shower room as usually cluttered with equipment, which he could not move, and stated that staff did not help him get set up in the shower despite his requests. A CNA stated the resident “did his own thing,” was not known to need help with showers, and provided his own care, while the DON stated all residents required staff assistance with hygiene and were expected to be clean, dry, and odor free. A third resident with severe cognitive impairment, type 2 diabetes, schizophrenia, and cerebral palsy had a care plan indicating an ADL self-care performance deficit and a need for maximum staff assistance with personal hygiene. The MAR showed an order for showers twice weekly on the evening shift, but two scheduled showers in the review month were not documented as given, and the resident was observed on two occasions with a strong sweat-like odor. Additionally, a cognitively intact resident with type 2 diabetes, hearing loss, and schizophrenia, care planned as dependent on staff for personal hygiene and oral care, was observed multiple times with long white curly hairs on the chin. This resident stated a desire to have the chin hairs removed. Nursing and CNA staff, as well as facility leadership, acknowledged that both CNAs and LPNs could assist with removal of unwanted facial hair and that staff should ask residents about grooming preferences, but this assistance had not been provided.
Failure to Provide Individualized Activities and Scheduled 1:1 Programming
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to assess residents’ activity preferences and to provide an ongoing activity program consistent with those preferences, as well as a failure to provide scheduled 1:1 activities to certain residents. The facility’s Activities Program policy, dated 6/2020, stated that the facility would provide an activity program designed to meet residents’ needs, interests, and preferences, with assessments completed within seven days of admission and individualized care plans developed and implemented. Observations on multiple days showed Mardi Gras decorations and an outdated February activity calendar posted, but no activities were observed being provided to residents at various times on several dates. The Activity Director reported that her first day was during the survey period, that the March activity calendar had not yet been created, and that she expected activities to be scheduled and calendars distributed and posted. Multiple residents who were cognitively intact and had various diagnoses reported that there were not enough activities and that they were bored. One resident with anxiety, depression, bipolar disorder, schizophrenia, and PTSD stated there were no activities taking place, that the previous Activities Director had left about two weeks earlier, and that the resident paid for a car ride to a store just to get out of the facility. Another resident with stroke, dementia, diabetes, kidney failure, and depression reported doing nothing all day except going to dialysis, expressed interest in puzzles, and recalled that the facility previously had a small bus for outings. Additional residents with diagnoses including diabetes, hearing loss, schizophrenia, multiple sclerosis, insomnia, hypertension, anemia, dementia, and bipolar disorder similarly stated that there were not enough activities, that there were not enough activity staff, and that they were bored most of the time. For several of these residents, record review showed no activity assessments and no care plan documentation related to activity participation or preferences, despite the facility’s policy and the Administrator and DON’s expectation that care plans reflect activity preferences. The survey also found that residents identified by the facility as needing 1:1 activities were not receiving them. A facility 1:1 Activity List showed three residents scheduled for 1:1 activities on specific days of the week, but their medical records contained no documentation of activities offered or provided. These residents had significant cognitive and neurological conditions, including dementia, bipolar disorder, hypertension, malnutrition, Alzheimer’s disease, stroke, hemiplegia, seizure disorder, anxiety disorder, aphasia, mild cognitive impairment, malnutrition, and Rett’s syndrome. Observations of these residents throughout the survey period showed them not engaged in any 1:1 activities. The Activity Director acknowledged that she had not started conducting 1:1 activities for residents on the 1:1 list, and the Administrator and DON stated they expected 1:1 activities to be provided to residents determined to benefit from them.
Incomplete and Illegible Narcotic Count Documentation
Penalty
Summary
The facility failed to establish a system of record for all controlled drugs with sufficient detail to allow accurate reconciliation for two of three medication carts reviewed. Review of the facility’s Storage of Controlled Substances policy showed that controlled substances are to be physically inventoried at each shift change by two licensed personnel, reconciled to the MAR, and documented on a control count sheet or similar form. The census was 53, and the deficiency had the potential to affect all residents with controlled substance orders. Review of the South Hall Nurses narcotic book count sheets from 3/1 through 3/10/26 showed eight of 19 shifts without a documented start-shift narcotic count and three of 19 shifts without a nurse signature on the shift-change count. Review of the North Hall Nurses narcotic book count sheets from 3/1 through 3/10/26 showed six of 19 shifts without a documented start-shift narcotic count, five of 19 shifts without an end-of-shift narcotic count, and handwritten counts on the back of the shift count sheet that were illegible from 3/8/26 through 3/10/26. An LPN stated the narcotic count is completed by one oncoming nurse and one off-going nurse, and that the count should be clear, accurate, and legible. The DON stated she expected the entire narcotic sheets to be completed and that staff should use another narcotic sheet rather than write on the back of one.
Failure to Complete Monthly Drug Regimen Reviews and Document Physician Responses
Penalty
Summary
The facility failed to ensure that monthly drug regimen reviews were completed and that physician responses were documented for pharmacist recommendations for five sampled residents. The facility’s Drug Regimen Review policy stated that the consulting pharmacist must review each resident’s medication regimen at least once a month, review the medical record, report irregularities to the attending physician, medical director, and DON, and that the attending physician must document review and action taken within 30 days unless the issue is emergent. For one resident with intact cognition and diagnoses including heart failure, hyperlipidemia, diabetes, peripheral vascular disease, COPD, malnutrition, and wound infection, the record showed pharmacist recommendations related to vitamin D monitoring and Jardiance for renal protection, but there was no documentation of physician response to those recommendations. The record also lacked documentation of monthly medication reviews for several months. For another resident with dementia, bipolar disorder, psychotic disorder, depression, anxiety, heart failure, CAD, diabetes, COPD, and malnutrition, the chart showed a pharmacist recommendation to obtain annual serum magnesium monitoring related to pantoprazole use, but there was no physician response and no documentation of multiple monthly medication reviews. A third resident with dementia, bipolar disorder, hypertension, DVT, hyperlipidemia, diabetes, COPD, and malnutrition had a pharmacist recommendation to discontinue one of duplicate famotidine orders, but there was no physician response and no documentation of monthly medication reviews for several months. A fourth resident with diabetes, hearing loss, and schizophrenia had consultant pharmacist communications recommending no gradual dose reduction for Invega Sustenna and later recommending Jardiance for renal protection and glycemic control; neither form was signed by the physician and there was no physician response. A fifth resident with bipolar disorder, schizophrenia, muscle spasms, chronic pain, and anxiety had pharmacist recommendations to reassess diclofenac use with low GFR and to consider discontinuing tizanidine, but there was no physician response. During interview, the DON and Administrator stated they expected the physician to review the MMRs weekly and sign off within a week, and to document a rationale if not following the pharmacist’s recommendation.
Kitchen sanitation and maintenance deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During repeated kitchen observations, surveyors found caked-on stains on the stove, heavy caked-on stains on the oven doors and oven surfaces, and noticeably dirty and streaked fronts on the reach-in cooler and freezers. The kitchen floor was observed to be dirty with food crumbs, dirt, debris, and stains, and a raised or buckled area was noted by the dishwasher. Review of the kitchen cleaning schedules and logs showed the daily/after each use, weekly, and monthly cleaning forms were blank. Surveyors also observed a metal pan containing dirty water leaking from a pipe underneath the sink by the dishwasher during each kitchen observation. In interview, the Dietary Manager stated that general cleaning was being done daily, but the cleaning schedule/logs were not filled out and deep cleaning was not being done by staff. She stated she had been doing deep cleaning herself and planned to have staff begin deep cleaning at least weekly. The RD stated that equipment should be clean and in proper working order and that the kitchen floor should be clean and repaired, and both the RD and Administrator acknowledged that the floor needed repair and the pipe underneath the sink should be repaired.
Failure to Maintain Clean and Sanitary Second-Floor Bathrooms
Penalty
Summary
The facility failed to maintain clean and sanitary second-floor bathrooms in accordance with its housekeeping policy, which requires all rooms to be kept clean and as free as possible of germs and other contaminating agents at all times. Surveyor observations on 3/9/26 showed that the toilet in the bathroom by the emergency exit door had brown and yellow matter on the seat with a strong bowel movement odor, the shower room floors had various dark stains and small hairs on the shower floor, and the toilet seat in the shower room had brown matter smeared on it. The bathroom across from the nurse's station also had a strong bowel movement odor, a dirty toilet seat with dark matter smeared on it, and toilet paper with a brown substance in the bowl. On 3/12/26, further observations of the same area showed the shower room toilet unflushed with toilet paper and urine in and on the toilet, and the shower floor with hairs and dark matter stains. Later that day, the shower room toilet again had brown smears and a strong bowel movement odor, with hair and dark matter stains on the shower floor. A cognitively intact resident with multiple sclerosis and insomnia reported that the second-floor bathrooms were dirty, not cleaned often enough, and that only one shower room was open and sometimes dirty. An LPN stated that bathrooms were expected to be clean but believed there were not enough housekeeping staff, and a housekeeper reported that normally one housekeeper is assigned to the second floor and that bathrooms are expected to be cleaned each shift. The Administrator and DON stated they expected bathrooms to be clean to prevent infection control issues and that housekeeping staff were responsible for cleaning bathrooms at least once daily and as needed.
Failure to Offer and Document Pneumococcal and Influenza Vaccinations for Eligible Residents
Penalty
Summary
Surveyors identified a deficiency in the facility’s implementation of its pneumococcal and influenza vaccination policies. The facility’s written policies, last revised in June 2020, require that all eligible residents be offered pneumococcal and annual influenza vaccines, receive education on benefits and potential side effects, and that informed consent or refusal, as well as vaccine administration, be documented in the medical record. Record review showed that these steps were not followed for several residents, despite the policies specifying that refusals and any education provided must be documented. For one resident with heart failure, COPD, and kidney disease, and another resident with COPD and high blood pressure, there was no documentation that the pneumococcal vaccine was received, offered, or that vaccine education was provided. For a third resident with kidney disease, Parkinson’s disease, Myasthenia Gravis, diabetes, and bladder cancer, there was no documentation that the influenza vaccine was received, offered, or that vaccine education was provided. During interview, the DON/IP confirmed that all residents should be offered influenza yearly and pneumococcal vaccine if eligible, and that all offers, refusals, education, and administrations should be documented in the medical record, which did not occur for these residents.
Failure to Obtain and Transcribe Wound Dressing Orders
Penalty
Summary
The facility failed to ensure care was provided according to physician orders for one resident with osteomyelitis of the vertebra and thoracic region, diabetes, and surgical aftercare following nervous system surgery. On admission, the resident had a surgical incision to the back with sutures and a dressing, but the baseline care plan did not address the incision. The resident's progress note documented a clean, dry, intact dressing with no active bleeding or drainage, yet the physician wound assessment later specified a daily treatment of cleaning the wound with normal saline, applying calcium alginate and Mupirocin ointment, and covering it with a dry dressing. The physician order sheets from admission through several days later did not contain dressing change orders for the surgical back incision. During observations, the resident stated the dressing had not been changed since the doctor changed it, and staff observed a large white dressing that was not dated. Later, the resident again stated the dressing had not been changed since the doctor changed it, and the dressing was found dated several days earlier with a moderate amount of yellow drainage, loose edges, and redness along the suture and staple line. An LPN who admitted the resident said the evening nurse was responsible for obtaining dressing change orders from the wound physician and that the orders were not obtained on admission. The DON stated she expected nurses to enter a dressing change order into the system on admission and expected wound physician orders to be transcribed into the resident's medical record by the nurse rounding with the physician.
Missed Skin Assessments, Delayed Incontinence Care, and Incomplete Wound Treatment
Penalty
Summary
The facility failed to ensure weekly skin assessments were completed and failed to ensure a resident who was frequently incontinent was repositioned and cleaned after being left in urine for an extended period. Resident #28 had severe cognitive impairment, hemiplegia, dependence on staff for toileting and hygiene, frequent bowel and bladder incontinence, and a history of pressure ulcers. The resident’s quarterly MDS showed moderate risk for pressure injury, and the care plan identified the resident as at risk for pressure ulcer development related to impaired mobility, incontinence, rejection of care, and contractures. Review of the resident’s records showed a skin assessment dated 2/16/26 with no skin impairments, but no further weekly skin assessments were available. The resident was not listed on the facility wound report from 1/1 through 3/9/26. During observation on 3/10/26, the resident was in bed eating lunch and had a strong odor of urine and body odor. When staff turned the resident, the brief, bed pads, and fitted sheet were saturated with urine, and two open wounds were observed on the right buttock and left inner buttock. CNA B stated the last check had been around 8:00 A.M., and both CNAs said the open areas were new. LPN G observed the buttocks and said the wounds were new and appeared to be stage two. The TAR showed an order for the right buttock wound only, and that treatment was documented as not completed the next day; there was no treatment order for the left inner buttock wound. On 3/12/26, staff observed that neither wound had a dressing in place. CNA I stated the dressing was missing when assisting the resident earlier that morning and was unsure whether the nurse had been notified. Interviews with nursing staff and the DON confirmed that weekly skin assessments were expected in the EMR, incontinent residents were expected to be checked every two hours, and there should have been two treatment orders because the resident had two separate wounds.
G-tube Care Not Properly Managed
Penalty
Summary
The facility failed to provide appropriate gastrostomy tube care for two residents who were dependent on tube feeding. One resident had a history that included aphasia, epilepsy, malnutrition, anxiety disorder, Rett's syndrome, scoliosis, adult failure to thrive, cachexia, and gastrostomy status, and the care plan documented tube feeding, residual checks, water flushes, and a head-of-bed elevation order. During observations, the resident’s tube feeding formula bag was labeled, but the water flush bag was not labeled, and the resident was seen lying in bed with the head of the bed elevated while the resident’s head rested at the foot of the bed. A nurse stated the resident’s head should have been elevated to 30 to 45 degrees and that the resident moved around a lot in bed. A second resident with diagnoses including dementia, bipolar disorder, hypertension, DVT, hyperlipidemia, diabetes, COPD, and malnutrition also had a g-tube and tube feeding orders, including continuous feeding, water flushes, and head-of-bed elevation. The resident’s care plan did not address the g-tube. During multiple observations, the resident’s tube feeding pump was running and the water flush bag was not labeled. On one observation, the resident was asleep with the head of the bed only slightly elevated, approximately 15 degrees, while the g-tube was flushing. The nurse stated the head of the bed did not appear elevated enough and said the water flush bag should be labeled with the resident’s name, formula name, date and time hung, and rate and frequency. The facility’s tube feeding manual required physician orders for enteral feedings and communication of formula, amount, fluid, and frequency, but it did not address labeling the water flush bag or head-of-bed requirements. In an interview, the DON stated the head of bed should be elevated 30 to 45 degrees during tube feeding and that the water flush bag should be properly labeled with the resident’s name, date, time hung, the person who hung it, and the rate and frequency. The deficiency was based on the facility’s failure to ensure labeled water flush bags, proper head-of-bed elevation during tube feeding, and inclusion of tube feeding care in the care plan for one resident.
Respiratory Care and Oxygen Order Deficiencies
Penalty
Summary
The facility failed to ensure respiratory care was provided in accordance with professional standards of practice for two residents receiving oxygen therapy. Resident #48 had diagnoses including COPD, dementia, and diabetes, and was moderately cognitively impaired. The resident had an order for oxygen at 2 L via nasal cannula as tolerated with titration for oxygen saturations greater than or equal to 92%, but there was no physician order for changing oxygen tubing and no documentation in the care plan regarding oxygen therapy via concentrator. During multiple observations, the resident’s oxygen tubing and nasal cannula were found on the floor next to the oxygen concentrator or left uncovered on top of the concentrator, and the tubing was undated. The oxygen concentrator was also observed dusty, and at one observation the concentrator was on and set to 4 L. Resident #6 had a comprehensive MDS showing cognitive intactness, continuous oxygen therapy, and diagnoses including dementia, bipolar disorder, hypertension, DVT, high cholesterol, diabetes, COPD, and malnutrition. The resident’s physician orders included oxygen via nasal cannula for oxygen saturations less than 88% on room air every shift and oxygen every shift related to acute respiratory failure with hypoxia, but there was no order specifying oxygen flow rate or whether oxygen was continuous or PRN. During repeated observations, the resident was in bed with eyes closed and oxygen on via nasal cannula, with the oxygen concentrator set at 2.5 L. Staff interviews stated oxygen tubing should be stored properly when not in use, placed in a plastic bag with the resident’s name, changed weekly, and dated, and the Administrator and DON stated they expected oxygen tubing to be stored properly and physician orders to include the flow rate.
Delayed Pain Medication Administration
Penalty
Summary
The facility failed to ensure safe, appropriate pain management for two residents who required pain medication. Resident #57 was admitted with diagnoses including osteomyelitis of the vertebra and thoracic region, post-surgical aftercare involving the nervous system, and diabetes. His/her baseline care plan did not address pain, although physician orders included oxycodone 10 mg every 4 hours as needed for severe pain and oxycodone 5 mg every 4 hours for pain. During observation, the resident was lying in bed, requested pain medication from the CMT, and stated the pain level was 10 out of 10 and that staff were late with pain medication all the time. Resident #2 had diagnoses including anxiety, depression, bipolar disorder, schizophrenia, and PTSD, and the MDS indicated the resident was cognitively intact and received scheduled and PRN pain medication. The resident had an order for oxycodone 10 mg every 6 hours as needed for moderate pain. During observation, the resident was lying in bed rubbing the left hip area, stated that pain medication had been requested about an hour earlier, and rated the pain as 8 out of 10, saying staff were late with pain medication all the time. The CMT stated only nurses could give pain medications and had not informed the nurse or ADON that the residents were waiting. An LPN later stated the residents received their pain medication about two hours after requesting it and said they should have received it within fifteen minutes. The DON stated waiting nearly two hours was unacceptable and that the nurse on the other hall or the DON could have given the medication if informed.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post the nurse staffing information daily in a prominent place readily accessible to residents and visitors. The census was 53. The facility’s nursing department staffing, scheduling, and posting policy dated 6/2020 required the facility to post, on a daily basis at the beginning of each shift, the facility name, current date, and the total number and actual hours worked for nursing staff in a clear and readable format in a prominent place readily accessible to residents and visitors. Observations on 3/10/26 at 10:32 A.M., 3/11/26 at 10:00 A.M., and 3/12/26 at 9:12 A.M. showed the nurse staffing sheet hanging on a bulletin board behind the first floor nurse’s station, but the document was blank and had a date of 3/6/26 written on it. During interviews on 3/13/26, the Administrator said CMT E, the staffing coordinator, was responsible for posting the daily nurse staffing numbers and expected them to be posted every day at the first floor nurse’s station. CMT E said she was responsible for posting the daily nurse staffing but had been documenting the daily nurse staffing in a binder instead of posting it.
Failure to Address Residents’ Behavioral Health Needs and Behaviors
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The deficiency involved two residents whose ongoing psychological and counseling needs were not identified and one resident whose behavior was not addressed. The facility’s own behavior management policy stated that the interdisciplinary team is responsible for identifying residents whose behaviors may pose a risk, developing individualized care strategies, and providing behavioral health care and services that support emotional and psychosocial well-being. For one resident with diagnoses including stroke, dementia, diabetes, kidney failure, and depression, the quarterly MDS showed little interest in doing things, feeling down and hopeless, sleep problems, fatigue, and little energy nearly every day. The care plan addressed antidepressant use and monitoring for depression symptoms, but did not address activities. The quarterly social service assessment noted very few visitors, decline after the death of the resident’s wife, and that the resident did not socialize or participate in activities, but the referral section was blank. The resident was being seen by a psychiatrist and psychologist, but progress notes showed no further social service notes for several months. During interviews and observations, the resident was found in bed with poor hygiene, strong body odor, uncombed oily hair, and an unshaven face, and stated that the cluttered shower room, lack of staff help with shower setup, grief over the spouse’s death, lack of purpose, and lack of meaningful counseling contributed to depression. Staff interviews showed some were unaware of the resident’s grief and depression, and the SSD acknowledged she should have made more notes about conversations and behaviors. A second resident had diagnoses including anxiety, depression, bipolar disorder, schizophrenia, and PTSD. The MDS showed no activities assessment, and the care plan again focused on antidepressant use and monitoring depression symptoms without addressing activities. Handwritten psychologist notes documented depression, anxiety, and full orientation, but the treatment strategies and goals were illegible. The resident reported there were no activities taking place, that the Activities Director had recently left, and that the resident did not like the psychologist because the conversations were not meaningful. The resident also reported trying to contact the SSD for help obtaining a different psychologist, but the SSD’s phone was broken and voicemail was full. The SSD said she was unaware the resident did not like the psychologist and could not read the psychologist’s notes, while the DON and Administrator stated the SSD’s phone should have worked and the notes should have been legible. A third resident with diabetes, schizophrenia, and severe cognitive impairment had a care plan focused on ADL deficits and supervision for eating because the resident would eat others’ food if not supervised and would go into other residents’ personal space. Progress notes documented wandering into staff offices and resident rooms, eating food from rooms, and eating out of the trash. During observation, the resident was seen entering the HR office when no nursing staff were nearby, taking chips from a trash can and eating them, and then taking chips from another resident’s open bag in a room. The DON stated the resident had previously eaten out of the trash but had not displayed that behavior since due to staff oversight, and staff acknowledged the resident needed consistent monitoring and would benefit from more activities. The Administrator and DON also stated the resident had been removed from psychiatric services after psychiatric medication was discontinued, despite the history of behaviors.
Opened eye drops lacked required dating
Penalty
Summary
Drugs and biologicals were not labeled in accordance with accepted professional principles because the facility did not have a system in place to ensure opened eye drop medications were dated with an open date and expiration date. On observation of the South Hall CMT cart, six vials of Timolol maleate 0.5% eye drops, two vials of Latanoprost 0.005% eye drops, and one vial of Brimonidine 0.2% eye drops were found with the manufacturer seal broken and no open date or expiration date documented. The facility policy on Storage of Medications stated that when the original seal of a manufacturer’s container or vial is broken, the container or vial will be dated, and the nurse shall place a date opened sticker on the medication and record the date opened and new date of expiration. During interview, the CMT stated that all eye drops should have an open date and expiration date and are good for 30 days once opened, and the staff member who opens them is responsible for placing the dates. The DON also stated that eye drops should have an open date and expiration date to ensure the efficacy of the medication.
Failure to Provide Effective CPR Due to Missing Equipment and Staff Incompetency
Penalty
Summary
The facility failed to provide effective cardiopulmonary resuscitation (CPR) to a resident who was identified as a full code, resulting in a delay of up to nine minutes before rescue breaths and oxygen could be administered. When the resident stopped breathing and had no pulse, the DON initiated chest compressions, but no rescue breaths were given initially because the Ambu bag mask was missing from the crash cart. Staff searched for the necessary equipment, with one LPN retrieving the mask from the nurse's desk and another attempting to set up the oxygen tank but unable to locate the key immediately. The oxygen was eventually connected, but only after a delay due to the missing mask and difficulty finding the key. During the code, staff also attempted to use the suction machine to clear the resident's airway, as the resident had significant secretions and a history of dysphagia and aphasia. However, staff were not knowledgeable about operating the suction machine, and it was never successfully used on the resident. The crash cart checklist had been marked as complete, but the required mask was not present at the time of the emergency, indicating a failure in equipment checks and readiness. The AHA guidelines and facility policy required rescue breaths and suctioning as part of CPR, but these were not provided in a timely manner due to missing supplies and lack of staff competency with the equipment. Additionally, when EMS arrived, staff stopped CPR before EMS personnel were ready to take over, resulting in a lapse in compressions. EMS had to ask if CPR was still needed and then resumed compressions upon entering the room. The resident, who had severe cognitive impairment and multiple medical diagnoses including sepsis and pressure ulcers, ultimately expired. The deficiency was identified through observation, interviews, and record review, and was determined to be at the immediate jeopardy level due to the failures in emergency response, equipment availability, and staff competency.
Failure to Prime Insulin Pens Results in Significant Medication Errors
Penalty
Summary
Staff failed to ensure residents were free from significant medication errors by not priming pre-filled insulin pens before administering insulin to two residents. For one resident with diabetes, kidney disease, obesity, and other conditions, an LPN administered insulin aspart without priming the pen, contrary to manufacturer guidelines that require priming to ensure accurate dosing. The LPN was unable to confirm whether the pen was primed prior to administration. The resident's care plan included monitoring for complications related to diabetes, but the insulin was given while the resident was eating, and the necessary step of priming was omitted. For another resident with diabetes, kidney disease, and additional diagnoses, a different LPN also failed to prime a Basaglar KwikPen before administering the prescribed insulin glargine. The LPN admitted to not priming the pen, despite manufacturer instructions and facility expectations to do so. The DON confirmed that priming is necessary to avoid administering air instead of the correct insulin dose. The facility's insulin administration policy did not specifically address the use of insulin pens, contributing to the medication errors observed.
Resident Found with Restrictive Clothing Used as Physical Restraint
Penalty
Summary
A deficiency occurred when a resident was found with the sleeves of their long-sleeve shirt tied together at the wrists, restricting the use of their hands and limiting freedom of movement. This action constituted the use of a physical restraint, as defined by the facility's own policy, which prohibits restraints unless necessary to treat a specific medical symptom and only after less restrictive interventions have failed. There was no documentation or physician order for the use of any restraint for this resident, nor was restraint use addressed in the resident's care plan. The resident involved had severe cognitive impairment, was rarely or never understood, and was totally dependent on staff for all activities of daily living. The resident had a history of non-traumatic brain dysfunction, hemiplegia, malnutrition, and anxiety disorder, and exhibited behavioral symptoms such as agitation, resistance to care, and repetitive movements like rubbing the scalp. Staff interviews confirmed that the resident could not have tied the sleeves themselves and that the knot was intentional, not accidental. The resident was unable to communicate what had happened and did not appear to be in distress at the time of discovery. Multiple staff, including CNAs and LPNs, reported that they were unaware of how or when the sleeves were tied, and no one took responsibility for the action. The facility's leadership, including the Interim Administrator and DON, acknowledged that it was never determined who tied the resident's sleeves. The care plan did not include any interventions involving restraints, nor did it address the resident's repetitive behaviors. The incident was identified through observation, interview, and record review, confirming a failure to protect the resident's right to be free from physical restraints.
Failure to Transcribe and Implement Wound Care Orders
Penalty
Summary
The facility failed to ensure that wound care treatment orders for a resident were appropriately transcribed and implemented according to physician instructions. The resident, who had multiple diagnoses including peripheral vascular disease, diabetes, and a recent diagnosis of cellulitis, was assessed by the Wound Doctor, who ordered daily dressing changes and specific wound care interventions for venous insufficiency ulcers on both lower legs. However, these orders were not transcribed into the electronic Physician Order Sheet (ePOS) or the Medication Administration Record (MAR), and there was no documentation of the wounds in the resident's care plan. Observations revealed that the resident had visible wounds on both legs, which were not covered with dressings or compression socks as ordered. The resident reported having wounds for one to two months and stated that a doctor had prescribed medication nine days prior, but the treatment had not been received. Interviews with staff indicated confusion regarding responsibility for transcribing and implementing physician orders, with the desk nurse responsible for order entry but failing to transcribe the wound care orders into the electronic medical record. The Director of Nursing was unaware of the new wound care orders, and the LPN involved stated that only an order for the resident to be seen by the Wound Doctor had been entered. The Wound Doctor confirmed that he expected his orders to be followed and that the treatments he prescribed had not been administered. This sequence of events resulted in the resident not receiving necessary wound care as ordered by the physician.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain an environment free of accident hazards by not ensuring safe water temperatures in resident rooms on the North and South halls. The hot water temperatures in the resident room bathrooms were found to be between 141 to 153 degrees Fahrenheit, significantly exceeding the safe range of 105-120 degrees Fahrenheit. This deficiency was identified during a survey where 16 out of 31 sampled residents were affected by the excessively high water temperatures, posing a risk of scalding and burns. Observations revealed that the Maintenance Director had been adjusting the water heater temperatures in response to resident complaints about cold water, without verifying the actual water temperatures in the rooms. The facility's Safety of Water Temperatures Policy, which mandated water temperatures to be maintained within a safe range to prevent scalding, was not being effectively implemented. Residents with varying levels of cognitive impairment and mobility were exposed to dangerously high water temperatures, as evidenced by specific examples such as Resident #49, Resident #14, Resident #12, and Resident #15, among others. Interviews with staff members, including the Maintenance Director, Director of Nursing, and Corporate Regional Nurse, highlighted a lack of awareness regarding the high water temperatures and the inappropriate use of a laser thermometer for temperature checks. The report also noted that residents who wandered and had access to the bathrooms were at increased risk of being harmed by the hot water. The deficiency was classified as an immediate jeopardy (IJ) level K violation, indicating a serious threat to resident safety due to the failure to maintain safe water temperatures in the facility.
Lack of Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities or one-on-one activities for residents dependent on staff for their needs. The activity calendar showed a limited range of activities, primarily focused on bingo, cards, and occasional parties. Residents expressed dissatisfaction with the lack of variety and meaningful engagement in the activities offered. The Activities Director (AD) confirmed that most activities were self-governed, and there was no regular activities program in place. The AD also mentioned that she was the only one responsible for activities and had limited formal training. Resident #27, who was cognitively moderately impaired and had a history of schizophrenia, heart disease, stroke, and cancer, expressed a desire for outdoor activities and Bible study, which were not provided. Resident #5, who was cognitively intact and had diagnoses of diabetes, anxiety, depression, and schizophrenia, did not participate in activities due to the lack of variety and choices. Resident #28, who was also cognitively intact and had schizophrenia, expressed a similar sentiment, stating that the facility only offered bingo, which did not interest them. Resident #33, who had cancer and schizophrenia, also reported a lack of activities beyond bingo. The AD's work hours were limited to weekdays, and there were no structured activities on weekends. The AD relied on a resident volunteer to help with activities, and there was no documentation of one-on-one activities for residents. The Administrator acknowledged that the AD lacked formal training and that resident activities should be specific to their preferences and documented in progress notes. The facility's failure to provide a diverse and meaningful activities program led to the deficiency identified in the report.
Unqualified Activity Director
Penalty
Summary
The facility failed to ensure the activity program was directed by a qualified professional. The Activity Director, who had been employed at the facility for about two years and transferred to the activity program a year ago, had not received any formal training on how to run an activity program. Although she was enrolled in a state-approved activities director course, she had not started the program yet. The Administrator confirmed that the Activity Director did not have any formal training and had been enrolled in the class since September 2023 but had not started the classes because the facility wanted to see if she would remain consistent with the activity program. The facility's job description for the Activity Director required a high school diploma, completion of a state-approved activities director course, and one year of experience in a resident activities program in a healthcare setting, which the current Activity Director did not meet.
Ice Machine Lacks Required Air Gap
Penalty
Summary
The facility failed to ensure the ice machine in the main kitchen had an air gap between the drain pipe to prevent back siphonage. Observations on multiple dates showed a gray plastic tube extending from the back of the ice machine into a white PVC drain pipe, which was connected to the floor drain without an air gap. The area where the gray tubing was inserted into the PVC drain pipe was covered with dirt and debris. This deficiency had the potential to affect all residents who consumed drinks with ice, given the facility's census of 55 residents. During an interview, the Dietary Manager acknowledged awareness of the requirement for an air gap but was unaware that the ice machine did not have one. The Administrator also confirmed the expectation for an air gap to be present at the ice machine. The facility's Air Gap Policy for Ice Machine Draining Pipe outlined the necessity of an air gap to prevent backflow contamination, but this policy was not adhered to in practice, leading to the observed deficiency.
Infection Control Deficiencies in Perineal and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection control during perineal care and wound care for several residents. For Resident #28, a Certified Medication Technician (CMT) improperly wiped the resident's anal area from top to bottom while the resident was standing, using the same wipe multiple times without turning it. The CMT admitted to not regularly providing personal care due to their primary task of administering medications. Similarly, Resident #35 received improper perineal care from a Certified Nurse Aide (CNA) who did not separate the labia while wiping from front to back. Both staff members failed to change gloves appropriately during the care process, increasing the risk of cross-contamination and infection. In another instance, Resident #258, who had a surgical wound, received wound care from a Registered Nurse (RN) who did not perform hand hygiene before changing gloves multiple times during the procedure. The RN removed and replaced gloves without washing hands, thereby compromising the sterility of the wound care process. Additionally, Resident #46, who had an ingrown toenail, was assisted by the same RN who failed to change both gloves and perform hand hygiene after assisting another resident. The RN handled treatment supplies and touched the resident's wounds without proper glove changes and hand hygiene, further risking cross-contamination. Interviews with staff, including the Director of Nursing (DON), confirmed that the facility's policies and procedures for hand hygiene and glove changes were not followed. The DON acknowledged that failing to change both gloves and perform hand hygiene could lead to cross-contamination or infection. The Administrator also expected staff to adhere to the facility's policies and procedures, which were not followed in these instances, leading to the deficiencies observed during the survey.
Failure to Complete Dialysis Assessments and Maintain Accurate Care Plan
Penalty
Summary
The facility failed to complete pre and post dialysis assessments and did not have an accurate care plan for a resident requiring dialysis services. The resident, who was cognitively intact and diagnosed with end-stage renal disease (ESRD), received dialysis at an outside facility. The care plan did not reflect the current dialysis site location, and there were multiple instances where the dialysis communication forms were incomplete or missing vital information. Specifically, on several dates, the dialysis center information and post-dialysis assessments were either blank or not documented, and there was no record of the resident refusing these assessments or the facility contacting the dialysis center to obtain the necessary information. Interviews with the facility staff, including a registered nurse (RN) and the Director of Nursing (DON), revealed that the expected protocol was for pre and post dialysis assessments to be completed and documented on the dialysis communication form. These assessments included checking the graft site, vital signs, and observing for any complications. However, it was noted that sometimes the resident forgot to take the communication form to the dialysis center, or the dialysis center did not return the form. Additionally, if the resident refused the assessment, it was supposed to be documented, but this was not consistently done. The Director of Nursing confirmed that the dialysis communication forms were often incomplete and that the facility's policies and procedures were not always followed. The Administrator also stated that he expected the staff to adhere to the facility's policies and procedures. The lack of proper documentation and adherence to protocols led to the deficiency in providing safe and appropriate dialysis care for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Saint Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lansdowne Village | 0.2 mi | ★★★★★ | 18 | 0 |
| Magnolia Wellness Center | 1.4 mi | ★★★★★ | 10 | 1 |
| Beauvais Rehab And Healthcare Center | 2 mi | ★★★★★ | 1 | 0 |
| Carrie Elligson Gietner Health Care Center | 2.1 mi | ★★★★★ | 8 | 0 |
| St Louis Altenheim | 2.2 mi | — | 20 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.