Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Tiffany Springs Rehabilitation & Health Care Cente during CMS and state inspections, most recent first.
A resident with COPD, CHF, and mobility difficulties had a physician-signed Out of Hospital DNR documented in the EMR and a care plan stating that advance directives would be honored. When the resident was found unresponsive in a wheelchair without apparent respirations or pulse, an LPN, who later reported panicking, performed a sternal rub, found no pulse, assisted with moving the resident to the floor, and initiated CPR without first checking the resident’s code status in the EMR or the crash cart notebook, contrary to facility policy. After two cycles of chest compressions, a pulse was detected, and EMS arrived, recorded vital signs, and transported the resident to the hospital. Staff interviews confirmed that code status is clearly available in the EMR and on the crash cart list and that the expectation is to verify code status before starting CPR.
A resident admitted with a left ankle fracture and a soft cast, and identified as at risk for pressure ulcers, later had a CAM boot applied with orders to keep it on except for hygiene. Nursing documentation repeatedly noted no skin issues other than a Stage I pressure injury on the right great toe, and staff (including an RN, LPN, and CNA) reported they never removed the boot to assess skin or provide hygiene, despite the resident’s ongoing complaints of significant foot pain. The resident stated the boot and underlying sock were never removed for more than two weeks and that staff told them they could not take the boot off. When the resident finally returned to the orthopedic physician after more than three weeks, a large medial ankle/foot ulcer was found, and wound clinic evaluation documented a large unstageable wound with eschar under the CAM boot, which was attributed to the boot not being removed for three weeks. Subsequent surgery revealed a full-thickness ulcer with eschar, partial tendon exposure, and associated hardware infection requiring debridement and hardware removal.
Failure to provide hygiene care in accordance with resident preferences: Two residents who were cognitively intact and dependent on staff for bathing did not receive showers or bed baths as planned. One resident's showers were documented on days and times that did not match the care plan, and the resident reported going nearly two weeks without a shower. The other resident reported getting bed baths only about every other week, and observation found greasy, unkempt hair and a strong foul body odor. Staff said showers were assigned by room number, a shower aide was no longer available on days, and residents should have a choice of date and time.
Resident trust fund accounts were not properly managed when one resident’s account went into a negative balance after room and board was charged without confirming available funds, and six discharged residents had personal funds still held by the facility instead of being refunded in a timely manner. The BOM stated the negative balance occurred because she did not verify the account before issuing the check, and the Administrator acknowledged resident monies should be returned within the facility’s required timeframe and resident accounts should never be negative.
Failure to notify residents of over-limit trust fund balances. Four residents with intact cognition and multiple chronic diagnoses had Resident Trust Account balances at or above the SSI limit, but the BOM did not send the required formal letters to the resident or responsible party. The BOM said she discussed the balances but had never sent the letters, and the Administrator stated a letter is required when a resident is within $200 of the limit.
Medication, Pain, and Care Plan Management Failures: Surveyors found multiple lapses in care, including missed scheduled opioid doses for a resident with chronic pain, no documentation that the provider was notified when pain meds were unavailable, and use of emergency kit medication without clear supporting documentation. Another resident received meds that did not match the stated symptom, while a resident with diabetes had delayed BG monitoring and missed weights with significant wt loss and no provider notification. A third resident’s constipation and pain-related orders were not followed, and the care plan did not address key diagnoses or symptoms.
Incomplete perineal care was observed for two residents who were dependent for toileting and hygiene. CNAs did not fully separate and cleanse skin folds or clean all areas exposed to urine or feces during incontinent care, despite one resident having severe cognitive impairment and total dependence for personal hygiene and the other having impaired mobility and frequent bowel and bladder incontinence.
Food was not consistently served at a safe, appetizing temperature and was described as unpalatable. Two residents reported cold meals, and one said the food was sometimes very spicy and not hot enough, while another said meals in the dining room were sometimes cold and did not taste good. In resident council, most residents said the food was cold, and one reported chicken that was tough and hard. Surveyors observed delays in tray passing on the hall, and a test tray showed lima beans and french fries below the required serving temperature, with the fries described as bland, starchy, gritty, dry, and not crispy.
Bathroom exhaust vents in 11 resident rooms were observed covered in dirt. The Maintenance Director said the vents were cleaned twice a year and were last cleaned in July to August 2025, and he believed maintenance staff may have started the task but were called away to other jobs before completing all vents.
Failure to develop a baseline care plan for a resident's immediate needs, including pain control and incontinence care. The resident was admitted with a fractured lower leg, frequent pain, bowel and bladder incontinence, and dependence on staff for toileting, hygiene, transfers, and mobility, but the care plan did not include staff interventions for pain management or toileting/incontinence support. The resident was later observed yelling that he/she was in pain, and a family member requested help with incontinence care.
A resident with moderate cognitive impairment, malnutrition, Parkinson's disease, and heart failure had significant unplanned weight loss and orders for fortified foods and a Magic Cup. Staff did not consistently provide the ordered Super Cereal or Magic Cup, served corn flakes instead of the ordered fortified breakfast, and did not document missed intake or notify the nurse, physician, or RD when the prescribed diet was not consumed.
A resident on EBP for a wound, with severe cognitive impairment and incontinence, received peri care and brief changes from CNAs who entered the room and provided care without wearing gowns, and in one instance without gloves as well. The resident’s care plan and orders required gown and glove use for high-contact care, and both CNAs and the DON acknowledged that PPE should have been worn.
A resident with a signed DNR order did not have their code status accurately updated in the physician orders or medical record banner. When the resident was found unresponsive, staff could not verify the DNR status and performed CPR, with EMS continuing life-saving measures. The failure to update and communicate the resident's code status led to the deficiency.
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were hospitalized with septic shock due to untreated UTIs, as the facility did not carry out lab orders despite repeated communications from hospice staff. Another resident was without psychotropic medication for fourteen days because the pharmacy required lab results, which the facility failed to obtain. This resulted in increased stress and sleep disturbances for the resident.
The facility failed to provide timely laboratory services, resulting in a resident being without psychotropic medication for two weeks due to missing lab results. Several residents with UTI symptoms did not receive timely urine cultures, leading to one resident's hospitalization for sepsis. The facility also lacked necessary lab supplies, further delaying care.
The facility failed to maintain safe food handling practices and a sanitary kitchen environment. Observations showed staff using the same gloves for multiple tasks, leading to potential contamination. The kitchen had significant cleanliness issues, including greasy surfaces and food debris. Staff interviews revealed a lack of training in food safety practices, and the Dietary Manager acknowledged the unsanitary conditions.
The facility failed to provide properly prepared pureed food to residents on a pureed diet. Observations revealed that the pureed sausage served was dry and crumbly, requiring chewing, contrary to the required smooth, mashed potato consistency. Cook1 admitted to not blending the sausage long enough, leading to the deficiency.
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. A resident with severe pain did not receive timely medication, despite clear communication of her pain. Another resident experienced a five-day delay in receiving effective pain management due to an expired prescription and lack of follow-up. A third resident with chronic pain syndrome did not receive scheduled pain medication consistently, affecting her daily activities. Interviews revealed a lack of communication and failure to ensure medication availability.
A resident with chronic pain conditions did not receive prescribed pain medications due to unavailability, and the facility failed to notify the physician. The resident's Norco and lidocaine patch were not administered on several occasions, and there was insufficient documentation of physician notification. Interviews with staff revealed a lack of communication and adherence to protocol, resulting in inadequate pain management for the resident.
A facility failed to conduct a timely PASARR Level II screening for a resident who returned from a psychiatric facility with a new diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services, the necessary screenings were not initiated, as confirmed by the Social Services Designee and the DON, highlighting a lapse in the facility's process for handling significant changes in residents' conditions.
A facility failed to create a comprehensive care plan for a resident with an ICD, despite the resident's cognitive intactness and specific health needs. The care plan lacked focus on ICD-related interventions, and facility leaders believed no specific plan was needed, assuming staff would call 911 if necessary. This oversight was identified during a review of the resident's EMR.
A resident with Parkinson's and dementia experienced a decline in ADL abilities, which the facility failed to address. Despite being assessed as needing minimal assistance, observations showed the resident struggled with personal hygiene and grooming. Staff interviews confirmed the resident required more help than previously assessed, indicating a need for reassessment of care needs.
A resident with emphysema was observed with an oxygen e-tank standing unsupported against the wall, while connected to an oxygen concentrator. The MDSC confirmed the e-tank should have been secured in its carrier, and the DON stated that e-tanks are to be secured.
A resident with a PICC line for IV antibiotics had their dressing unchanged for 15 days, contrary to the facility's policy of changing it every seven days. The dressing was observed to be partially detached, increasing infection risk. The ADON confirmed the oversight.
A resident with rheumatoid arthritis, chronic pain syndrome, and anxiety did not receive timely administration of medications due to prescription changes, pharmacy delays, and lack of communication with the physician. The facility staff, including the DON and NP, were not adequately informed of the missed doses, leading to a failure in ensuring the resident received her necessary medications.
A facility failed to document the death of a resident and did not include a physician order to release the body. The resident, who had a history of lumbar fracture, congestive heart failure, and COVID-19, experienced respiratory distress and stabilized after oxygen intervention. Despite the family's decision to avoid hospitalization, there was no further documentation after 4:00 AM. Interviews revealed the resident's rapid decline and the absence of hospice care before death. The Medical Director acknowledged the lack of documentation and the missing release order.
A CNA at a LTC facility recorded two videos of a resident without consent, violating the resident's right to privacy. The resident, who had severe cognitive impairment, was filmed in undignified situations. The facility lacked clear policies and training on resident rights and cell phone use, contributing to the incident.
A resident in a long-term care facility was found unresponsive and without a pulse, but CPR was not initiated immediately due to an LPN's incorrect assumption about the resident's code status. Despite being informed by CNAs that the resident was a full code, the LPN delayed CPR until the DON arrived and confirmed the status. The LPN, an agency nurse, had not received proper orientation on emergency procedures, contributing to the delay in life-saving measures.
Failure to Honor DNR Order and Follow CPR Policy
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s documented Do Not Resuscitate (DNR) order and to follow its own Cardiopulmonary Resuscitation (CPR) and Resident Rights policies. The resident, who was their own responsible party, had diagnoses including COPD, CHF, pain, and difficulty walking, and had an Out of Hospital DNR form signed by both the resident and the primary care physician in the electronic medical record. The resident’s comprehensive care plan stated that the resident was not near end of life but that advance directives would be honored. The facility’s CPR policy required clinical staff to verify code status in the clinical record when a resident was found unresponsive and not breathing normally, and if the resident was a DNR, to notify the attending provider. The Resident Rights policy stated that residents have the right to self-determination, autonomy, and choice regarding receipt of care. On the day of the incident, an LPN entered the resident’s room to provide skin treatment and found the resident in a wheelchair, unresponsive, with head bent down, and without apparent breathing or pulse. The LPN performed a sternal rub without response, checked for a pulse at the wrist and neck and felt none, then, with assistance from other staff, moved the resident to the floor and initiated chest compressions. The LPN completed 30 compressions, rechecked for a pulse, found none, and performed another 30 compressions, after which a pulse was detected. Emergency Medical Services arrived, documented vital signs including a heart rate of 83 bpm and blood pressure of 146/60, and transported the resident to the hospital. The LPN later stated that they panicked, did not check the resident’s code status in the electronic medical record or the crash cart notebook before starting CPR, and acknowledged that code status should have been verified first. Other nursing staff and leadership confirmed that code status is available in the EMR and in a crash cart notebook and that staff are expected to check code status prior to initiating CPR.
Failure to Monitor Skin Under CAM Boot Resulting in Unstageable Pressure Injury
Penalty
Summary
The deficiency involves the facility’s failure to prevent the development of an unstageable pressure injury under a removable medical device for one resident. The facility’s own skin policy required licensed nurses to evaluate skin integrity on admission, weekly, and with significant changes, and required CNAs to observe skin during ADLs and report changes so that licensed nurses could initiate preventive or treatment interventions. On admission from the hospital, the resident had a left ankle fracture, a soft cast/splint applied by the orthopedic surgeon, and no documented skin lesions other than a Stage I pressure injury on the right great toe that was present on admission. The admission MDS identified the resident as at risk for pressure ulcers, with partial to moderate assistance needs for ADLs and diagnoses including ankle fracture, muscle weakness, anxiety, stroke, and dementia. Early nursing documentation repeatedly stated there were no other skin issues besides the right great toe. The resident initially had a soft cast that was not to be removed until an orthopedic follow-up. At the follow-up, the orthopedic physician removed the soft cast and placed a CAM boot on the left ankle, with orders that the boot be left on at all times except for hygiene. Despite this order, multiple nursing staff, including an RN and an LPN, reported they never removed or opened the boot to assess the skin or provide hygiene, stating they believed they should not open it if the order was to leave it in place. A CNA reported the resident complained of a lot of pain in the left foot and that she loosened the boot strap once to assist with pain relief but did not remove the boot. The resident stated that after arriving at the facility, the CAM boot was never removed until the return visit to the physician, that a sock under the boot was left in place for more than two weeks, and that facility staff told the resident they could not take the boot off. The resident reported significant ankle pain but could not distinguish whether it was from the skin or the surgery. When the resident eventually returned to the orthopedic physician after more than three weeks instead of the ordered two-week follow-up, the physician found a medial foot/ankle ulceration measuring approximately 3–6 cm with a fibrous base and mildly erythematous edges. The orthopedic surgeon and wound clinic RN attributed the open wound to the CAM boot not being removed for three weeks, and the wound clinic RN documented a large unstageable wound with eschar on the left ankle/foot measuring 3.3 cm by 3.1 cm by 0.1 cm. The DON acknowledged that, with an order to remove the boot for hygiene, staff should have opened the boot and checked the skin every shift and admitted that the facility did not check the resident’s skin and that this was wrong. The orthopedic surgeon stated it was unacceptable that the boot was not removed and the skin was not checked for three weeks. Subsequent operative documentation showed the resident developed a full-thickness ulcer to the fat layer with large eschar and partial tendon exposure, associated with a hardware infection in the left ankle that required irrigation, debridement, hardware removal, and preparation of the wound bed for a skin graft. The sequence of events shows that, despite the resident’s identified risk for pressure ulcers, the presence of a removable CAM boot, and ongoing complaints of pain, facility staff did not perform periodic skin checks under the device for more than 20 days. Nursing notes during this period continued to document no skin issues other than the right great toe, and staff interviews confirmed that the boot was not removed for skin assessment or hygiene. The NP and Unit Manager both stated they would have expected staff to open the boot and check the skin and pulses, and the Unit Manager stated that an order to check the skin under the boot was not necessary. The failure to follow the facility’s skin monitoring policy and to assess the skin under the CAM boot as ordered for hygiene led to the development of an unstageable pressure injury and subsequent complications documented in the medical record and operative reports.
Failure to Provide Hygiene Care in Accordance with Resident Preferences
Penalty
Summary
The facility failed to promote resident self-determination by not providing showers and personal hygiene care in accordance with resident preferences and care plans for two residents. Resident #76 was cognitively intact, required assistance with showering, bathing, and toileting, and had diagnoses including seizures, diabetes, and heart failure. His/her care plan called for showers on Wednesdays and Saturdays in the evening, with two staff assisting and a consistent routine, but the electronic record showed six showers in the past 30 days were given on Mondays or Fridays between 11:26 A.M. and 2:59 P.M., not as planned. The resident said he/she did not get showers that often, it had been almost two weeks since the last shower, staff said showers could be requested but then did not return, and going without showers made him/her feel dirty. Resident #92 was cognitively intact, dependent on staff for transfers, bathing, and toileting, and had diagnoses including morbid obesity, diabetes, and respiratory failure. The care plan directed staff to provide a bath and to give a sponge bath when a full bath or shower could not be tolerated, while keeping the resident's skin clean, dry, and moisturized. The resident said he/she was lucky to get one bed bath, usually every other week, and became upset when told a shower had already been given. Observation showed greasy, unkempt hair and a strong foul body odor. Staff interviews indicated the facility no longer had a shower aide during the day, showers were assigned by room number, missed showers were sometimes made up on Sundays, and the DON stated residents should receive showers or bed baths twice a week and have a choice of date and time.
Resident Trust Fund Accounts Not Properly Managed
Penalty
Summary
The facility failed to implement policies and procedures to ensure resident trust fund accounts were not allowed to go into a negative balance and failed to refund resident funds within the required timeframe after discharge. Review of the facility policy showed that discharged residents’ refund checks were to be completed within 5 business days, trust fund accounts were to be reconciled monthly, and the facility was to refund the balance of a resident’s personal funds when the resident was discharged. The business office aging report showed discharged residents with credit balances still held in the facility’s operating account, including balances of $870.42, $5,683.00, $2,118.00, $1,077.00, $40.00, and $399.00 for six residents. Record review also showed one resident’s trust fund account had a negative balance of $1,891.89 on multiple quarterly statements. The quarterly statements showed the account was debited for room and board, bringing the balance to negative $1,891.89, and later the resident deposited $1,891.89 to bring the balance back to zero. During interview, the BOM stated the account went negative because she did not verify that funds were available before issuing the check to the corporate account, and said resident trust fund accounts should never be negative because that indicates resident funds are missing from the account. The BOM also stated the refunds for the discharged residents were delayed despite the issues being resolved, and the Administrator stated monies owed to residents should be returned within the timeframe in facility policy and residents should not ever have a negative balance in the Resident Trust Account.
Failure to Notify Residents of Over-Limit Trust Fund Balances
Penalty
Summary
The facility failed to notify four residents when their Resident Trust Account balances were within $200.00 of the SSI limit or when their accounts were over the SSI limit. Review of the facility policy showed that any Resident Trust Account nearing the state-specified maximum balance required notification to the resident or responsible party by form letter, but no such letters were sent for the affected residents. This deficiency affected four of 24 residents sampled in a facility with a census of 116. Resident #16 had a Quarterly MDS showing the resident was cognitively intact and had diagnoses including coronary artery disease, heart failure, kidney disease, diabetes, anxiety disorder, depression, and dementia. The resident’s monthly trust fund balances were over the SSI limit in January, February, March, May, June, and August 2025. Resident #23 was cognitively intact with diagnoses including coronary artery disease, heart failure, GERD, psychotic disorder, and depression, and had a trust fund balance of $6,263.27 over the SSI limit. Resident #75 was cognitively intact with diagnoses including cerebral palsy, anxiety disorder, and depression, and had a trust fund balance of $6,114.33 over the SSI limit. Resident #106 was cognitively intact with diagnoses including anemia, hypertension, kidney disease, and depression, and had trust fund balances of $16,859.00 in June 2025 and $18,027 in August 2025, both over the SSI limit. The BOM stated she discussed over-limit balances with residents but had never sent formal letters, and the Administrator stated residents should be assisted in spending down funds if within $200 of the limit and that a letter is required to be sent.
Medication, Pain, and Care Plan Management Failures
Penalty
Summary
The facility failed to provide services and care that adhered to accepted standards of quality in several areas, including pain management, medication administration, physician notification, and diabetes management. Surveyors identified deficiencies involving four sampled residents. The report also noted that the facility’s Medication Administration Policy required staff to administer medications as ordered, and the Ordering Medications Policy described refill request processes, but there was no facility policy provided regarding emergency kit narcotics. For one resident with heart failure, spinal stenosis, neuropathy, and low back pain, the resident was cognitively intact, dependent on staff for medication administration, and prescribed scheduled opioid pain medications. The resident missed five scheduled doses of Hydrocodone/Acetaminophen because the medication was not available, and two scheduled doses of Fentanyl transdermal patch were also not administered because they were not available. The record showed no documentation that the provider was notified about the missed pain medication doses, no documentation that the medications were reordered from the pharmacy for all missed doses, and no additional pain medication was ordered or administered while the resident was without the prescribed Hydrocodone and Fentanyl. The resident stated that the missed medication period was a rough few days and that pain increased, and Tylenol did not help decrease the pain level. For another resident with a recent arm fracture and surgical repair, the record showed orders for Acetaminophen for fever and Oxycodone for severe pain, along with an inhaled ProAir order for shortness of breath or wheezing. Surveyors observed the resident asking for a nasal spray and being given an Albuterol inhaler instead, with the CMT stating it might work. The resident had received Acetaminophen only as ordered for fever, and there were no fevers documented. The resident also received ProAir doses without supporting documentation of shortness of breath or wheezing. For a resident with kidney failure, diabetes, heart failure, and failure to thrive, the record showed four missed daily weights out of 16, a documented 25.3-pound or 13% weight loss in 19 days, and no documentation that the provider was notified. The resident also reported that blood glucose monitoring had not been performed until requested by the resident and family, and facility records showed blood glucose monitoring did not begin until after that request. For a resident with a left leg fracture with surgical repair, dementia, incontinence, and constipation concerns, the care plan did not mention pain, incontinence, constipation, or the recent fracture. Physician orders included Milk of Magnesia and Bisacodyl suppository for constipation, but there was no documentation that Milk of Magnesia was given, and the resident later removed their own fecal impaction with their fingers. The resident reported intermittent pain since surgery and said they were only pain free when immobile. The DON stated that physician orders should be followed and that pain should have been on the care plan for a resident admitted with pain as a diagnosis.
Incomplete Perineal Care During Incontinent ADL Assistance
Penalty
Summary
The facility failed to ensure dependent residents received complete perineal care and assistance with ADLs to maintain good personal hygiene. The facility’s ADL policy stated residents are to receive care according to their care plan and ability to perform bathing, dressing, grooming, and toileting. During observation, staff provided incomplete cleansing for two residents during incontinent care, including not separating and cleaning all skin folds and not cleaning all areas that urine or feces had touched. One resident had severe cognitive impairment, required extensive assistance of two staff for bed mobility, transfers, toileting, and personal hygiene, and was incontinent of bowel and bladder with diagnoses including dementia and depression. During incontinent care, CNAs washed hands, applied gloves, removed the wet brief, and cleaned only selected areas of the groin and buttocks, but did not separate and clean all skin folds or all areas exposed to urine and feces. Another resident had intact cognition, impaired upper and lower extremity function, required assistance with transfers and toilet use, and was frequently incontinent of bowel and bladder. During bedpan care, CNAs cleaned parts of the groin and buttocks, but did not separate and clean all skin folds and used wiping motions that did not fully cleanse all areas where urine had touched.
Food Served Cold and Unappetizing
Penalty
Summary
Food and drink were not ensured to be palatable, attractive, and served at a safe and appetizing temperature during meal service. Resident #22, whose quarterly MDS dated 11/17/25 showed cognitive intactness and diagnoses including heart failure, Parkinson's disease, anxiety disorder, depression, and respiratory failure, told the surveyor on 1/20/26 that the food is cold at all meal times and that some of it is very spicy. The resident said he/she normally eats in his/her room and would prefer food that is hotter than what is received. Resident #95, whose quarterly MDS showed diagnoses of coronary artery disease, diabetes, and seizure disorder, stated on 1/20/26 that food is sometimes cold in the dining room and does not taste good, which is disappointing because looking forward to meals is important. During a resident council interview, 13 of 14 residents said the food was cold, and one resident reported being unable to eat chicken because it was tough and hard. On observation of the 300 hall, trays were delivered in an insulated cart, but there was a delay before all trays were passed. A lunch test tray showed lima beans at 116.0 degrees Fahrenheit and french fries at 106.0 degrees Fahrenheit, both below the required 120 degrees Fahrenheit, and the fries were described as bland, starchy, gritty, dry inside, and not crispy. The Dietary Manager stated the expectation was to serve food at a minimum of 120 degrees Fahrenheit and to deliver hall trays with minimal delay, while the Administrator stated meals should be served according to state regulations and with no more than a five-minute delay after delivery to the hall.
Bathroom Exhaust Vents Not Kept Free of Excess Dust
Penalty
Summary
The facility failed to ensure bathroom exhaust vents were free of excess dust in residents' rooms. Observation on 1/20/26 at 11:17 A.M. showed bathroom exhaust vents covered in dirt in 11 resident rooms, identified as room [ROOM NUMBER] through room [ROOM NUMBER]. The facility census was 116. During an interview on 1/21/26 at 3:08 P.M., the Maintenance Director said the bathroom exhaust vents were cleaned twice a year and were last cleaned in July to August 2025. He stated that maintenance staff may have started the task and then been called away to other jobs before completing it for all exhaust vents, which he believed was why some of them had so much dirt on them.
Failure to Develop Baseline Care Plan for Pain and Incontinence Needs
Penalty
Summary
The facility failed to develop a baseline care plan for Resident #113 within 48 hours of admission, including pain control. The resident's admission MDS dated 1/6/26 showed the resident was not cognitively intact, was incontinent of bowel and bladder, needed partial to moderate assistance with toileting, toilet hygiene, dressing, transfers, and mobility in bed, and reported frequent pain during the last five days. Diagnoses included fracture of the left lower leg with repair, pain due to internal orthopedic prosthetic devices, and cognitive communication deficit. The care plan dated 1/8/26 identified risk for skin breakdown related to an existing pressure injury to the coccyx and leg splint and stated the resident was dependent on nursing staff for all personal hygiene, grooming, and transfers, but it did not include a plan for incontinence care or toileting programs with staff intervention. It also did not initiate a pain management regimen with staff interventions for the newly fractured leg, even though the resident was dependent on facility staff to assess pain and provide pain management including pain medications. During observation on 1/20/26, the resident was heard yelling from the room, saying, "I am in pain," for approximately half an hour, and later a family member asked staff to clean the resident after incontinence. The resident later stated that he/she had intermittent pain since surgery and that not being moved was the only time he/she did not feel pain. The DON and Administrator stated they expected pain to be identified on the resident's care plan if the resident was admitted with pain as a diagnosis.
Failure to Provide and Monitor Ordered Nutrition Support for a Resident With Weight Loss
Penalty
Summary
The facility failed to implement and monitor interventions for a resident with significant unplanned weight loss. The resident had moderate cognitive impairment, required substantial assistance with ADLs, and had diagnoses including Parkinson's disease, malnutrition, and heart failure. The resident's record showed a weight of 144.8 lbs in June 2025 and 129.4 lbs in December 2025, reflecting a 15.4 lb loss, or 10.64%, over 6 months. The resident also had physician orders for a regular diet with Magic Cup at lunch and fortified foods with Super Cereal at breakfast, and the RD recommended Super Cereal with breakfast and ice cream with lunch. Observation and interview showed the resident was not consistently offered the ordered supplements. On one occasion, CNA A served lunch without Magic Cup or ice cream and stated the kitchen provided the Magic Cup and that he/she did not know much about it; the CNA did not obtain the supplement or notify the nurse. On another occasion, the resident said he/she was hungry because breakfast had not been received that morning. A review of the breakfast meal ticket showed Super Cereal was circled, but the tray served contained corn flakes and milk instead of Super Cereal. Staff interviews showed the meal omissions were not reported or documented. CNA A stated the resident did not get a breakfast tray and that he/she did not tell the nurse. CNA F stated he/she did not tell the nurse or kitchen if the resident did not eat and had never documented when the resident did not eat or did not get what was ordered. The Dietary Manager, ADON, DON, and Administrator all stated that the resident should have received the ordered Super Cereal and Magic Cup and that the nurse, physician, RD, or unit manager should have been notified if the resident was not consuming the prescribed diet, but the resident's record showed no documentation that the ordered diet had not been consumed and no notification to the physician or RD was identified.
Failure to Use PPE During EBP Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment when staff did not use PPE during care for a resident on enhanced barrier precautions (EBP). Resident #13 had severe cognitive impairment, required extensive assistance from two staff for bed mobility, transfers, toileting, and personal hygiene, was incontinent of bowel and bladder, and had a wound on the coccyx/left buttock. The resident’s care plan and physician’s orders indicated EBP due to the wound and specified that staff were to wear a gown and gloves when providing personal hygiene and toileting or other high-contact care activities. During observation, CNAs entered the resident’s room and provided incontinent care, peri care, and brief changes while the resident had a wet brief and a bandage on the left buttock, but they did not put on isolation gowns before entering the room or before providing care. On one occasion, two CNAs entered the room and provided care without gowns or gloves; on another, two CNAs washed their hands and applied gloves but still did not put on isolation gowns before providing peri care. Both CNAs stated they should have worn a gown and gloves before entering the room and providing care. The DON stated she expected staff to put on full PPE when entering a room with EBP, and the Administrator stated she expected staff to follow the facility protocol for infection control and PPE.
Failure to Honor Resident's DNR Due to Incomplete Medical Record Update
Penalty
Summary
Facility staff failed to honor a resident's Do Not Resuscitate (DNR) advanced directive when they performed Cardiopulmonary Resuscitation (CPR) and notified Emergency Medical Services (EMS) to complete all life-saving measures. This occurred because the DNR order, although signed by the resident and uploaded to the miscellaneous section of the medical record, was not accurately entered into the physician orders or reflected in the resident's medical record banner. As a result, staff were unable to quickly verify the resident's code status during the emergency. The resident involved was on hospice services, had a diagnosis of lung cancer and depression, and was dependent on staff for all activities of daily living. The resident had intact cognitive skills and had signed a DNR order prior to the incident. However, the admission record did not list an advance directive, and the electronic medical record did not indicate the DNR status. When the resident was found unresponsive, staff checked the available records and, not finding the DNR status, initiated CPR and called EMS, who continued resuscitation efforts until the resident was pronounced deceased. Interviews with staff revealed that the process for updating code status was not consistently followed. Social services had uploaded the DNR and notified nursing to change the code status, but the nurse responsible was interrupted and did not complete the entry. The code status was not updated in the physician orders or on the code status roster, leading to confusion during the emergency. Staff relied on the code status report and the medical record banner, both of which did not reflect the resident's DNR status, resulting in the failure to honor the resident's documented wishes.
Failure to Provide Timely Lab Testing and Results
Penalty
Summary
The facility failed to provide timely lab testing and results for three residents, leading to significant health issues. Two residents were admitted to the hospital with septic shock due to untreated urinary tract infections (UTIs). The facility did not carry out lab orders for one resident, despite the hospice nurse providing new orders for tests such as TSH and C-diff. The resident's condition deteriorated, resulting in hospitalization for sepsis, pneumonia, and a UTI. The resident's representative and hospice staff had repeatedly communicated concerns about the resident's condition and the lack of lab results, but the facility did not act promptly. Another resident experienced a delay in receiving lab results for a UA, which was crucial for monitoring their condition due to a history of UTIs and sepsis. Despite the resident and their spouse requesting a UA to check for a bladder infection, the lab specimen was mishandled, and results were delayed. This resident was also hospitalized for a UTI with sepsis, highlighting the facility's failure to ensure timely lab testing and results. A third resident was without their psychotropic medication for fourteen days because the pharmacy required lab results before dispensing the medication. The facility failed to obtain the necessary lab tests, leaving the resident without essential medication. The resident experienced increased stress and sleep disturbances due to the lack of medication. The facility's inability to coordinate lab services and ensure timely testing and results significantly impacted the residents' health and well-being.
Failure to Provide Timely Laboratory Services
Penalty
Summary
The facility failed to provide necessary laboratory services for its residents, resulting in significant delays in obtaining and reporting lab results. This deficiency was evident in the case of a resident who was without their psychotropic medication, clozapine, for fourteen days because the pharmacy required lab results before dispensing the medication. Despite multiple orders for weekly complete blood count with differential (CBCD) labs, the facility did not ensure these were completed, leading to the resident experiencing increased stress, insomnia, and physical discomfort due to the lack of medication. Additionally, the facility did not ensure timely collection and reporting of urine cultures for several residents showing signs and symptoms of urinary tract infections (UTIs). Multiple residents, including those with severe cognitive impairments and those receiving end-of-life hospice care, were affected by the facility's failure to obtain necessary lab tests. In one instance, a resident's condition deteriorated to the point of hospitalization for sepsis and pneumonia, with the hospital identifying a severe infection that had not been addressed due to the lack of timely lab results. The facility also failed to maintain adequate laboratory testing supplies, such as urine specimen containers, which further hindered the ability to collect necessary samples. This lack of supplies, combined with the failure to follow up on lab orders and results, contributed to the facility's inability to meet the residents' healthcare needs effectively. The deficiency in laboratory services was compounded by poor communication and coordination between the facility, the laboratory, and the pharmacy, leading to significant delays in treatment and care for the residents involved.
Deficiencies in Food Handling and Kitchen Sanitation
Penalty
Summary
The facility failed to ensure safe food handling practices, proper labeling, dating, and sealing of food in cold storage, and maintaining a clean and sanitary kitchen environment. Observations revealed that Cook1 was preparing food while wearing the same pair of gloves, touching various surfaces and utensils, and handling food without changing gloves. This practice was observed multiple times, indicating a lack of adherence to proper hand hygiene and glove usage policies. Further observations of the kitchen environment showed significant cleanliness issues. The two-compartment vegetable prep sink had romaine lettuce in one side and dirty blender parts in the other. The standing mixer was uncovered and had dried food on the splash guard. Bulk food tubs were greasy and had food debris, and the walk-in refrigerator and freezer had food debris, cardboard pieces, and ice build-up. The kitchen floor was greasy, with stained grout and food debris pushed against the baseboards. Appliances and shelves were also found to be greasy and covered in food debris. Interviews with kitchen staff revealed a lack of awareness and training regarding safe food handling practices. Cook3 and Cook2 admitted to using gloved hands to handle food without changing gloves or using utensils, and they could not recall receiving food safety education. The newly hired Dietary Manager acknowledged the unsanitary conditions and was in the process of creating new cleaning schedules, but the issues persisted at the time of the survey.
Improper Preparation of Pureed Diet
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received food prepared in the appropriate pureed form. Observations during a kitchen tray line inspection revealed that the pureed breakfast sausage served to residents was dry, crumbly, and had a ground texture rather than the required smooth, mashed potato consistency. This inconsistency in food texture was confirmed during an evaluation of a test tray with the Dietary Manager, who acknowledged that the pureed sausage was not prepared correctly and required chewing to be swallowed. The deficiency was attributed to Cook1, who admitted to not blending the sausage long enough to achieve the desired smooth texture. The facility's recipe for pureed sausage links specified that the ingredients should be blended until a smooth, mashed potato consistency was reached, which was not adhered to in this instance. The failure to properly prepare the pureed sausage had the potential to cause issues such as choking, aspiration, malnutrition, weight loss, or dissatisfaction with meals for the residents on a pureed diet.
Inadequate Pain Management for Residents
Penalty
Summary
The facility failed to provide adequate pain management for three residents, leading to significant deficiencies in care. Resident 107, who was cognitively intact and experiencing severe pain, did not receive timely pain medication despite having a documented pain level of 10. The resident expressed ongoing pain and a desire for hospice care due to inadequate pain management. Interviews with the Director of Nursing (DON) and Nurse Practitioner (NP) revealed a lack of communication and failure to schedule pain medication appropriately, despite the resident's clear communication of her pain. Resident 82, who was also cognitively intact, experienced a delay in receiving effective pain management for five days. The resident's pain medication prescription had expired, and there was a lack of follow-up to obtain a new prescription. The resident reported significant pain and a lack of timely intervention, which was confirmed by staff interviews. The DON acknowledged the absence of a pain management policy and the failure to document follow-up on the resident's pain management. Resident 4, with a history of rheumatoid arthritis and chronic pain syndrome, did not receive scheduled pain medication consistently. The resident reported daily pain and missed doses of her prescribed medication, which affected her daily activities. Interviews with the DON and NP highlighted a lack of communication and failure to ensure the availability of pain medication. The NP was unaware of the missed doses and emphasized the importance of notifying him to prevent such occurrences. The facility's failure to manage pain effectively for these residents demonstrates a significant deficiency in care.
Failure to Notify Physician of Unavailable Pain Medications
Penalty
Summary
The facility failed to notify the physician when pain medications were unavailable for a resident, leading to missed doses of prescribed pain management. The resident, who was moderately cognitively impaired, suffered from chronic pain conditions including polymyalgia rheumatica, rheumatoid arthritis, and chronic pain syndrome. Despite having orders for Norco and a lidocaine patch, the medications were not administered on multiple occasions due to unavailability, and there was insufficient documentation to confirm that the physician was notified of these missed doses. Interviews with the facility's staff, including the Director of Nursing, Infection Preventionist/Assistant Director of Nursing, and Nurse Practitioner, revealed that the expected protocol of notifying the physician and documenting follow-up actions was not followed. The Nurse Practitioner was unaware of the missed doses and stated that he would have taken necessary actions to ensure the resident received the required pain medication. The lack of communication and documentation contributed to the resident not receiving adequate pain management.
Failure to Conduct Timely PASARR Level II Screening
Penalty
Summary
The facility failed to ensure a resident, who initially had a negative Preadmission Screening and Resident Review (PASARR) Level I, was accurately and timely referred for a PASARR Level II after experiencing a significant change in status with a new diagnosis of serious mental illness. The resident, identified as R29, was admitted with acute heart failure and later placed on a psychiatric hold, returning with a diagnosis of major depressive disorder with severe psychotic symptoms. Despite receiving psychiatric services upon return, a new Level I PASARR Screen was not conducted, which was necessary due to the change in the resident's mental health status. Interviews revealed that the facility lacked a policy on PASARR, and the Social Services Designee (SSD) acknowledged the oversight, stating that a new Level I and subsequent Level II screening should have been initiated upon the resident's readmission. The Director of Nurses (DON) confirmed that the resident should have been treated as a new admission following the psychiatric hospital stay, indicating a lapse in the facility's process for handling significant changes in residents' conditions.
Failure to Develop ICD Care Plan for Resident
Penalty
Summary
The facility failed to develop a comprehensive, patient-centered care plan for a resident with an Implantable Cardioverter Defibrillator (ICD). The resident, who was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15 out of 15, was admitted with diagnoses including chronic heart failure and an ICD. Despite these conditions, the care plan did not include any focus area or interventions related to the ICD, which is crucial for managing the resident's health needs. The deficiency was identified during a review of the resident's electronic medical record (EMR), which showed no mention of the ICD in the care plan. The facility's cardiac nurse practitioner had seen the resident for a cardiac follow-up, and plans for ICD interrogation were discussed with the nursing staff. However, during an interview, the Medical Director and the Director of Nursing stated that the resident did not need a specific care plan for the ICD, as staff would know to call 911 if an issue arose. This oversight in care planning could potentially lead to harm, as it does not address the specific precautions and interventions necessary for residents with ICDs.
Resident's Decline in ADL Abilities Not Addressed
Penalty
Summary
The facility failed to maintain the current abilities of a resident, identified as R80, in performing activities of daily living (ADLs). R80, who was admitted with diagnoses including Parkinson's disease, dementia, and major depressive disorder, was observed to have declined in self-care abilities. Despite being coded as independent to needing set-up assistance for ADLs in the Minimum Data Set (MDS), observations revealed that R80 struggled with personal hygiene tasks such as shaving and nail care. Interviews with staff, including a Certified Nurse Assistant (CNA) and the Assistant Director of Nursing (ADON), confirmed that R80 required more assistance than previously assessed, indicating a decline in his ability to perform ADLs independently. The resident was found with unkempt hair, long and dirty fingernails, and a soiled appearance, suggesting inadequate grooming and personal care. The ADON acknowledged that R80 needed grooming assistance and a reassessment of his care needs. Despite the resident's insistence on performing ADLs independently, staff interviews revealed that he required more help than he was receiving. The Director of Nursing (DON) and MDS Coordinators also recognized the need for a reassessment to accurately reflect R80's current abilities, as his previous assessments did not align with his present condition.
Unsafe Storage of Oxygen E-Tank
Penalty
Summary
The facility failed to safely store an oxygen emergency tank (e-tank) for a resident who was reviewed for respiratory care. The resident, who was admitted with a diagnosis of emphysema, was observed asleep in a wheelchair and connected to an oxygen concentrator via nasal cannula tubing. During the observation, the e-tank was found standing against the wall unsupported, with the oxygen carrier nearby. The Minimum Data Set Coordinator confirmed that the e-tank should have been in the carrier and was indeed unsupported. The Director of Nursing also stated that e-tanks are required to be secured.
Failure to Change PICC Line Dressing Timely
Penalty
Summary
The facility failed to ensure the timely change of an occlusive dressing on a peripherally inserted central catheter (PICC) line for a resident receiving intravenous (IV) antibiotics. The facility's policy required that the dressing be changed every seven days to prevent infection. However, for one resident, the dressing was observed to be dated 15 days prior, indicating it had not been changed as required. This oversight was confirmed by the Assistant Director of Nursing (ADON), who acknowledged that the dressing was not occlusive and should have been changed every seven days. The resident in question was admitted with a diagnosis of arthritis due to bacteria in the right knee and wrist and was receiving Ceftriaxone intravenously for septic arthritis. The resident's care plan included monitoring the PICC line site for signs of infection but did not specify the need to change the dressing every seven days. During an observation, the dressing was found to be partially detached and not adhering to the skin, increasing the risk of infection and complications. The ADON confirmed the lapse in following the facility's policy for dressing changes.
Failure to Administer Medications Timely for a Resident
Penalty
Summary
The facility failed to ensure timely administration of medications for one resident, identified as R4, which put her at risk of complications. R4, who was moderately cognitively impaired, had diagnoses including rheumatoid arthritis, chronic pain syndrome, and anxiety. She was admitted to the facility and required scheduled pain medication. However, there were multiple instances where her medications were not administered as ordered. Specifically, R4 missed doses of Hydrocodone/acetaminophen, Lidoderm Patch, and Ativan due to issues such as prescription changes, pharmacy delays, and lack of notification to the physician for new prescriptions. Interviews with facility staff, including the Director of Nursing (DON), Infection Preventionist/Assistant Director of Nursing (IP/ADON), and Nurse Practitioner (NP), revealed a breakdown in communication and procedure. The DON acknowledged that narcotic medications required a written prescription to be accessed from the emergency medication kit, and staff were expected to notify the physician of unavailable medications. However, the NP and IP/ADON were not informed of the missed doses, and there was insufficient documentation to confirm notifications were made. The NP expressed that he was unaware of the situation and emphasized that medication should have been available through the emergency kit, indicating a failure in the process to ensure R4 received her necessary medications.
Failure to Document Resident Death and Release Order
Penalty
Summary
The facility failed to document the death of a resident, identified as R115, and did not include a physician order to release the body. This deficiency was identified during a review of the facility's policy on charting and documentation, which requires detailed documentation of a resident's condition, treatments, and events surrounding their death. R115 was admitted with diagnoses including a lumbar fracture, congestive heart failure, and COVID-19. On the day of the incident, a Nursing Progress Note indicated that at 4:00 AM, R115 was experiencing respiratory distress with oxygen saturation below 90%, which stabilized after increasing oxygen flow. Despite these interventions, the resident showed signs of distress, and the family was informed of the condition, opting to avoid hospitalization. There was no further documentation in the Nursing Progress Notes after 4:00 AM regarding R115's condition or subsequent death. Interviews with the Assistant Director of Nursing and the Medical Director revealed that the resident's condition was declining rapidly, and a family meeting was needed. The Medical Director had written a comfort measures order, but hospice care was not initiated before the resident's death. The Medical Director acknowledged the lack of documentation and the absence of an order to release the body to the funeral home, which was a deviation from the facility's policy.
Unauthorized Video Recording of Resident Violates Privacy
Penalty
Summary
The facility failed to maintain a resident's right to personal privacy when a Certified Nurse's Aide (CNA) used a personal cell phone to record two videos of a resident without consent. The first video showed the resident lying in bed, and the second video captured the resident with glasses on upside down. The facility did not provide the requested policy regarding resident rights or video recording of residents, and the CNA admitted to recording the videos without obtaining consent from the resident, the resident's responsible party, or the administrator. The resident involved had severe cognitive impairment and was diagnosed with Alzheimer's Disease, diabetes mellitus, and high blood pressure. The resident's care plan emphasized honoring the resident's preferences, and the admission agreement highlighted the resident's right to refuse being photographed or videotaped. Despite these stipulations, the CNA recorded the videos and shared them with siblings to demonstrate work activities, violating the resident's privacy and dignity. Interviews with facility staff, including the Director of Nursing and the Administrator, revealed a lack of clear policies and training regarding resident rights and the use of cell phones for recording. The facility's employee handbook prohibited the use of cell phones during duty and required explicit permission for taking photographs or recordings. However, the CNA was not educated on these policies, leading to the unauthorized recording of the resident, which was deemed undignified and a violation of the resident's right to privacy.
Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to perform life-saving measures, including CPR, for a resident who was found unresponsive and without a pulse or respirations. The resident was identified as a full code, meaning that life-saving measures should have been initiated immediately. However, the Licensed Practical Nurse (LPN) on duty did not start CPR or instruct the Certified Nursing Assistants (CNAs) to do so, despite being informed multiple times by the CNAs that the resident was a full code. The LPN incorrectly assumed the resident was on hospice and a Do Not Resuscitate (DNR) status, leading to a delay in initiating CPR. The Director of Nursing (DON) was notified by the LPN about the resident's condition and arrived at the scene approximately five to ten minutes later. Upon arrival, the DON confirmed the resident's full code status and instructed the CNAs to begin chest compressions while preparing the crash cart. The DON had to demonstrate the use of the Ambu bag to the LPN, indicating a lack of familiarity with emergency procedures. Emergency Medical Services (EMS) arrived and took over the resuscitation efforts, but the resident was pronounced dead shortly after. Interviews with staff revealed that the LPN was an agency nurse who had not received proper orientation on the facility's emergency procedures, including the location of the crash cart and how to determine a resident's code status. The LPN admitted to having difficulty in the past with identifying residents' code statuses due to discrepancies in the medical records. The facility's failure to ensure that all staff, including agency nurses, were adequately trained and familiar with emergency protocols contributed to the delay in providing life-saving measures to the resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 759 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| New Mark Rehab And Healthcare Center | 4.6 mi | ★★★★★ | 11 | 0 |
| Pinnacle Point Wellness & Rehabilitation | 6 mi | ★★★★★ | 13 | 0 |
| Linden Woods Village | 6 mi | ★★★★★ | 0 | 0 |
| Mccrite Plaza At Briarcliff Skilled Facility | 7.1 mi | ★★★★★ | 4 | 0 |
| Ignite Medical Resort Kansas City, Llc | 8 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.