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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at U-city Forest Manor during CMS and state inspections, most recent first.
Improper Hand Hygiene and Hair Restraint Use During Meal Service: A CNA handled multiple residents’ trays, silverware, coffee cups, and personal contact during meal service without proper hand hygiene between tasks, while a dietary aide prepared food with hair hanging out of a hair net in the kitchen. The facility’s policies required frequent handwashing after contact with unsanitary surfaces or residents and proper hair restraints while in kitchen areas.
Failure to return resident trust funds after discharge and to send TPL letters for deceased residents. Six residents were discharged with account balances ranging from small amounts to over $3,000, and there was no record their funds were returned within the required timeframe. Two residents expired with balances remaining in their accounts, and there was no record that TPL letters were sent. The BOM said he did not know the exact timeframe and had no proof the letters were sent.
A facility failed to keep common areas clean and homelike, including resident wheelchairs, the Memory Care courtyard, and shower rooms on multiple halls. Two residents who used wheelchairs were observed with dust, hair, food particles, and a white powdery substance on their wheelchair frames and wheels, despite a night shift expectation for routine cleaning. The courtyard had overgrown weeds, cigarette butts, leaves, dirty windows, and unused animal traps, while shower rooms contained excrement, clutter, wet linens, briefs, and blocked access from carts and wheelchairs; staff said these areas were supposed to be cleaned routinely but were not maintained.
Controlled meds were not stored under two locks in the med room when a locked refrigerator contained expired Lorazepam that was not secured in a locked container. In addition, multiple eye drops on two med carts and one CMT cart had broken seals but no open date or expiration date, despite staff stating they should be labeled when opened.
Staff failed to follow EBP and infection control practices during resident care. An RN administered meds via a g-tube without a gown, an LPN changed a wound dressing without a gown, and CNAs provided peri care and dressing assistance without gowns despite EBP signs and PPE being available. An LPN also performed blood glucose checks on multiple residents without disinfecting the glucometer between uses. In addition, a resident had consented to a two-step TB test, but the facility had no documentation that it was completed.
Surveyors found that the facility failed to keep call lights within reach for two residents, despite a policy requiring accessible call lights and frequent checks for those unable to use them. One resident, with multiple medical conditions, an above‑knee amputation, moderate cognitive impairment, and a history of numerous falls, was repeatedly observed asleep in a wheelchair by the bed with the call light on the floor or under the bed, and the care plan did not address the resident’s falls or related interventions. Another resident with Alzheimer’s disease, dementia, contractures of all extremities, and hospice care needs was observed lying in bed with the call light at the foot of the bed or under the bed, out of reach, even though the care plan specified the call light should be within reach. Staff, including an LPN, a CNA, the Administrator, and the DON, all stated that call lights should always be within reach for all residents, and that frequent rounding was expected when residents could not use the call light, confirming that practice did not align with stated expectations.
A non-verbal resident with severely impaired cognition and total dependence for ADLs was seated in a WC with an arm looped around the WC handle when a CNA/restorative aide repeatedly attempted to reposition the arm to the front. Despite the resident’s non-verbal refusals and resistance, the aide pried the resident’s fingers from the WC wheel, grabbed the arm, and forcefully jerked it forward, causing the resident’s body to lurch and nearly fall from the chair. Video review showed the aide tugging and pulling on the arm multiple times as the resident refused further assistance, and a staff witness reported the aide was yelling and grabbing at the resident while the resident fought to get free. The resident later stated staff were rough and that he/she was afraid. These actions, inconsistent with the resident’s care plan and the facility’s abuse policy, resulted in a finding that the resident was subjected to physical abuse.
Two residents with significant risk factors for skin breakdown did not receive consistent, accurately documented wound care. One resident with multiple comorbidities and existing pressure-related wounds had no skin or wound interventions on the care plan, lacked an EMR order for a newly identified ankle wound, and had numerous missed or undocumented treatments for buttocks, hip, and ankle wounds, including barrier creams and Medi Honey applications. Another high-risk resident with a low Braden score had no skin-related care plan, an ankle wound that was reported as healed while MAR/TAR entries continued, weekly skin checks documented as normal despite an active ankle dressing, and a right ankle wound that went unreported in shift report until surveyors observed an outdated dressing; subsequent documentation by the wound specialist and facility conflicted on the wound’s type and measurements. The DON later confirmed expectations that staff follow wound policies, enter and document orders and refusals in the EMR, and update care plans, which were not met in these cases.
The facility failed to implement and document effective fall interventions for a resident with an above‑knee amputation, lower extremity impairment, and a history of multiple witnessed and unwitnessed falls related to attempting independent transfers. Although the care plan noted general assistance needs, it did not address the repeated falls or specify individualized fall‑prevention measures, and fall investigations recorded no new interventions despite ongoing events. Surveyors observed the resident in a wheelchair by the bed multiple times with the call light out of reach on the floor. In addition, the facility did not complete a required smoking safety assessment for a resident with Huntington’s disease, weakness, and moderately impaired cognition, even though this resident was observed smoking outside and facility policy required a smoking assessment at admission to determine needed supervision.
Failure to maintain dignity and privacy during care: an RN entered a resident's room without knocking, did not explain the care, moved the resident's arms to access the G-tube, and administered meds without pulling the privacy curtain or closing the door. The roommate and passersby could see the care being provided, and staff later stated residents should be treated with dignity and respect.
Advance directive and code status documentation was not consistently documented, updated, or reviewed for three residents. One resident with Alzheimer’s disease and hospice care had conflicting full code and DNR orders across the POS, hospice binder, EMR banner, and care plan; another resident with Huntington’s disease had a signed full code directive in the EMR documents but no active order or visible code status on the main screen; and a third resident with severe cognitive impairment had full code in the EMR but a signed DNR in the hospice binder. Staff interviews confirmed the code status information was not readily available or consistent across records.
MDS assessments did not accurately reflect that two residents receiving hospice had a prognosis of 6 months or less. One resident’s MDS listed multiple chronic conditions and severe cognitive impairment but marked Section J as no for limited life expectancy, despite a physician recertification stating the resident was terminally ill. Another resident’s comprehensive MDS also marked Section J as no while showing hospice in Section O, even though the hospice order certified a prognosis of 6 months or less. The Administrator and Regional Director of Clinical Services stated they expected the MDS to be accurate and Section J to show both residents had a life expectancy of 6 months or less.
A resident with Huntington’s disease, weakness, and moderately impaired cognition did not have a baseline care plan created within 48 hours of admission. EMR review and staff observations confirmed the care plan was missing, and CNA, LPN, the Administrator, and the DON all acknowledged it should have been in place to guide care.
A facility failed to keep care plans current for three residents with specific care needs. One resident had repeated falls and a care plan that only addressed general safety, another resident was receiving hospice services but the care plan did not reflect hospice care, and a third resident had a high Braden score, wound care orders, and a stage 2 pressure injury, yet the care plan did not include skin concerns or wound-prevention interventions.
A resident with heart failure, diabetes, and cognitive impairment repeatedly did not wear ordered TEDS because they were too tight, and staff documented multiple missed applications without notifying the physician. The resident was observed with moderate bilateral leg edema, pain, heaviness, and discomfort, and stated no alternative had been offered. The DON later assessed the resident and the physician was called for leg pain, but there was no documentation that the physician had been notified about the ongoing TEDS nonuse or that alternative interventions for the edema were obtained.
A resident with a suprapubic catheter, end stage renal disease, legal blindness, dementia, and major depressive disorder had no physician orders for catheter care, maintenance, or observation in the POS. The care plan called for monitoring for obstruction, infection, dislodgment, bowel perforation, or trauma, and for documenting urine output every shift, but the catheter bag and tubing were observed undated. An LPN, the DON, and the Administrator stated orders should have been in place for catheter care and urine monitoring.
Improper Head-of-Bed Positioning During G-Tube Feeding: A resident with Alzheimer's disease, dementia, malnutrition, and a g-tube was observed receiving continuous tube feeding while the head of the bed was positioned at about 10 degrees and later flat, despite care plan guidance and a physician order to keep the head of the bed elevated during feeding. Staff interviews confirmed the expected elevation during tube feeding.
Failure to obtain ordered lab tests for a resident with seizure disorder. A resident with anxiety and traumatic brain dysfunction was found slumped over and unresponsive, then later confused and showing signs of seizure activity. The physician ordered a CBC, CMP, and Keppra level, but no corresponding physician orders were found in the chart and the labs were not done. An LPN said lab orders should be entered into the physician orders and lab portal, and the DON and Administrator confirmed the labs were not completed.
Failure to Provide Routine Dental Care: A resident with moderate cognitive impairment, poor follow-through, and a need for set up, supervision, and verbal cues for oral care was not placed on the dentist list and had no dental order or documented oral cavity assessment. During observation, the resident had halitosis and multiple dark brown and black teeth, with some chipped and missing, and stated he/she had not seen a dentist in a very long time and did not know where the toothbrush was.
A resident with significant weight loss and multiple medical conditions did not receive dietary supplements as ordered, nor was the supplement increased as recommended by the dietitian. Staff were unaware of the updated recommendations, and the supplements were not provided with meals as required.
A resident on anticoagulant therapy experienced a nose bleed that was not properly assessed or documented across all shifts, and physician orders for saline nasal spray were not followed due to its omission from the MAR and lack of administration documentation. Staff failed to consistently communicate and document the resident's change in condition, and the event was not recognized as requiring a formal assessment, despite ongoing bleeding and the resident's risk factors.
A resident with dysphagia and a history of choking was left unsupervised during lunch, leading to a fatal choking incident. The resident choked on broccoli, which was not part of their meal, indicating it was taken from another plate. The facility failed to follow policies on supervision and dietary modifications, and staff were unaware of the resident's specific needs, contributing to the incident.
A facility failed to update a resident's care plan with speech therapy recommendations for choking prevention. The resident, with severe cognitive impairment and a history of choking, did not have a care plan reflecting necessary strategies for safe swallowing. Despite speech therapy's efforts to educate staff, the care plan lacked updates due to communication failures, leading to continued choking incidents.
The facility did not ensure an RN was present for eight consecutive hours each day, as required, resulting in multiple days without RN coverage. Staff confirmed only one RN was employed full time, and recruitment efforts had not filled the staffing gaps.
The facility failed to obtain and maintain proper Power of Attorney (POA) documentation for two residents, resulting in confusion over decision-making authority. One resident with cognitive impairment was moved to a locked memory care unit after a minor behavioral incident, without assessment, alternative interventions, or required notifications to the physician or family. Documentation and communication failures were identified, including inconsistent records regarding POA status and lack of proper notification for significant changes.
A resident who was dependent for ADLs, cognitively impaired, and always incontinent was left in a urine-soaked brief without timely perineal care. Multiple CNAs removed the soiled brief but failed to clean the resident or apply a clean brief as required by facility policy. Staff interviews confirmed awareness of the need for perineal care after incontinence, but the care was not provided, leaving the resident feeling unclean and uncared for.
A cockroach was observed crawling on a resident's blanket while the resident, who was cognitively impaired and dependent for care, was in bed. Despite regular pest control treatments targeting German roaches throughout the facility, staff interviews confirmed an ongoing cockroach problem. The incident demonstrated that the pest control program was not effective in preventing pest presence in resident areas.
The facility did not follow their policy of retaining grievance logs for three years, as only logs from January 2024 to the current date were available. The ADON confirmed the change in the logging process and the inability to locate previous logs. The administrative team expected compliance with the three-year retention policy.
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering, as well as failed to ensure smoking assessments were completed for two residents who smoked. Staff did not follow physician's orders to monitor wanderguard devices, and there was confusion about who was responsible for smoking assessments.
The facility failed to provide eight hours of RN coverage for 16 out of 92 days, potentially causing unmet health needs for all residents. Despite the facility's staffing policy requiring adequate RN and nursing staff, the Payroll Based Journal (PBJ) Staffing Data Report showed no RN coverage on 16 specific dates. Interviews with administrative staff confirmed this deficiency.
The facility failed to ensure proper labeling and storage of medications, with issues found in three out of four medication carts and one medication room. Insulin pens were opened and dated beyond 28 days, and multiple OTC medications were undated and expired. Staff interviews confirmed that medications should be dated upon opening and expired medications should not be administered, but these practices were not consistently followed.
The facility failed to ensure accurate and updated code statuses for three residents. One resident had conflicting information in their records, another had an outdated full code status despite being rarely understood, and a third resident's code status had not been updated for over a year. The Social Worker was responsible for these updates but had not performed them in a timely manner.
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents. The Regional Business Office Manager indicated that SNFABN forms were provided for Medicare Part B discharges, not Medicare Part A, which was confirmed by the Administrator, DON, ADON, and Regional Operational Director.
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. Three residents with significant cognitive impairments and psychiatric diagnoses had no PASARR Level I on file, and the facility's administration confirmed that these screenings should have been completed within 30 days of admission.
The facility failed to complete a discharge summary for a resident with high blood pressure, depression, and stroke. The resident was discharged in stable condition with necessary medications and documentation, but no discharge summary was included in the medical record. The Regional Clinical Director confirmed this oversight.
The facility failed to provide adequate ADL care for two residents who were dependent on staff for personal care. Both residents were observed with excessively long and dirty fingernails, despite expressing a need for grooming. Staff interviews revealed confusion about responsibilities for nail care, particularly for diabetic residents, leading to a lack of proper grooming.
The facility failed to ensure a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract. The resident's care plan required monitoring of vital signs, weight, and the AVF site, but these were not documented. Staff interviews revealed that dialysis communication forms were often lost and not completed, and the facility lacked a dialysis contract with the provider.
The facility failed to maintain a medication error rate below 5%, resulting in a 7.41% error rate. An LPN did not follow proper procedures for insulin pen use, including wiping the rubber seal with alcohol and priming the pen, for two residents with diabetes. The facility lacked a policy on insulin pen priming, contributing to the errors.
The facility failed to follow infection control standards by not properly disinfecting glucometers between uses and not adhering to proper hand hygiene and glove use during wound care for two residents. Staff used alcohol pads instead of EPA-registered disinfecting wipes for glucometers and double-gloved during wound care, contrary to facility policy.
Improper Hand Hygiene and Hair Restraint Use During Meal Service
Penalty
Summary
The facility failed to ensure staff used proper hand hygiene during meal service and failed to ensure hair restraints were worn properly while handling food in the kitchen. During breakfast observation in the main dining room, CNA E touched Resident #54 on the shoulder, then went to the serving line, handled Resident #2’s tray and silverware to cut up the resident’s food, carried the tray back to the serving line, poured coffee for Resident #2, then poured coffee for Resident #47 and later for Residents #25, #29, and #26. CNA E also touched another CNA’s shirt, put his/her hands in his/her pocket, repositioned Resident #47 in the wheelchair while holding the resident, and patted Resident #30 on the shoulder. The sample included residents with diagnoses such as chronic kidney disease, diabetes, dementia, legal blindness, schizoaffective disorder, hemiplegia, and severe cognitive impairment. Observations also showed Dietary Aide F preparing plates at the steam table with a hair net on, but approximately 2 inches of hair hanging out of the hair net around the front of both sides of the face during breakfast and again during lunch. The facility’s handwashing policy stated staff should wash hands frequently and after touching unsanitary areas of the body, unclean equipment or work surfaces, soiled clothing, or other soiled materials. The personal hygiene and appearance policy stated hair nets or hair coverings shall be worn while in the kitchen or storage areas. The Dietary Manager and Administrator both stated they would expect staff to sanitize hands after touching unclean surfaces, residents, or clothing, and to wear hair restraints properly so hair does not get into food.
Failure to Return Resident Trust Funds and Send TPL Letters
Penalty
Summary
The facility failed to ensure resident trust funds were returned within 30 days after discharge for six residents. Review of resident trust accounts showed that Residents #89, #90, #91, #92, #93, and #94 were discharged with balances of $1,644.00, $378.68, $60.67, $3,016.56, $25.97, and $30.00, respectively, and there was no record that the funds were returned to the residents. The facility’s resident trust policy stated that discharged resident accounts need to be refunded to the resident or Medicaid no later than 30 days from the date of discharge. The facility also failed to ensure third party liability (TPL) letters were sent for two residents who expired with money remaining in their accounts. Resident #96 expired with a balance of $.03 and Resident #95 expired with a balance of $717.45, and there was no record that TPL letters had been sent. During interview, the BOM stated he expected money to be out of resident accounts within the required time frame when residents discharged or expired, but he did not know the exact timeframe and said he did not send the TPL letters because corporate office sent them out. The Administrator stated she expected the facility policy to be followed for resident funds and expected TPL letters to be sent when a resident expired.
Unclean Wheelchairs, Courtyard, and Shower Rooms
Penalty
Summary
The facility failed to maintain common areas in a clean, comfortable, and homelike condition, including resident wheelchairs, the Memory Care Courtyard, and resident hall shower rooms on the 100, 200, and 300 halls. The report identified concerns for two residents who used wheelchairs. One resident had diagnoses including depression and schizophrenia, and another had diagnoses including diabetes and bipolar disorder. Observations on multiple occasions showed both residents sitting in wheelchairs in the Memory Care dining room with visible buildup on the wheelchair frames and wheels, including a white powdery substance, dust, hair, and food particles. The facility’s night shift assignment sheet indicated wheelchairs should be cleaned nightly, and staff interviews showed the wheelchairs were expected to be cleaned by night shift nursing staff, but this was not being done. The Memory Care Courtyard was observed with overgrown weeds, cigarette butts, dandelions, overgrown grass, piles of leaves near the entrance, two animal traps with weeds growing over them, and windows covered with dirt, dust, and spiderwebs. Residents used the courtyard for activities and smoking, and staff stated it had not been cleaned for several months. The Maintenance Director said he was responsible for the courtyard and had not cleaned anything there since last year, had not done fall or winter maintenance or cleaning, and acknowledged the courtyard needed cleanup work. The Housekeeping Supervisor also stated the windows were very dirty and needed to be washed. The resident hall shower rooms were repeatedly observed in unclean and cluttered conditions. In the 100 hall shower room, what appeared to be excrement was seen on the walls and baseboards near the toilet, and the whirlpool tub contained packages of incontinence briefs and a soft positioning wedge, along with dirty clothes and toiletries on a chair. In the 200 hall shower room, the whirlpool tub contained briefs, linens, and a positioning wedge, and trash cans and laundry carts blocked access to the room. In the 300 hall shower room, the whirlpool tub contained briefs, wet towels and a wet chucks pad were on the floor, gloves and a comb were on the floor under the sink, and wheelchairs blocked the shower stall; another observation noted the toilet appeared clogged with excrement and toilet paper. Staff interviews indicated housekeeping was responsible for daily cleaning of shower rooms, nursing staff should clean them after resident use, and housekeeping was responsible for weekly deep cleaning, but the rooms were repeatedly found in disarray and obstructed.
Controlled Medications Not Secured and Eye Drops Unlabeled
Penalty
Summary
Controlled medications were not securely stored under two locks in the central medication room. During observation, a refrigerator with no lock contained 56 vials of Lorazepam 2 mg/ml, a controlled substance, and the medication was not secured in a locked container. The Lorazepam vials were expired, and the RN stated he/she did not know the medication was in the refrigerator because it was not being counted. The DON and ADON stated that once a medication was discontinued or expired, it should be brought to the DON's office for destruction and that the Lorazepam was expected to be secured under two locks. Eye drops on two medication carts were not labeled with an open date or expiration date after the manufacturer seal had been broken. On the 100 and 400 hall medication cart, two bottles of Dorzolamide-Timolol, one bottle each of Ciprofloxacin, Tobramycin, Asteline, and Brimonidine eye drops all lacked open and expiration dates. On the Memory Care CMT cart, one bottle of Ciprofloxacin eye drops also lacked an open date and expiration date. RN Q and the CMT stated that eye drops should be labeled when opened, and the DON and ADON stated they expected staff to label eye drops with an open date and expiration date to ensure medication efficacy.
Infection control failures during wound care, EBP use, glucose testing, and TB screening
Penalty
Summary
The facility failed to follow enhanced barrier precautions and acceptable infection control practices during wound care, medication administration, direct resident hygiene care, and blood glucose testing. The report states that staff did not consistently use gowns with gloves during high-contact care for residents who had chronic wounds and/or indwelling medical devices, and that glucometers were not disinfected between resident blood sugar checks. The facility also did not document completion of a required two-step TB screening for one newly admitted resident despite consent being obtained. For one resident, diagnoses included Alzheimer’s disease and a gastrostomy tube. The resident had orders for medications to be given via g-tube, and the care plan did not address EBP. During observation, an RN entered the room, prepared and administered medications through the g-tube with gloved hands, but did not wear an isolation gown. The resident had an EBP sign posted on the door and above the bed, and the RN later stated a gown should have been worn when administering the medications. For another resident with diabetes and peripheral vascular disease, the resident had two left foot wounds with an order for wet-to-dry dressing changes using wound cleaner, Medihoney, and a border dressing. During observation, an LPN removed the dressing, cleansed the wounds, applied Medihoney, and covered the wounds while wearing gloves but not an isolation gown. A third resident had morbid obesity, bipolar disorder, intellectual disability, a right ankle wound, and a g-tube. During observation, two CNAs provided peri care and dressed the resident without gowns, despite an EBP sign and PPE caddy being present. The report also states that an LPN performed blood glucose checks on three residents in the dining room and did not disinfect the glucometer between uses. In addition, a resident admitted with consent for a two-step TB test had no documentation showing the test was completed, and the ADON stated there was no documentation beyond the consent form.
Failure to Keep Call Lights Within Reach for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ needs and preferences by not ensuring call lights were within reach, contrary to its own “Answering the Call Light” policy. That policy required staff to keep call lights within easy reach for residents in bed or confined to a chair and to frequently check residents unable to use the call light. Despite this, surveyors observed multiple instances where residents’ call lights were out of reach or on the floor, and staff interviews confirmed that the expectation was for call lights to be accessible at all times when residents were in their rooms. One resident had diagnoses including type 2 diabetes, acute kidney failure, and an above-knee amputation, with cognition changing from intact on admission to moderately impaired on a subsequent MDS. The resident’s care plan addressed admission for LTC, need for assistance with bed/chair mobility, transfers, and locomotion, and use of a wheelchair with safety reminders, but did not address the resident’s multiple falls or any fall interventions. Facility event reports documented numerous falls, both witnessed and unwitnessed, over a three‑month period. During several observations on different days and times, this resident was seen asleep in a wheelchair by the bed, with the call light out of reach—on the ground on the opposite side of the bed or under the bed—despite staff acknowledging the resident fell frequently and liked to sleep in the wheelchair. Another resident had diagnoses including Alzheimer’s disease and dementia, was unable to communicate, and had all four extremities contracted. The care plan identified risk for dehydration and increased pain due to contractures, skin integrity issues, and hospice care, with specific interventions to keep the call light within reach and remind the resident to call for assistance. However, during multiple observations, this resident was lying in bed with the call light positioned at the foot of the bed or on the floor under the bed, out of reach. Staff, including an LPN and a CNA, stated that call lights should be within reach for all residents regardless of cognitive status and that frequent rounding was expected if a resident could not use the call light. The Administrator and DON also stated they expected call lights to be in reach for all residents at all times and specifically for residents with frequent falls, underscoring that the observed conditions did not meet facility expectations or policy.
Resident Physically Abused During Forceful Arm Repositioning
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse and to honor the resident’s right to be free from the willful infliction of physical harm. The facility’s abuse policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish, and required staff training in abuse prevention and sensitivity to residents’ rights and needs. The policy also required that all incidents, allegations, or suspicions of abuse be documented and investigated. Despite these policies, a staff member, identified as Restorative Aide/CNA E, used excessive force while attempting to reposition a resident’s arm, in a manner inconsistent with the resident’s care plan and the facility’s abuse prevention standards. The resident involved had severely impaired cognition, unclear speech, and was non-verbal, with dependence on staff for all ADLs, and weighed 213 lbs. The resident’s care plan identified impaired communication and decision-making, with approaches that included explaining procedures prior to tasks, providing cues and reorientation, offering simple choices, and using alternative communication methods as needed. On observation, the resident was seated in a wheelchair at the nurse’s desk with his/her arm positioned on the back of the wheelchair and looped around the handlebar. Restorative Aide/CNA E stood to the right of the resident and repeatedly attempted to move the resident’s right arm forward. The resident responded with non-verbal refusals, moving the arm away and then propelling slightly forward to grasp the wheelchair wheel. Despite these non-verbal refusals, Restorative Aide/CNA E pried the resident’s fingers off the wheelchair wheel, grabbed the resident’s right arm with one hand while placing the other hand behind the triceps area, and forcefully jerked the arm forward. This action caused the resident’s seated body to lurch forward to the point that the resident nearly fell out of the wheelchair onto the tile floor. A subsequent observation showed the aide wiping the resident’s hands with a washcloth that had a red substance on it. Shortly afterward, the resident, when interviewed, stated that staff were rough and that he/she was afraid. Review of security camera footage with facility leadership showed the aide tugging and pulling on the resident’s arm in a forward motion multiple times, with the resident refusing further assistance and the aide becoming more aggressive. A laundry assistant also reported seeing the aide yelling and grabbing at the resident, with the resident resisting and fighting to get the aide off, and believed the incident affected the resident’s behavior afterward. These observed and documented actions constituted the use of excessive force and physical abuse toward the resident. Additional interviews further described the context of the incident. Restorative Aide/CNA E stated that the resident liked to sit with the arm behind the chair and claimed to be repositioning the arm at the resident’s request, acknowledging that the resident’s hand was locked on the wheelchair wheel and that the aide moved it off. The aide reported the resident complained of arm pain and that a red substance seen on the arm was ketchup from lunch, and did not believe the handling was rough. In contrast, an LPN who had cared for the resident for three months stated the resident commonly rested the arm behind the wheelchair, had never required arm repositioning for that posture, and had not complained of arm pain in that position. Facility leadership, after viewing the video, agreed that the staff member used excessive force and that the aide should have stopped and re-approached the resident instead of continuing to pull and tug on the arm in the face of resistance. These facts collectively demonstrate that the resident’s right to be free from physical abuse was not upheld.
Failure to Provide Consistent Wound Care and Accurate Skin Assessment Documentation
Penalty
Summary
The deficiency involves the facility’s failure to provide consistent wound treatments, timely and accurate wound orders, and accurate skin assessments for two residents with wounds. For one resident with multiple comorbidities including open right foot wound, coccyx pressure ulcer, stroke, hemiplegia, dysphagia, severe protein-calorie malnutrition, seizures, and peripheral vascular disease, the care plan in use during the survey contained no problems, goals, or interventions related to skin or wound prevention, despite these conditions. A readmission skin observation documented no abnormalities, but shortly afterward an NP note identified a new open area to the right ankle and ordered cleansing and Medi Honey treatment. The corresponding physician orders reflected Medi Honey treatment to the right buttocks, but there was no EMR order for the right ankle wound treatment on the MAR/TAR. Multiple subsequent skin observation reports and wound doctor notes documented MASD and a stage 3 right hip pressure injury with specific measurements and treatment orders, yet the documentation of wound locations was sometimes incomplete or inconsistent. Medication and treatment administration records for this resident showed numerous missed or undocumented wound care treatments. The December and January MAR/TARs reflected missed opportunities for Medi Honey and right hip dressing changes, including refusals without required progress notes and missed treatments without explanation. In February, barrier cream and zinc oxide orders for the peri area and buttocks were documented as missed in all or many opportunities, and wound treatments to the right buttocks, right hip, and right ankle were missed multiple times without progress notes. A new ankle wound was noted by the DON, with an NP confirming the resident did not need hospital evaluation and suggesting continuation of the wound doctor’s plan, and later documentation described a right ankle/foot stage 2 ulcer with specific measurements. However, the EMR showed missed treatments for the ankle wound and the facility’s wound report later listed multiple MASD sites (right buttocks, coccyx, groin) with onset dates and durations, indicating these wounds were not present on admission but had remained open for extended periods. For a second resident with morbid obesity, bipolar disorder, and intellectual disability, the annual MDS showed no skin concerns, and the care plan in use during the survey contained no skin-related problems, goals, or preventive interventions, despite a Braden score of 11 indicating high risk for pressure injury. Physician orders included offloading pressure areas on the heels and elevating extremities every shift, as well as an order to cleanse the right lateral ankle and apply a foam dressing every three days. Wound specialist notes indicated the resident was not seen on two occasions, once due to being away with family and once because the DON reported the right ankle wound as healed. Weekly skin observation reports in March documented no skin abnormalities, yet the March MAR/TAR showed ongoing documentation of right ankle dressing changes and refusals. On observation, the resident had a foam dressing on the right ankle dated several weeks earlier, and the LPN acknowledged the outdated dressing, stated night shift was scheduled to change it, and then discovered in the EMR that the resident was listed as refusing care over a prolonged period, although the LPN was unaware of the wound and it had not been mentioned in shift report. The wound measured 2 cm by 2 cm at that time, and the DON later described discoloration to the left heel and stated he could not make clinical decisions on staging without the wound doctor. A wound specialist note that same day identified a new stage 2 pressure injury over the right ankle with specific measurements and treatment orders, while the facility’s wound report listed the same area as an abrasion with different initial measurements, demonstrating inaccurate and inconsistent documentation of the wound’s status and type. The DON stated that nursing staff were expected to follow facility policies, that weekly assessments were completed but not ordered, and that staff were prompted in the EMR scheduler. The DON explained that shift nurses were expected to enter treatment orders or provide them to the DON to enter, that nurses were expected to document progress notes when residents declined treatments, and that the medical doctor should be notified of new hospital wound treatment recommendations. The DON also stated that care plans should be updated within 24–48 hours to reflect new changes and that staff should attempt a second approach or allow time before documenting a refusal. Despite these expectations and the facility’s wound management policy requiring Braden assessments, daily or weekly skin checks based on risk, accurate wound differentiation and documentation, and consistent use of wound protocols, the records for both residents showed failures to consistently administer ordered treatments, failures to enter and maintain accurate wound treatment orders in the EMR, and failures to accurately document skin assessments and wound characteristics needed for appropriate follow-up and monitoring.
Failure to Implement Fall Interventions and Complete Smoking Safety Assessment
Penalty
Summary
The deficiency involves the facility’s failure to maintain an accident‑hazard‑free environment and to provide adequate supervision and interventions to prevent accidents, specifically falls and unsafe smoking. For one resident with lower extremity impairment, an above‑knee amputation, diabetes, and acute kidney failure, the admission MDS showed a need for partial to moderate assistance with transfers and use of a wheelchair. The resident’s care plan addressed general needs for assistance with bed/chair mobility, transfers, and locomotion, and noted the need for monitoring to prevent falls, but it did not address the resident’s actual history of multiple falls or specify any individualized fall interventions. Facility event reports documented numerous falls over several months, including unwitnessed and witnessed falls in the bathroom and room, often related to the resident attempting independent transfers from wheelchair to toilet or from bed to wheelchair without assistance. Fall investigations dated across this period identified root causes such as the resident leaving the dining area and attempting to transfer independently in a common bathroom, and attempting to get out of bed and into a wheelchair without assistance despite having an amputated leg. These investigations documented that the resident was encouraged or educated to ask for help or call for assistance, but no new interventions were recorded following these events. Observations by surveyors showed the resident seated in a wheelchair by the bed with eyes closed on multiple occasions, with the call light not in reach and at times on the floor on the opposite side of the bed. The Director of Therapy stated the resident was receiving PT, OT, and speech therapy and recommended a wedge (tilt‑in‑space) wheelchair with foot pedals, more frequent rounding, and ensuring the call light was in reach, and expected these interventions to be reflected on the care plan. An LPN and facility leadership acknowledged the resident had frequent falls and that interventions, including those tried such as frequent rounding and ensuring call light access, should have been documented on the care plan. The deficiency also includes failure to assess another resident for smoking safety. This resident had diagnoses including Huntington’s disease and weakness, with moderately impaired cognition documented on the admission MDS. Review of the electronic medical record showed no smoking assessment, despite the facility’s smoking policy requiring assessment at admission and at least quarterly or with significant change to determine needed assistance and supervision. Surveyor observations documented this resident smoking outside on more than one occasion. An LPN, the Administrator, and the DON all stated that a smoking assessment should have been completed upon admission to ensure the resident’s safety while smoking, but no such assessment was found in the record.
Failure to Maintain Resident Dignity and Privacy During G-Tube Medication Administration
Penalty
Summary
Facility staff failed to treat a resident with dignity while providing care. The resident had diagnoses of Alzheimer's disease, dementia, and a gastrostomy tube (G-tube). During an observation, an RN prepared the resident's medication at the medication cart and entered the resident's room without knocking. The resident was lying in bed, and the RN moved the resident's arms away to access the G-tube without first explaining the care that was going to be provided. The RN did not pull the privacy curtain between the resident and the roommate and did not close the resident's door while administering medication through the G-tube. The roommate watched the medication administration, and multiple staff members and residents in wheelchairs passed by and could see directly into the room while care was being provided. During interviews, the RN stated the door should have been knocked on before entering, care should have been explained immediately, and privacy should have been maintained with the curtain or closed door. A CNA and the Administrator also stated residents should be treated with dignity and respect, with staff knocking before entering, explaining care, and maintaining privacy during care.
Advance directive and code status records were inconsistent or missing for three residents
Penalty
Summary
The facility failed to ensure advance directive and code status forms were documented, updated, and/or reviewed annually for three sampled residents. The deficiency involved Resident #7, Resident #15, and Resident #47, whose records contained inconsistent or missing code status information across the EMR, physician order summary, hospice binder, and care plan. The facility policy stated that advance directives would be respected, displayed prominently in the medical record, and reviewed annually during the MDS process. Resident #7 had moderately impaired cognition, Alzheimer’s disease, hospice care, and protein calorie malnutrition. The annual MDS showed the resident was on hospice, and the physician order summary contained a full code order. However, the hospice binder contained an outside-the-hospital DNR order, the EMR banner identified the resident as DNR, and the care plan did not address code status. During interview, an LPN stated the full code order should have been changed or canceled to reflect the hospice binder and that code status should have been entered on the face sheet; otherwise, CPR would be started and 911 called. Resident #15 had moderately impaired cognition, Huntington’s disease, and weakness. The physician order summary did not show an active advance directive order, while the EMR document section contained a signed full code advance directive. The EMR banner did not indicate an advance directive, and there was no baseline care plan. During observation and interview, a CNA stated the code status was not visible on the main screen and could not be found in the care plan binder. Resident #47 had severe cognitive impairment, chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder. The EMR banner and document section showed full code, but the hospice binder contained a signed DNR advance directive. The care plan listed advanced directive/full code status, and an LPN stated the EMR should match the hospice binder and the old directive should have been removed. The DON stated code status should be constant throughout the chart and that all residents should have a care plan focused on code status.
MDS Did Not Accurately Reflect Hospice Prognosis
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected two residents’ status of having a life expectancy of less than six months while receiving hospice services. For Resident #47, the quarterly MDS listed chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder, and indicated severe cognitive impairment, but Section J was marked “no” for having a life expectancy of six months or less. A 60-day physician recertification of terminal illness stated that the patient was terminally ill with a life expectancy of six months or less if the terminal illness ran its normal course. For Resident #69, the comprehensive MDS listed dementia, chronic kidney disease, type 2 diabetes, and muscle weakness, and indicated severe cognitive impairment. Section J was also marked “no” for having a life expectancy of six months or less, while Section O indicated hospice services. The resident’s hospice order stated that the medical director/hospice physician certified the patient’s prognosis as six months or less if the disease ran its normal course. During interview, the Administrator and Regional Director of Clinical Services stated they would expect the MDS assessments to be accurate and would expect Section J to indicate that both residents had a life expectancy of six months or less.
Failure to Create Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to ensure that Resident #15 had a baseline care plan created within 48 hours of admission. The resident’s admission MDS, completed on 3/19/26, listed Huntington’s disease and weakness, with moderately impaired cognition. Review of the resident’s EMR on 3/24/26 showed that no baseline care plan had been created. During observation on 3/26/26 at 9:48 A.M., CNA D accessed the resident’s care plan on a tablet and a message appeared stating the resident did not have a care plan; the CNA stated the resident should have one so staff would know how to care for him/her. On 3/27/26 at 7:28 A.M., LPN C reviewed the EMR and confirmed there was no care plan, stating one should have been completed within 48 hours of admission. Later that day, the Administrator and DON also reviewed the record and stated they would expect a care plan to have been created within 48 hours of admission so the resident would be properly cared for.
Incomplete care plans for falls, hospice, and skin needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and updated to reflect the specific needs of three sampled residents. The facility’s RAI policy required a comprehensive care plan within seven days of completion of the resident assessment and updates when there was a significant change in condition, when the desired outcome was not met, or at least quarterly. Facility leadership stated that care plans should be completed within 14 days after admission and updated to reflect resident-specific needs. Resident #26 had diagnoses including diabetes, acute kidney failure, and an acquired absence of the right leg above the knee. The admission MDS showed the resident was cognitively intact, while a later 5-day MDS showed moderately impaired cognition. The facility event summary documented multiple falls during the resident’s stay, including unwitnessed, witnessed, and other falls on several dates between 12/24/25 and 3/19/26. The care plan addressed general safety needs such as assistance with bed/chair mobility, transfers, locomotion, wheelchair use, and safety reminders, but it did not address the resident’s repeated falls or list fall interventions that had been put in place. Resident #47 had diagnoses including chronic respiratory failure, dementia, major depressive disorder, chronic kidney disease, and schizoaffective disorder, with severe cognitive impairment on the quarterly MDS. The EMR showed the resident began receiving hospice services on 10/8/25, but the care plan did not indicate hospice services or include hospice-related interventions. Resident #77 had diagnoses including morbid obesity, bipolar disorder, and intellectual disability, with moderately impaired cognition and full dependence for ADLs on the annual MDS. The resident had a Braden Scale score of 11, indicating high risk for pressure injury, and orders included offloading pressure areas and wound care for the right ankle. Observations showed a foam dressing on the right ankle, heels positioned on pillows directly under the heels, and a dark circular discoloration on the left inner heel. The wound specialist documented a stage 2 pressure injury over the right ankle with treatment orders, but the care plan did not include skin problems, goals, or interventions to prevent wounds.
Failure to Notify Physician of Repeated TEDS Nonuse and Address Bilateral Leg Edema
Penalty
Summary
The facility failed to ensure a resident with moderate cognitive impairment, heart failure, diabetes, mild intellectual disabilities, and borderline intellectual functioning received care and services in accordance with physician orders and the resident’s needs. The resident’s care plan included thromboembolic deterrent stockings (TEDS) as ordered, and the MAR showed the TEDS order was repeatedly documented as not administered over multiple opportunities in February and March 2026. When the stockings were not applied, staff documented that the resident said they were too tight, and on one occasion documented that the resident did not wear TEDS. During observation, the resident was not wearing TEDS and reported that the legs felt swollen, heavy, and uncomfortable. The resident’s lower legs were observed to have a moderate amount of edema, and later the resident was crying and stated the legs were hurting badly. The resident’s bilateral legs remained moderately edematous, with the left leg more edematous than the right, and the resident continued to report discomfort and pain. The resident also stated that staff had not offered an alternative to the stockings to help with the edema. The record showed that when the DON assessed the resident, the bilateral lower extremities were warm to touch and the resident reported pain to both lower legs. The physician was called and a venous doppler was ordered, but there was no documentation that the physician had been notified the resident was not wearing TEDS and no documentation of further recommendations for the bilateral leg edema. Staff interviews reflected that the resident had not been wearing TEDS, that the legs were usually swollen, and that alternatives such as leg sleeves, elevating the legs, or a larger size stocking could have been considered. The DON stated staff should have notified the physician after repeated missed applications and expected alternative orders and interventions for the edema.
Missing Physician Orders for Catheter Care
Penalty
Summary
The facility failed to ensure physician orders for catheter care were obtained for one resident with a suprapubic catheter. The resident’s quarterly MDS dated 2/26/26 listed diagnoses of end stage renal disease, legal blindness, dementia, and major depressive disorder, and described moderately impaired cognition. The resident’s care plan identified the suprapubic catheter and included monitoring for obstruction, signs of infection, dislodgment, bowel perforation, or trauma secondary to catheter manipulation, with urinary output to be documented every shift and as needed, including amount, type, color, and odor. Review of the physician orders summary dated 3/2026 showed no physician orders for catheter care, catheter maintenance, or catheter observation. During observation on 3/24/26, the resident was sitting on the side of the bed awake and pulled up a pant leg to expose the catheter; the bag and tubing were undated. An LPN stated the resident should have physician orders for catheter care and that orders normally include monitoring for side effects and tubing change frequency. The DON and Administrator also stated there should be physician orders for catheter care, including monitoring for catheter concerns and urine input and output.
Improper Head-of-Bed Positioning During G-Tube Feeding
Penalty
Summary
The facility failed to ensure staff maintained the head of the bed in an elevated position during g-tube feeding for one resident. Resident #5 had diagnoses including Alzheimer's disease, dementia, and malnutrition, was dependent on staff for assistance with eating, and had a feeding tube noted on the quarterly MDS. The resident's care plan identified a risk for dehydration secondary to tube feeding and directed staff to keep the head of the bed elevated while in bed. The physician orders included Jevity 1.5 cal at 45 ml per hour with water flushes every four hours through the g-tube, along with an order to elevate the head of the bed 30 degrees while receiving continuous tube feeding. Observations on multiple occasions showed the resident lying in bed with the tube feeding pump on and connected while the head of the bed was positioned at approximately 10 degrees, and later flat. During interviews, a CNA stated the head of bed should be elevated 30 to 45 degrees during tube feeding to prevent aspiration, an LPN stated it should be positioned 45 to 90 degrees, and the DON and ADON stated the head of bed is expected to be at 45 degrees while receiving tube feeding to prevent aspiration.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to provide or obtain laboratory services to meet the needs of one resident. Resident #53 had diagnoses including seizure disorder, anxiety, and traumatic brain dysfunction. After the resident was observed slumped over to the right side and unresponsive while out on a smoke break, then later sitting up, conscious, slightly confused, and able to answer only yes and no questions, the nurse documented signs and symptoms of seizure activity with decreased responsiveness. The resident was then able to stand and walk to breakfast, and seizure precautions were in place. The physician was notified and ordered a CBC, CMP, and Keppra level, but review of the resident's physician order sheets for February and March 2026 showed no physician orders for those labs. An LPN stated there were no physician orders for the lab work and that once obtained, the orders should be placed in the physician orders and entered into the lab portal. The DON and Administrator stated the resident's labs were not done, and the DON said the nurse who documented the lab orders was new and did not inform nursing management of any concerns about obtaining the labs.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care for one resident who had moderate cognitive impairment and required set up and clean up assistance for oral hygiene. The resident’s care plan stated that the resident needed set up, supervision, and verbal cues for oral care because of poor follow through and decreased task initiation. The resident’s diagnoses included nicotine dependence to cigarettes, anxiety, bipolar disease, and adult failure to thrive. The physician order sheets for March 2026 showed no order for the resident to see the dentist, and the observation detail list showed the oral cavity assessment was blank. The resident was not listed on the facility’s dentist consult list for the January and February 2026 dental visits. During observation, the resident had halitosis and multiple teeth that were dark brown and black, with some teeth chipped and missing. The resident stated he/she had not seen a dentist in a very long time, did not know where his/her toothbrush was, and had smoked cigarettes for over 30 years. A CNA stated the resident required reminders about personal hygiene and did not notice any tooth issues or halitosis. The DON and ADON stated they expected residents’ oral cavities to be inspected routinely and as needed, and that nurses should notify Social Services when a resident needs to be placed on the dentist list.
Failure to Provide and Increase Dietary Supplements as Ordered
Penalty
Summary
The facility failed to provide a dietary supplement as ordered and did not implement the dietitian's recommendation to increase the supplement for a resident experiencing weight loss. The resident, who had diagnoses including cerebral palsy, severe cognitive impairment, and severe protein-calorie malnutrition, was on a regular pureed diet with nectar thickened liquids and was supposed to receive a house shake twice daily and Majic Cup with lunch and dinner. The dietitian recommended increasing the house shake to three times daily with meals due to ongoing weight loss, but this recommendation was not implemented. Documentation showed the resident continued to receive the supplement only twice daily, and there was no evidence of the increased frequency being provided. Observation during a meal revealed the resident did not receive the required supplements with lunch, and staff were unaware of the missed supplements and the dietitian's updated recommendation. The process for communicating dietary changes involved verbal and email notifications from the dietitian to the ADON, who was then responsible for ensuring nurses updated orders and dietary slips. However, this process was not followed, resulting in the resident not receiving supplements as ordered or as recommended by the dietitian.
Failure to Assess, Document, and Follow Physician Orders After Resident Nose Bleed
Penalty
Summary
The facility failed to properly assess and document a resident's change in condition following a nose bleed, and did not ensure physician orders were followed regarding the administration of saline nasal spray. The resident, who had diagnoses including hypertension, diabetes, major depressive disorder, and was on anticoagulant medications for a history of stroke, experienced a nose bleed that was initially addressed by an LPN with non-pharmacological interventions. The physician was notified and subsequently ordered to hold the resident's anticoagulant medications and to administer saline nasal spray three times daily. However, the saline nasal spray was not added to the Medication Administration Record (MAR), and there was no documentation that it was administered as ordered. Documentation gaps were evident across shifts. There were no nursing notes during the overnight shift following the initial nose bleed, despite evidence of continued bleeding observed the next morning. The overnight LPN did not document any care or observations in the resident's chart, and the CNA on duty was not given specific instructions regarding the resident's care. The following morning, another LPN found the resident with blood on the face and bedding, and the resident reported ongoing nose bleeds. The resident was subsequently sent to the hospital for evaluation and treatment after further assessment revealed lethargy and abnormal vital signs. Interviews with staff revealed inconsistent communication and follow-through regarding the resident's change in condition. The LPN who initially responded to the nose bleed did not complete a formal change in condition assessment. The overnight LPN and CNA did not witness active bleeding but observed evidence of it and did not document or escalate the situation. The Assistant Director of Nursing and Administrator stated they did not consider a nose bleed a change in condition, despite the resident's risk factors and care plan instructions to monitor for bleeding. The lack of documentation, assessment, and timely administration of ordered treatments contributed to the deficiency.
Inadequate Supervision Leads to Resident Choking Incident
Penalty
Summary
The facility failed to provide adequate supervision for a resident with a diagnosis of dysphagia and a history of choking. The resident was left unsupervised during lunch in the dining room, which led to a choking incident. Despite staff intervention, they were unable to clear the resident's airway, and the resident eventually expired after emergency medical staff dislodged a large piece of broccoli from the resident's throat. The broccoli was not part of the resident's lunch tray, indicating that the resident may have taken it from another resident's plate. The facility's policies on safety and supervision of residents, as well as the interdepartmental notification of diet changes, were not adequately followed. The resident's care plan did not address previous choking incidents or the speech therapist's discharge recommendations for close supervision and specific dietary modifications. Staff interviews revealed a lack of awareness and implementation of these recommendations, contributing to the resident's unsupervised state during meals. The resident had a history of severe cognitive impairment, anxiety disorder, aphasia, and stroke, which increased the risk of choking. Despite these known risks, the facility did not ensure that staff were within arm's reach of the resident during meals, as recommended by the speech therapist. The failure to provide appropriate supervision and adhere to dietary restrictions directly led to the resident's choking incident and subsequent death.
Failure to Update Care Plan with Speech Therapy Recommendations
Penalty
Summary
The facility failed to ensure that a resident's care plan reflected current needs, specifically regarding speech therapy recommended choking strategies. The resident, who had a history of choking, was not provided with a care plan that included the necessary strategies to prevent further incidents. The resident had severe cognitive impairment and was on a mechanical soft diet with thin liquids, but continued to experience choking episodes, including one incident involving a breadstick. The resident's care plan did not incorporate the speech therapy discharge recommendations, which included close supervision and specific strategies to facilitate safe swallowing. Despite the speech therapist's efforts to educate staff and provide cues to the resident during meals, the care plan was not updated to reflect these necessary interventions. Interviews with staff revealed a lack of awareness and understanding of the resident's care plan requirements, including the need for close supervision and monitoring for signs of dysphagia. The MDS Coordinator, responsible for updating care plans, was unaware of the speech therapy recommendations due to a lack of communication from the speech therapy department. This oversight resulted in the resident's care plan not being updated to include critical strategies for preventing choking incidents. The Assistant Administrator and Assistant Director of Nursing acknowledged the deficiency and expressed that the speech therapy recommendations should have been included in the care plan.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours per day, seven days a week, as required. Review of daily assignment sheets revealed that there was no RN present in the facility on eight specific days within a fifteen-day period, despite a census of 75 residents. Interviews with the Assistant Director of Nursing (ADON) and the Assistant Administrator (AA) confirmed awareness of the requirement and acknowledged that only one RN was employed full time, resulting in gaps in RN coverage. The facility had been actively recruiting for additional RNs but had not been successful in filling the positions, leading to the deficiency.
Failure to Obtain Proper POA Documentation and Involuntary Seclusion Without Assessment
Penalty
Summary
The facility failed to uphold residents' rights to dignity, self-determination, and communication by not obtaining or maintaining proper Power of Attorney (POA) documentation for two residents. In one case, a former facility employee was listed as a resident's POA for nearly two years without the appropriate, legally valid forms, as the documentation was incomplete and not notarized. When the error was discovered, the resident's family attempted to submit new POA paperwork, but it was also found to be incomplete, resulting in the resident being considered responsible for their own decisions despite documented cognitive impairment and a diagnosis of dementia. Staff interviews confirmed that the facility acted as if the former employee was the POA without proper verification, and there was confusion and lack of clarity among staff regarding the resident's decision-making status. Additionally, the facility failed to respect a resident's right to be free from involuntary seclusion. The resident, who had moderate cognitive impairment and a history of dementia, was moved to a locked memory care unit after being observed peeling wallpaper in the facility's entryway. Staff interviews and documentation revealed that the resident was easily redirected, not a threat to themselves or others, and did not display aggressive or combative behavior. The decision to move the resident to a more restrictive environment was made without prior assessment, alternative interventions, or notification to the resident's physician, psychiatrist, or family. There was also a lack of documentation in the resident's electronic medical record regarding the incident, the rationale for the room change, and the notifications that should have occurred. For another resident with severe cognitive impairment and a diagnosis of dementia, there was inconsistency in the facility's records regarding the existence of a POA. While the care plan and face sheet indicated that the resident's family member was the POA, a faxed document from the ADON stated otherwise. Staff interviews highlighted a lack of consistent procedures for verifying, documenting, and communicating POA status, as well as failures to notify the appropriate parties of significant changes or incidents as required by facility policy.
Failure to Provide Timely and Appropriate Perineal Care After Incontinence Episode
Penalty
Summary
Facility staff failed to provide timely and appropriate perineal care to a dependent resident following an incontinence episode. The resident, who was cognitively impaired, dependent for toileting and transfers, always incontinent of bladder and bowel, and at risk for pressure ulcers, was observed lying in bed with a urine-soaked brief. Staff did not attend to the resident's incontinence needs that morning, as confirmed by the resident during an interview. During observations, two CNAs removed the urine-soaked brief but did not perform perineal care or apply a clean brief before leaving the resident covered with a blanket. Later, two other CNAs entered the room, placed a clean brief on the resident, and dressed and transferred the resident without performing perineal care. Interviews with the CNAs revealed that they were aware of the expectation to provide perineal care after incontinence episodes but failed to do so, with some staff assuming the care had already been provided by others. The resident reported feeling unclean and uncared for when perineal care was not performed after incontinence episodes and stated this occurred often. Facility policy required staff to provide incontinence care and barrier cream after each episode, and staff interviews confirmed knowledge of these expectations. The failure to provide perineal care was acknowledged by staff and administration as not meeting the resident's needs and not respecting the resident's dignity.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of a cockroach crawling on a resident's blanket while the resident was lying in bed. The resident involved was cognitively impaired, had impairment on both sides of the lower body, was dependent for toileting and transfers, and was always incontinent of bladder and bowel. Diagnoses included diabetes mellitus, stroke, and dementia. The pest control company's service report indicated ongoing efforts to address a German roach infestation, including treatments in the kitchen, therapy room, and resident rooms. Despite these measures, a cockroach was observed on the resident's blanket, and staff confirmed the ongoing presence of cockroaches in the facility. Interviews with staff revealed that cockroaches had been a persistent issue in the building, with monthly pest control treatments failing to fully eliminate the problem. The Housekeeping Supervisor confirmed the incident and acknowledged the ongoing problem, suggesting that recent treatments in other areas may have displaced cockroaches to new locations within the facility. The Assistant Administrator stated that staff and residents were expected to report sightings, but acknowledged that cockroaches had been reported earlier in the month. The deficiency had the potential to affect all residents in the facility.
Failure to Retain Grievance Logs for Required Period
Penalty
Summary
The facility failed to follow their policy by not retaining three years of grievance logs. During a review, it was found that the grievance binder only contained logs from January 2024 to the current date, with no logs available for 2022 or 2023. The Assistant Director of Nursing (ADON) confirmed that the facility had recently changed the process of logging grievances and was unable to locate any other grievance binders. The Administrator, Director of Nursing, ADON, and Regional Operational Director all stated that they expected the facility to retain grievance logs for three years, as per their policy.
Failure to Monitor Wanderguards and Conduct Smoking Assessments
Penalty
Summary
Facility staff failed to provide 24-hour protective oversight for two residents with a history of elopements and wandering. The residents resided on a secured behavior unit, and staff did not follow physician's orders to monitor the residents' wanderguard devices as ordered. Specifically, Resident #42 was discovered not wearing their wanderguard, and Resident #53's wanderguard was found to be non-functional. The facility's Elopement Policy and Procedure required that each wanderguard be checked for functionality every shift and documented on the Treatment Administration Record (TAR), but this was not done. Additionally, staff were unaware of how to check the functionality of the wanderguards, and the necessary handheld testing device was not readily available or used correctly. This lack of oversight and adherence to policy resulted in the residents being at risk of elopement without proper monitoring. The facility also failed to ensure that smoking assessments were completed for two residents who smoked. Resident #41 and Resident #39 both had care plans indicating they chose to smoke cigarettes and required monitoring during smoking times for safety. However, there were no smoking assessments documented in their medical records. Interviews with staff revealed confusion about who was responsible for completing these assessments, with the Social Worker admitting that she had not completed any smoking assessments during her tenure. This oversight left the residents at risk of smoking-related injuries without proper evaluation and monitoring. During interviews, the Assistant Director of Nurses (ADON) and other staff members acknowledged the deficiencies. The ADON was unaware of the missing or non-functional wanderguards until informed by state surveyors. The ADON also found the wanderguard testing device in its original box, indicating it had not been used. The facility's Administrator, ADON, and Director of Nursing confirmed that wanderguards should be monitored and documented as ordered, and smoking assessments should be completed annually and as needed. These failures in following established protocols and ensuring staff competency in using safety devices and conducting assessments led to significant lapses in resident safety and care.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide eight hours of Registered Nurse (RN) coverage for 16 out of 92 days, which had the potential to cause unmet health needs for all residents. The facility's staffing policy, dated July 2019, stated that adequate staffing would be maintained to meet residents' needs, including having licensed RN and nursing staff available to provide and monitor care. However, a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report for the first fiscal quarter of 2023 showed that there was no RN coverage on 16 specific dates. Interviews with the Assistant Director of Nursing (ADON) and other administrative staff confirmed the lack of RN coverage on these dates, despite the expectation that the facility would have eight hours of RN coverage daily.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored according to acceptable standards of practice. During an inspection, it was found that three out of four medication carts and one medication room had issues. Specifically, insulin pens were opened and dated more than 28 days, and multiple bottles of over-the-counter (OTC) medications were undated and expired. The facility's Medication Storage Policy mandates that medications and biologicals be stored safely and securely, and that outdated or deteriorated drugs be immediately withdrawn from stock and disposed of properly. However, observations revealed that this policy was not followed, as evidenced by the presence of expired and undated medications in the medication carts and room checked during the survey. The census at the time was 73 residents. During interviews, a Certified Medical Assistant (CMT) acknowledged that medications should be dated upon opening and that expired medications should not be administered to residents. A Licensed Practical Nurse (LPN) instructed the CMT to discard expired medications. The Director of Nursing (DON) confirmed that staff were expected to date OTC medications upon opening and that insulin pens should only be used for 28 days. The DON also stated that staff should check expiration dates before administering medications and properly dispose of expired medications. Despite these expectations, the survey revealed significant lapses in adherence to the facility's medication storage policy, leading to the identified deficiencies.
Failure to Ensure Accurate and Updated Code Statuses
Penalty
Summary
The facility failed to ensure that code statuses were accurate, signed, and updated in the medical records for three residents. Resident #52 had conflicting information in their records, with a care plan indicating a full code status while the resident expressed a desire to be a Do Not Resuscitate (DNR). The Licensed Practical Nurse (LPN) confirmed the confusion, noting that both the electronic medical record (EMR) and paper chart contained conflicting code statuses. The Social Worker was identified as responsible for updating code statuses but had not done so in a timely manner. Resident #48's code status was also outdated, with records showing a full code status that had not been updated for over a year. The resident was rarely or never understood and had no speech, making it crucial for the responsible party to update the code status. Similarly, Resident #19's code status was outdated, with records showing a full code status that had not been updated for over a year. The Social Worker initially thought the Nursing Manager was responsible for updating code statuses but later clarified that it was her responsibility. The Administrator, Assistant Director of Nursing (ADON), and Director of Nursing (DON) confirmed that the Social Worker was responsible for ensuring code statuses were clear, accurate, and updated yearly or as needed.
Failure to Provide SNFABN for Medicare Part A Services
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or a denial letter at the initiation, reduction, or termination of Medicare Part A benefits for two residents who remained in the facility upon discharge from Medicare Part A services. Specifically, Resident #44 had Medicare Part A skilled services from 11/1/23 to 11/17/23, and Resident #34 had Medicare Part A skilled services from 4/3/24 to 4/25/24. In both cases, no SNFABN form was issued to inform the residents of their potential liability for payment for non-covered services. During interviews, the Regional Business Office Manager indicated that the facility provided SNFABN forms when residents were discharged from Medicare Part B, not Medicare Part A. Additionally, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Regional Operational Director confirmed that they would expect the SNFABN to be completed after a resident's discharge from Medicare Part A. This oversight led to the deficiency noted in the report.
Failure to Ensure PASARR Screening for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure that residents with mental disorders had a DA-124 Level I screen (PASARR) as required. This deficiency was identified for three residents who had diagnoses including seizures disorder, depression, dementia, schizophrenia, and bipolar disorder. For Resident #8, admitted on 9/18/20, the medical record showed no PASARR Level I on file despite the resident having moderate cognitive impairment and multiple psychiatric diagnoses. The Corporate Nurse mentioned that the old computer system used by previous owners might have contained the PASARR, but the current facility did not have access to it. Similarly, Resident #41, admitted on 4/1/22, and Resident #3, admitted on 3/6/2013, also had no PASARR Level I on file despite having significant cognitive impairments and psychiatric diagnoses. Interviews with Social Services and the facility's administration confirmed that PASARRs should have been completed within 30 days of admission, but they were unable to locate the necessary documentation for these residents.
Failure to Complete Discharge Summary
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident, including a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The resident, who had diagnoses of high blood pressure, depression, and stroke, was admitted on an unspecified date and discharged on another unspecified date. Progress notes indicated that the resident was scheduled for discharge and left the facility in stable condition with necessary medications and documentation. However, a review of the medical record showed no discharge summary was completed. During an interview, the Regional Clinical Director confirmed that the discharge summaries were not done and should have been completed prior to the resident's discharge.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide adequate Activities of Daily Living (ADL) care for two residents who were dependent on staff for personal care. Resident #27, who is cognitively impaired and dependent on staff for all ADLs except eating, was observed over several days with extremely long and dirty fingernails. Despite the resident expressing a desire to have their nails cut, staff interviews revealed that CNAs were unsure about their responsibilities regarding nail care for diabetic residents, leading to a lack of proper grooming for Resident #27. The care plan for this resident included goals for restorative therapy and collaboration between nursing and restorative staff, but these were not effectively implemented to address the resident's grooming needs. Similarly, Resident #67, who is cognitively impaired and at risk for poor hygiene due to dementia, was also observed with excessively long fingernails. The resident expressed a need for nail trimming, but staff interviews indicated confusion about who was responsible for this task. The care plan for Resident #67 included specific instructions for maintaining hygiene, including nail care, but these were not followed. Interviews with various staff members, including CNAs, an LPN, and the Assistant Director of Nursing, highlighted a lack of clarity and communication regarding the responsibility for nail care, ultimately leading to the deficiency in ADL care for these residents.
Failure to Ensure Accurate Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure that a resident receiving routine dialysis had accurate physician's orders, consistent communication, and a dialysis contract with the dialysis provider. The resident, who was cognitively impaired and diagnosed with heart failure, end-stage renal disease (ESRD), and dementia, had no dialysis contract, no recent dialysis communication forms, and no monitoring of the arteriovenous fistula (AVF) dialysis site documented in their medical record. The resident's care plan indicated the need for monitoring vital signs, weight, and the AVF site, but these were not reflected in the Treatment Administration Record (TAR) or physician's orders for several months. Interviews with facility staff, including an LPN, the Assistant Director of Nursing (ADON), the Director of Nursing (DON), and the Administrator, revealed that the dialysis communication forms were often lost and not completed as required. The ADON confirmed that the resident's weight and vitals should have been documented each time the resident attended dialysis, and the dialysis site should have been checked every shift. The facility also lacked a dialysis contract with the provider, and there were discrepancies in the physician's orders regarding the resident's dialysis schedule and site monitoring.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure a medication error rate of less than 5%, resulting in a 7.41% error rate. This was observed during the administration of insulin to two residents. For Resident #44, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 20 units of Novolog insulin. Similarly, for Resident #20, the LPN did not wipe the insulin pen's rubber seal with alcohol and did not prime the insulin pen before administering 9 units of Humalog insulin. Both residents have significant medical histories, including diabetes, which necessitates precise insulin administration to manage their conditions effectively. During interviews, it was revealed that the LPN was unaware of the priming steps required for insulin pens, and the Director of Nursing (DON) was unsure about the necessity of pen priming before insulin administration. The facility did not have a policy for insulin pen priming and relied on the manufacturer's instructions, which were not followed in these instances. The DON and other staff members acknowledged the expectation for staff to be free of medication errors but did not have a clear understanding or policy in place to ensure compliance with proper insulin administration procedures. The lack of adherence to the manufacturer's instructions for insulin pen use and the absence of a facility policy on insulin pen priming contributed to the medication errors observed. The facility's leadership, including the Administrator, DON, Assistant Director of Nursing, and Regional Operational Director, recognized the expectation for error-free medication administration but did not have adequate measures in place to prevent these errors, leading to the identified deficiency.
Infection Control Deficiencies in Glucometer Cleaning and Wound Care
Penalty
Summary
The facility failed to follow acceptable standards of practice for infection prevention and control when it did not clean shared medical equipment between resident use with an approved Environmental Protection Agency (EPA)-registered disinfectant. Specifically, the facility did not properly disinfect glucometers between uses for two residents. Licensed Practical Nurse (LPN) G used alcohol pads instead of the required EPA-registered disinfecting wipes to clean the glucometer between uses for two residents. This practice was observed and confirmed through interviews with other staff members, who indicated that the correct procedure involved using bleach wipes or Sani wipes, not alcohol pads. The Director of Nursing (DON) and other staff members confirmed that the facility's policy required the use of Clorox wipes for disinfecting glucometers, and alcohol pads were not acceptable for this purpose. Additionally, the facility failed to ensure proper hand hygiene and glove use during wound care for two residents. LPN E did not follow the correct procedure for changing gloves and performing hand hygiene while providing wound care. The LPN was observed double-gloving and not removing all gloves before performing hand hygiene, which is against the facility's infection control standards. Interviews with other staff members, including Certified Medication Technician (CMT) F, LPN G, and the Assistant Director of Nursing (ADON), confirmed that double-gloving is not an acceptable practice and that all gloves should be removed, and hand hygiene should be performed between dirty and clean tasks. The deficiencies were observed during wound care for two residents with severe cognitive impairments and multiple diagnoses, including Alzheimer's disease, dementia, and high blood pressure. The facility's failure to adhere to proper infection control practices was confirmed through multiple observations and interviews with staff members, including the Nurse Practitioner (NP), Registered Nurse (RN) B, and the Regional Operational Director. The facility's leadership, including the Administrator, DON, ADON, and Regional Operational Director, acknowledged that staff were expected to follow acceptable infection control standards of practice.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,079 citations issued within 25 miles in the last 12 months — including the 29 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.
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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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Normandy Nursing Center | 1.1 mi | ★★★★★ | 2 | 0 |
| Monarch Springs Wellness & Rehabilitation | 1.2 mi | ★★★★★ | 29 | 0 |
| Barnes-jewish Extended Care | 2.4 mi | ★★★★★ | 15 | 0 |
| Delhaven Manor | 2.6 mi | ★★★★★ | 1 | 0 |
| Oak Park Care Center | 3.1 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.