Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Valley Manor And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food safety and sanitation, including improper hand hygiene, lack of hair restraints, incomplete temperature and sanitation logs, expired and unlabeled food items, and unclean kitchen conditions. Two residents expressed dissatisfaction with food presentation, specifically bowls touching other foods on their plates. These deficiencies had the potential to impact all residents.
The facility failed to maintain staff competency records and failed to ensure staff followed infection control and EBP practices. An RN leadership team could not locate annual training records for multiple CNAs, and staff were observed providing care to a resident with a PICC line and wound without gowns, changing gloves, or washing hands between tasks. Dietary staff and a CNA were also observed handling food and resident care items without proper hand hygiene or glove changes, and an LPN performed wound-related care without the required gown. The infection surveillance binder was also incomplete, with missing monthly monitoring and incomplete infection documentation.
The facility failed to monitor and review 2025 PIPs for resident pressure ulcers, resident snacks, and medication administration. Review of the QAPI policy showed the facility was to maintain an ongoing, data-driven QAPI program with PIPs and monitoring of corrective actions, but the PIPs had no signatures showing who was responsible and no tracking of performance improvement. The Administrator said she had reviewed the prior PIPs and noticed they were lacking.
QAPI oversight was deficient when the facility failed to prioritize improvement activities, measure success, track performance, or regularly review and analyze data tied to its PIPs. Review of PIPs for pressure ulcers, resident snacks, and med admin showed no signatures identifying who was responsible for follow-through and no tracking of performance improvement. The Administrator stated she had reviewed the prior PIPs and found them lacking.
Missing Staff Training and Competency Records: The facility failed to maintain an effective training program for new and existing staff, including CNA competency documentation and required education in dementia care and abuse prevention. The facility also did not complete a facility assessment with staff competencies and skill sets, and it failed to track training attendance and yearly hours. Review of employee files showed no required training documentation for three CNAs, and the DON and Administrator both stated they did not know where the training records were located.
Two residents did not have comprehensive care plans reflecting their current needs and interventions. One resident's care plan failed to address the use of a wheelchair seatbelt, while another resident's plan omitted essential care needs such as ADL support, diet, catheter care, and skin integrity interventions, despite these being documented elsewhere and discussed by staff. Staff interviews confirmed that care plans should include all required interventions and preferences, but these omissions resulted in incomplete guidance for care delivery.
Several dependent residents did not consistently receive the required two showers per week, as documented in their care plans and facility policy. Despite staff acknowledging that residents who requested two showers weekly should receive them, documentation and resident interviews revealed that some residents went up to ten days without a shower, leading to discomfort and embarrassment due to inadequate personal hygiene.
Staff failed to follow infection prevention protocols by not changing gloves between clean and dirty tasks and not using required PPE, such as gowns, when providing care to two residents on enhanced barrier precautions. One resident had a surgical wound and a PICC line for IV antibiotics, requiring strict infection control. The facility also lacked an effective infection surveillance program.
Failure to obtain informed consent before starting psychotropic medications affected three residents. One resident with impaired cognition, depression, and a CVA history started antidepressants before consent was signed, while another resident with severe cognitive impairment and dementia had incomplete consent forms for an antipsychotic and an anxiolytic that were not properly signed or dated. A third resident with severe cognitive impairment, dementia, depression, psychotic disorder, and anxiety had psychotropic consent forms that were not signed by the legal guardian and were otherwise incomplete.
A facility failed to honor resident choice by not providing a means for a cognitively intact resident with liver cancer to attend Saturday Seventh Day Adventist services, despite staff knowing the resident’s religious needs and no Saturday services being scheduled. The facility also did not post a substitute food list for meals for three residents, including residents with GERD, DM, dementia, depression, Parkinson’s disease, anxiety, seizure disorder, CAD, HTN, and depression; residents reported not receiving or seeing a list, and staff confirmed the substitute menu was not posted.
Surety bond for residents' personal funds was below the required amount. Record review showed the facility's approved bond was $18,000, while the average monthly balance of residents' personal funds required at least $21,000 in coverage. The BOM said corporate recently changed the calculation method and reduced the bond using an aging report method she had not used before, and the Administrator stated the bond did not cover the facility's current liability.
Failure to investigate a bruise of unknown origin and an alleged physical abuse incident. A resident with severe cognitive and mobility impairments had a dark purple bruise on the hand, but the record showed no formal investigation, no staff interviews, and no root cause. In a separate event, a resident with dementia and multiple chronic conditions reported that a CNA hit him/her with a wheelchair; the RN documented the allegation and notified the DON, MD, and family, but there was no documented Administrator notification and no formal abuse investigation was completed.
Incomplete Care Plans for Behavior, Falls, and Resident Preferences: The facility did not develop complete person-centered care plans for three residents. One resident with dementia, anxiety, depression, and psychotropic use had documented aggression toward staff, hoarding, and confused statements, but these behaviors were not care planned. Another resident with severe cognitive impairment, dependence for all ADLs, and a fall history had bolsters used for positioning without care plan direction or a physician order. A third resident’s activity preferences were not included in the care plan.
Failure to Provide Ongoing Individualized Activities: Three residents did not receive an ongoing activities program consistent with their care plans, assessments, and preferences. One resident had severe cognitive and physical impairments, another had no cognitive impairment but had anxiety and depression, and a third had severe cognitive impairment with limited ROM and Alzheimer's disease. Activity records showed no documentation of activities offered or attended, and observations repeatedly found the residents sitting in the TV area or in their rooms with no group or 1:1 activities offered. The AD stated she had no orientation or training, did not keep activity notes, and did not track resident participation.
A facility failed to properly document and store oxygen equipment for three residents. Surveyors observed undated oxygen tubing, humidifier bottles, and storage bags, including one resident with no storage bag attached and another with an outdated humidifier bottle. Residents involved had significant respiratory and other medical conditions, and staff interviews confirmed that oxygen tubing, humidifier bottles, and storage bags should be changed and dated.
Medication refrigerator temperatures were not being checked and documented as required. In one med room, the temp log was kept outside the room and multiple days had no recorded checks, while another med room had no current log sheets or initials on the logs. The refrigerators contained liquid Ativan and insulin, and staff stated the temps should be checked and initialed daily.
A resident with a documented religious restriction against pork was repeatedly served pork products and was not provided with a suitable substitute meal during a lunch service. Despite staff awareness of the restriction and the resident's preference for alternatives like grilled cheese and tomato soup, the only substitute offered was cold cereal, leading to resident frustration and a sense that their dietary needs were not respected.
Failure to Follow Wound Treatment Order: A resident with a pressure ulcer, diabetes, HTN, and anemia had a wound care order for cleansing the coccyx, applying barrier cream to the peri wound, applying collagen powder to the wound bed, and leaving it open to air. During observation, an RN completed the treatment but did not apply the ordered barrier cream to the peri wound, and the RN, DON, and Administrator all acknowledged that treatment orders should be followed as written.
A nurse aide worked beyond the 4-month timeframe without documentation of completing a nurse aide training program or CNA certification. The facility had no policy on nurse aide training, and the aide stated he/she had not passed the CNA knowledge test and was unaware of the certification requirement. The DON and Administrator said they were not aware the aide had been working there more than 4 months.
The facility failed to maintain an antibiotic stewardship program with written protocols and a system to monitor antibiotic use. Records showed incomplete infection surveillance, missing McGeer’s Criteria checklists, and monthly logs with missing organisms, cultures, x-ray results, and resolved dates, even though active infections were present. The ADON/IP said the facility followed provider preference for starting antibiotics and could not provide written stewardship protocols, while the DON and Administrator said such protocols should exist.
Unqualified Infection Preventionist: The facility failed to designate a qualified IP for the infection prevention and control program. Record review showed the current IP had completed only 15 of the 23 CDC-required training modules and no completion certificate was provided. The ADON/IP said she did not know how to obtain further documentation or her CDC site sign-on, while the DON and Administrator stated the person responsible for infection prevention should be certified.
A resident with multiple medical conditions and moderate cognitive impairment did not receive prescribed pregabalin for pain management as ordered, with several doses missed over a two-week period. The resident reported experiencing pain during this time, and staff interviews confirmed the medication was not administered according to physician orders.
The facility failed to maintain a clean and sanitary kitchen, with observations of grease and grime on surfaces, sticky floors, and improperly stored and labeled food items. The Dietary Manager acknowledged that cleaning tasks were not strictly followed, leading to unsanitary conditions. Additionally, refrigerator and freezer temperatures were not consistently monitored, and the dishwasher was not properly maintained, with logs not updated and the machine not cleaned as required.
The facility failed to respect the rights of four residents, leading to deficiencies in care and dignity. One resident lacked oral care, resulting in dry, cracked lips and secretions in the mouth. Another resident had a dirty urinal placed next to their food and drinks. A resident reported long wait times for toileting assistance, leading to incontinence accidents. Additionally, a resident experienced long wait times for call light responses, especially on weekends.
The facility did not adequately address or communicate the concerns of resident council members, as reported by seven of eight residents in a group meeting. Issues such as inconsistent ice water delivery, food quality, and staff response times were documented in council minutes but not resolved or communicated back to residents. Residents were unaware of grievance procedures, and the Activity Director failed to document resolutions. The DON expected concerns to be addressed and documented, but this was not done, potentially affecting all 68 residents.
The facility failed to manage and reimburse residents' personal funds after discharge, affecting several residents. The facility lacked a refund policy, and checks for refunds were delayed, with some requests not processed promptly. Interviews revealed that the facility had specific timeframes for returning funds, but these were not met, leading to the deficiency.
The facility failed to document and clarify the code status for six residents, leading to inconsistencies between care plans, physician orders, and electronic medical records. Despite the facility's policy requiring advance directives to be respected and documented, several residents had missing or conflicting code status information. Interviews with the DON and Administrator confirmed the expectation for physician orders to be present and consistent across records.
The facility failed to provide a safe, clean, and homelike environment for a resident and in common areas. A resident was found in an unkempt room with dirty floors, trash, and linens on the floor, and without adequate bed linens. Common areas had missing paint, strong odors, and maintenance issues. Staff interviews revealed challenges in maintaining cleanliness and addressing maintenance issues.
The facility did not ensure residents were informed about grievance procedures, as all interviewed residents were unaware of how to file a grievance. Despite the availability of grievance forms, the facility failed to adequately educate residents on their rights and the process, as evidenced by resident council minutes and staff interviews.
The facility failed to create individualized care plans for three residents, leading to unmet needs and preferences. One resident did not receive showers as often as desired due to staffing issues. Another resident's preferences for daily shaving and nail care were not addressed, resulting in irregular grooming. A third resident with advanced dementia lacked specific care interventions, leading to poor oral hygiene and unmet care needs. Staff interviews revealed a lack of awareness about care plans and supplies.
The facility failed to follow professional standards in medication and procedure administration, affecting several residents. A resident received incorrect Flonase dosage, another had improper eye drop administration, and two residents had blood sugar checks without proper drying time. Additionally, a resident received an incorrect Tylenol dosage. Staff acknowledged these deviations from prescribed orders.
The facility failed to provide adequate hygiene and grooming care for residents unable to perform ADLs independently. Observations showed incomplete perineal care and infrequent showers due to staffing shortages, affecting residents with conditions like paraplegia and Alzheimer's. Residents also reported dissatisfaction with irregular shaving and nail care.
A facility failed to ensure proper transfer techniques and supervision, affecting three residents. One resident's wheelchair was not locked during a transfer, another was moved with a Hoyer lift by a single CNA instead of two, and a third had the lift brakes locked against guidelines. These actions were inconsistent with facility policies and manufacturer instructions.
The facility failed to maintain proper hydration for several residents by not providing fresh ice water or thickened fluids as required. Observations showed that residents, including those with cognitive impairments and dietary restrictions, often lacked access to necessary fluids. Interviews with staff revealed inconsistencies in offering fluids, contrary to care plans that required regular hydration support.
The facility was found to have expired medications and biologicals in the medication room, including Calcium 600 mg with Vitamin D, Zinc Sulfate 220 mg, and Bisacodyl Suppositories. The facility's policy did not address expired medications, and the ADON believed the CMT was responsible for checking them. The Administrator stated that expired medications should be checked weekly by Medical Records or the CMT.
The facility failed to meet residents' nutritional needs and preferences, as staff did not follow dietician-approved recipes or dietary preferences, and did not post menu substitutions. A resident with dairy allergies had their preferences ignored, while others reported inconsistencies between the menu and meals served. Kitchen staff did not measure ingredients or follow recipes, and the dietary manager did not use formal tools to assess food preferences.
The facility failed to serve food at safe and appetizing temperatures, with residents receiving cold and burnt meals. Observations showed a lack of temperature documentation and inconsistent checks by dietary staff. Multiple residents reported dissatisfaction with the food's taste and temperature, highlighting a deficiency in the facility's food service quality.
The facility failed to implement proper infection prevention measures for several residents, including those with severe cognitive impairment, urinary catheters, and a history of MDRO infections. Staff were unaware of enhanced barrier precautions and proper PPE use, and hand hygiene practices were not followed during resident care.
The facility failed to implement an effective antibiotic stewardship program, lacking protocols for infection treatment and monitoring antibiotic use. The Director of Nursing, new to her role, was unaware of previous infection prevention management and current antibiotic data. The Administrator recognized the importance of stewardship but noted the Director's dual responsibilities. This lack of clarity and accountability led to the deficiency.
The facility failed to serve meals on time, affecting a resident with paraplegia and potentially impacting all residents. Observations showed significant delays in meal service, with lunch trays served up to 39 minutes late and hall trays delayed by up to 55 minutes. Staff interviews confirmed that meals were consistently late, sometimes by two hours, despite expectations for timely service.
Widespread Food Safety and Sanitation Deficiencies in Dietary Services
Penalty
Summary
Facility staff failed to adhere to professional standards for food service safety in multiple areas, as observed during kitchen inspections and interviews. Staff did not consistently perform proper handwashing or use hairnets and beard restraints while preparing and serving food. Handwashing stations were found without paper towels, and staff were seen changing gloves or touching their faces without washing hands before resuming food preparation. Additionally, staff were observed handling soiled gloves and then using the same hand to handle clean utensils, and some staff worked in the kitchen without appropriate hair coverings. Food storage and monitoring practices were also deficient. Several refrigerators and freezers lacked temperature logs for multiple days, and some units did not have thermometers. Food items, including frozen desserts and leftovers, were found without receipt or use-by dates, and expired food was present in storage. Food containers were sometimes unsealed or improperly labeled, and some food items were stored directly on the ground. The kitchen and food preparation areas were not maintained in a clean condition, with spills and food debris left unaddressed for extended periods, and sanitation buckets for cleaning surfaces were not consistently available or used. Food presentation did not meet facility policy or resident expectations. Meals were served with bowls of food placed directly on plates, causing the bowls to touch other food items, which residents found unappetizing and unsanitary. Residents expressed dissatisfaction with the appearance and arrangement of their meals. Additionally, logs for dishwasher sanitization were incomplete, and staff responsible for these tasks cited workload and staffing shortages as reasons for missed documentation. These failures had the potential to affect all residents in the facility.
Inadequate staff competency, infection control, and infection surveillance
Penalty
Summary
The facility failed to ensure that nurses and nurse aides had the appropriate competencies and skills to provide care, and no annual training records were found for Nurse Aide A, CNA A, and CNA C. The Director of Nursing and the Administrator both stated they did not know where the training records were located, and both said the facility should have a training program for all new and existing staff. The report also states that the facility did not provide the requested policy on education or staff competencies. During care for a resident with a PICC line, surgical wound, and enhanced barrier precautions (EBP) in place, Nurse Aide A and CNA A entered the room and provided peri care while wearing gloves but without gowns. Nurse Aide A used gloved hands to open a drawer and remove wipes without washing hands or changing gloves first. The resident's record showed dependence on staff for all ADLs, bowel and bladder incontinence, and diagnoses including seizure disorder, anxiety, and high blood pressure. Both aides later stated they should have worn gowns and changed gloves and washed hands between clean and dirty tasks, and the DON and Administrator said they expected staff to use PPE and change gloves and wash hands between tasks. In other observed care, dietary staff handled food and drinks without maintaining hand hygiene or proper food protection. Meal trays and drinks were transported uncovered, one dietary aide picked up dropped condiment packets from the floor with gloved hands and continued serving residents without washing hands, and another dietary aide served drinks in resident rooms while wearing gloves, touching cups with fingers, and not sanitizing or changing gloves between residents. A CNA also served a tray to one room and then moved to another room without washing hands. In addition, an LPN provided skin prep to a resident's toe wound without wearing a gown even though the resident had a door sign indicating EBP was required; the resident had Alzheimer's disease, left-sided hemiplegia, depression, and impaired skin integrity to the left second toe. The facility's infection surveillance binder was incomplete and lacked surveillance and monitoring for January through August 2025. The binder also lacked completed McGeer's Criteria checklists, and the monthly logs contained missing or incomplete infection details, including missing organisms, cultures, x-ray results, and resolved dates. The ADON and Infection Preventionist stated the surveillance binder should document and monitor infections by month and include resident test results, while the DON and Administrator stated the infection surveillance plan should be followed and documented every month.
QAPI PIPs Not Monitored or Tracked
Penalty
Summary
The facility failed to make a good faith attempt to use the best available evidence to define and measure indicators of quality and facility goals that reflect processes of care and facility operations shown to be predictive of desired resident outcomes when it did not monitor and review 2025 performance improvement plans (PIPs) for resident pressure ulcers, resident snacks, and medication administration. Review of the facility’s QAPI Program policy dated February 2020 showed that the facility was to maintain an ongoing, facility-wide, data-driven QAPI program with objectives that included measuring indicators for outcomes of care and quality of life, establishing and implementing performance improvement projects to correct negative or problematic indicators, and monitoring and evaluating corrective actions. Review of the 2025 PIPs for pressure ulcers, resident snacks, and medication administration showed there were no signatures indicating who was responsible for following through with the PIPs and no tracking of performance improvement related to the facility’s PIPs. During interview, the Administrator stated she had been at the facility for three weeks and had reviewed the PIPs from before she began and noticed they were lacking.
QAPI Program Lacked Oversight and Tracking of Performance Improvement Plans
Penalty
Summary
The facility failed to prioritize its improvement activities, measure the success of actions, track performance, and regularly review, analyze, and act on data collected for its performance improvement plan. Review of the facility’s QAPI Program policy, dated February 2020, showed that the facility was required to maintain an ongoing, facility-wide, data-driven QAPI program focused on resident outcomes of care and quality of life, with performance improvement projects to correct negative or problematic indicators and systems to monitor and evaluate corrective actions. Review of 2025 PIPs for pressure ulcers, resident snacks, and medication administration showed there were no signatures identifying who was responsible for following through with the PIPs and no tracking of performance improvement related to the PIPs. During interview, the Administrator stated she had been at the facility for three weeks and had reviewed the PIPs from before she began, noting that the PIPs were lacking.
Missing Staff Training and Competency Records
Penalty
Summary
The facility failed to ensure an effective training program was in place for new and existing staff, including nurse aide competencies and required education in dementia care and abuse prevention. The facility also failed to complete a facility assessment that included staff competencies and skill sets needed to provide the level and types of care required for the resident population, and it failed to track attendance and hours of training for staff members who were required to receive at least 12 hours of education yearly. The facility census was 67, and no policy on education or staff competencies was provided. Review of employee files showed no documentation of required trainings for CNA A, hired 11/20/24; CNA B, hired 6/14/24; and CNA C, hired 3/5/21. During interview, the DON stated she did not know where the trainings were located, had been hired a few weeks earlier, had not documented observations of care, and was unsure whether the acting Administrator knew where the education files were. The Administrator also stated she had been recently hired, did not know where the trainings were located, and said a training program should be in place for all new and existing staff.
Failure to Maintain Comprehensive and Accurate Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were accurately created and maintained for two residents. For one resident with a history of stroke and hemiplegia, the care plan did not address the use of a seatbelt on the resident's wheelchair, despite observations showing the resident regularly used a seatbelt. Both the MDS Coordinator and the Administrator confirmed that the use of a seatbelt should have been included in the care plan, but it was omitted. For another resident with diagnoses including diabetes, paraplegia, urine retention, and high blood pressure, the care plan lacked specific goals and interventions for activities of daily living and other care needs. The resident was dependent on staff for showering, toileting, and hygiene, and required a mechanical soft diet, urinary catheter care, blood glucose monitoring, pain monitoring, and skin integrity interventions. These needs were documented in the resident's order summary and progress notes but were not reflected in the care plan. The resident also reported inconsistent care regarding turning, hygiene, and shower frequency. Interviews with facility staff, including the MDS Coordinator, DON, ADON, RN, CNA, and Administrator, revealed that staff rely on care plans and the electronic Kardex to determine the care required for each resident. Staff acknowledged that all necessary care interventions, preferences, and significant changes should be included in the care plan, but in these cases, the care plans were incomplete and did not reflect the residents' current needs or preferences.
Failure to Provide Timely Showers for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically timely showers, to dependent residents who were unable to perform these tasks independently. Observations, interviews, and record reviews revealed that three sampled residents did not consistently receive two showers per week as outlined in their care plans and facility policy. Documentation showed gaps in shower provision, with some residents going up to eight to ten days without a shower, despite their preferences and care plans indicating a need for two showers weekly. One resident with intact cognition, diabetes, morbid obesity, and neuropathy reported only receiving one shower per week, sometimes with intervals of eight to ten days between showers, leading to feelings of embarrassment due to poor hygiene. Another resident with mild cognitive impairment, stroke, dementia, and diabetes, who required substantial assistance, also reported only receiving one shower per week, contrary to their care plan and expressed preferences. A third resident, dependent on staff for all ADLs due to paraplegia and other medical conditions, similarly reported not receiving two showers per week and expressed discomfort and embarrassment about their hygiene. Interviews with facility staff, including CNAs, the ADON, DON, and MDS Coordinator, confirmed that residents who requested two showers per week should have received them, and that resident preferences were to be care planned. However, documentation and resident interviews indicated that this standard was not consistently met, resulting in a failure to maintain good personal hygiene for these dependent residents.
Failure to Implement and Maintain Infection Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple lapses in staff adherence to infection control protocols. Dietary staff did not change gloves between clean and dirty tasks, and facility staff failed to apply appropriate Personal Protective Equipment (PPE) when providing care and treatment to two residents. Specifically, staff did not don isolation gowns or change gloves and perform hand hygiene between clean and dirty tasks while caring for a resident on enhanced barrier precautions (EBP) due to a surgical wound and a peripherally inserted central catheter (PICC) line. Staff were observed entering the resident's room, applying gloves, and providing peri care without wearing gowns, and one staff member used gloved hands to retrieve items from a drawer without changing gloves or washing hands afterward. Interviews with staff and facility leadership confirmed that the expected protocol was not followed, as staff should have worn gowns and changed gloves with hand hygiene between tasks for residents on EBP. The facility also lacked an effective infection surveillance program, further contributing to the deficiency. The affected resident had a history of surgery, a PICC line for IV antibiotics, and was dependent on staff for all activities of daily living, including care that required strict adherence to infection control measures.
Failure to Obtain Informed Consent Before Starting Psychotropic Medications
Penalty
Summary
The facility failed to inform residents and/or their responsible parties in advance of the risks and benefits of proposed care when it did not obtain written consent before starting psychotropic medications for three sampled residents. No policy related to obtaining consent for psychotropic medications was provided by the facility. Interviews with nursing staff and administration indicated that consent should be obtained before the first dose, but the records showed that this did not consistently occur. For one resident with impaired cognition, depression, an unspecified mood disorder, and a history of CVA, the record showed Cymbalta 30 mg daily began on 12/3/25 and escitalopram 10 mg daily began on 5/31/25. The consent for Cymbalta was signed on 12/11/25, after the medication had already started. The informed consent for escitalopram was undated, did not indicate whether the resident consented, and was not signed by a facility representative. Staff stated that consent should be obtained from the resident or family before psychotropic medications are started. For another resident with severe cognitive impairment, dementia, Alzheimer’s disease, diabetes, and hypertension, the record included incomplete informed consent forms for olanzapine 15 mg daily and buspirone 5 mg twice daily. The forms were missing completion of side effect information, were not signed by any facility representative, and were signed by the resident’s representative in the resident signature block without dates. For a third resident with severe cognitive impairment, CAD, kidney disease, diabetes, dementia, depression, psychotic disorder, and anxiety disorder, the record showed a legal guardian had been appointed, but the psychotropic consent forms for antipsychotic, antidepressant, and antianxiety medications were not signed by the resident or the legal guardian, and other consent forms were incomplete or signed by the resident without a date. The DON and Administrator stated that consent should be obtained before the resident begins the medication and that licensed nursing staff could obtain the consent.
Failure to Support Religious Services and Meal Choice Preferences
Penalty
Summary
The facility failed to create an environment respectful of resident choice when it did not provide a means for a cognitively intact resident with liver cell carcinoma to attend Saturday church services in accordance with Seventh Day Adventist preferences. The resident’s care plan did not address the religious preference for Saturday services. During interview, the resident stated the facility had no church services available on Saturdays. The Social Services Director acknowledged awareness of the resident’s denomination and related church and food requirements, but had not researched whether a Seventh Day Adventist church in the area could come to the facility or transport the resident to community services on Saturday. Facility staff stated that the only church services offered were non-denominational services on Saturday and Sunday services for residents, but the resident reported that he/she would only attend services on Saturday. Review of the activities calendar for October, November, and December 2025 showed no Saturday church services had been scheduled or provided at the facility. An LPN also stated there were no church services held on Saturday at the facility, and the only church services were held on Sundays. The facility also failed to post a list of food substitutes for each meal for three residents. One resident with GERD, diabetes, dementia, depression, and Parkinson’s disease stated he/she had not been offered a substitute list of food choices in two years and would like a list of alternate choices. Another resident with dementia, anxiety disorder, depression, and seizure disorder stated he/she did not recall being provided a substitute list and felt frustrated by repeated menu items and lack of variety. A third resident with CAD, HTN, DM, dementia, anxiety disorder, and depression said he/she did not recall receiving or seeing a substitute menu list but would use it if provided. Observation showed no substitute food item list posted, and staff confirmed the substitute menu was not posted; the ADON stated the substitute menu for resident meals is not posted, while the Dietary Manager said the list should be at the nurses’ station and posted at the kitchen door.
Surety bond for residents' personal funds was below required amount
Penalty
Summary
The facility failed to maintain a surety bond equal to or greater than one and one-half times the average monthly balance for residents' personal funds deposited with the facility. Record review for the last 12 consecutive months from December 2024 through November 2025 showed the facility's approved bond amount was $18,000, while the average monthly balance of residents' personal funds was $13,537.65, which required a bond of at least $21,000. The average monthly balance was calculated using the ending balances from each month's bank statements plus petty cash, divided by 12 months. The facility census was 67. A policy regarding the Surety Bond Policy was requested and not provided. During interviews, the BOM stated corporate had recently changed the methodology used to calculate the bond requirement and had reduced the bond from $25,000 to $18,000 on 12/15/25 using an aging report method she had never used before. The Administrator stated the current bond amount did not cover the facility's current liability and that the error was due to corporate direction to change the formula used to determine bond coverage.
Failure to Investigate Bruise of Unknown Origin and Alleged Physical Abuse
Penalty
Summary
The facility failed to follow its abuse and injury investigation policies when it did not fully investigate a bruise of unknown origin on a resident with severe cognitive impairment, upper and lower extremity impairment, wheelchair dependence, and diagnoses including atrial fibrillation, iron deficiency anemia, hypertension, and dementia. Nursing documentation showed a CNA reported a dark purple bruise on the resident’s right hand, and the resident said he or she did not know how the bruise occurred, then stated that somebody grabbed him or her but did not know who. The nurse documented that the ADON and Administrator were notified, but the DON later stated there was no formal investigation on file, only a post bruise investigation report. That report contained no staff interviews, no root cause, and no identification of where the bruise came from. The facility also failed to investigate an allegation of physical abuse involving a resident with CAD, HTN, diabetes, dementia, anxiety disorder, and depression. Nursing notes documented that an RN observed a CNA upset and scared, and the resident stated that the CNA entered the room, demanded that the resident get up, and hit the resident with a wheelchair, striking the legs. The RN ensured safety, assisted the resident back to a recliner, assessed for injury, and noted no visible injuries and no pain, while the DON and physician and family member were notified. However, there was no documentation that the Administrator was notified, the DON said she did not conduct a formal investigation based on reading the CNA’s statement, did not interview the resident, and did not recall notifying the Administrator. The Administrator stated she was not notified about the incident and that both incidents should have been fully investigated with interviews and a root cause identified.
Incomplete Care Plans for Behavior, Falls, and Resident Preferences
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three sampled residents. The facility’s policy required care plans with measurable objectives and timetables that address each resident’s physical, psychosocial, and functional needs, and that are revised when a resident’s condition changes. Survey review found that Resident #13 did not have activity preferences included in the care plan, Resident #67 did not have fall interventions included, and Resident #30 did not have behaviors addressed in the care plan. Resident #30 had diagnoses including coronary artery disease, hypertension, diabetes, dementia, anxiety disorder, and depression. The quarterly MDS showed cognition was not evaluated by facility staff. The care plan, revised 11/26/25, included psychotropic medication monitoring and review of behaviors and adverse reactions, but it did not document aggressive behavior toward staff, hoarding of items not belonging to the resident, or making up stories inconsistent with reality. Progress notes and staff statements documented that the resident was irate during bathing care, chased a staff member from the room, pushed and grabbed a CNA, struck the CNA with a wheelchair, and was verbally abusive. Additional notes showed the resident had other residents’ clothing and belongings, as well as medical supplies and dishes from the kitchen, stored in the room. During interview, the resident made statements about stolen items, a rash, and vision loss, while observation showed the resident was extremely confused to time, place, and situation. Resident #67’s quarterly MDS showed severe cognitive impairment, dependence on staff for all ADLs and positioning, use of a wheelchair, and one fall since admission. The care plan identified the resident as a fall risk but did not give staff direction regarding bolsters for positioning needs, and there was no physician order for bed bolsters in the December orders. Observation showed the resident in bed with one-piece bolsters on both sides from the shoulders to below the knees. Facility staff stated that fall interventions, including bolsters or positioning devices, should be care planned and that residents should not have bolsters used unless assessed, ordered by a physician, and care planned.
Failure to Provide Ongoing Individualized Activities
Penalty
Summary
The facility failed to provide an ongoing activities program for three residents when individualized and meaningful activities were not offered or documented in accordance with their care plans, assessments, and preferences. The facility policy stated that the activities program should support resident wellbeing, include group, independent, and assisted individual activities, and have all activities documented in the resident record. The activity calendars for October, November, and December 2025 showed one-on-one individual activities scheduled Monday through Friday at 8:30 A.M., but the records for the three residents showed no documentation of activity offered, attended, or provided during the reviewed period. Resident #67 had severe cognitive impairment, severe visual impairment, impairment of upper and lower extremities, and was dependent on staff for all ADLs. The care plan stated the resident was dependent on staff for emotional, intellectual, physical, and social needs, should attend activities of choice related to cognitive and physical limitations, needed escort to all activity functions, and required activities compatible with physical and mental capabilities. However, the activity record contained no documentation of activities offered or one-to-one activities, and observations on three separate mornings showed the resident sitting in a wheelchair in the TV area by the nurse's station with no group or one-to-one activities offered. Resident #8 had no cognitive impairment, was dependent on staff for toileting, and had diagnoses including HTN, anxiety, and depression. The care plan stated the resident had an ADL self-care performance deficit related to confusion and fatigue, would participate in activities of choice, and family would be invited to attend activities of choice. The resident's activity record showed no documentation of activities offered or one-to-one activities, and observations showed the resident sitting in a recliner in the room with no group or one-to-one activities offered; during interview, the resident stated he/she watched TV and took naps and that no staff had talked to him/her or the family about preferred activities. Resident #13 had severe cognitive impairment, limited range of motion in both upper and lower extremities, and diagnoses including Alzheimer's Disease and HTN. The care plan stated the resident had an ADL self-care performance deficit related to Alzheimer's Disease and confusion and attended activities of choice, but the activity record showed no documentation of activities offered or one-to-one activities, and observations showed the resident sitting in a wheelchair in the TV area or in a recliner in the room with no group or one-to-one activities offered. During interview, the Activity Director stated she checked MDSs and care plans to determine goals and activities, knew Resident #13 liked nails painted, had spoken with the resident's husband about activities, did not keep activity notes except at quarterly assessment, had received no orientation or training, was the only activities staff member, did not work evenings or weekends, and did not keep a record of which resident did what activity during the week.
Failure to document and store oxygen equipment properly
Penalty
Summary
The facility failed to provide proper respiratory care for three residents by not documenting when oxygen tubing was cleaned or changed and, for one resident, by not properly storing oxygen accessories at the bedside. The report states that no policies were provided related to oxygen tubing care or storage. Surveyors observed that oxygen tubing, humidifier bottles, and storage bags were not dated as required, and in one case the humidifier bottle was outdated for more than one month. The facility also observed that one resident had no storage bag attached to the oxygen concentrator, and another resident had an oxygen tank with a second nasal cannula attached without a date on the tubing. Resident #18 had diagnoses including dementia, COPD, and heart disease, was dependent on nursing staff for all cares, and had oxygen ordered continuously at 2 liters with humidification. The care plan directed staff to monitor for respiratory infection and the order summary directed weekly changes of oxygen tubing and rinsing of the concentrator filter. During observations, the resident was in bed with oxygen on at 2 liters, the humidifier bottle was dated 11/17/25 and was more than a month old, and no date was written on the oxygen tubing or the oxygen storage bag attached to the concentrator. Resident #56 had mild cognitive impairment, stroke, dementia, and diabetes, and required substantial assistance with showers. The record showed oxygen tubing and concentrator filter orders, but the care plan did not list oxygen therapy interventions. Observations showed the resident in bed with oxygen applied, the tubing dated 11/12/25 and over a month old, no storage bag attached to the concentrator, and an undated empty humidifier bottle. Resident #10 had hypercapnia, respiratory failure, and heart failure, with oxygen via nasal cannula at 2 liters continuously. Observations showed no date on the oxygen tubing in bed and no date on the tubing attached to an oxygen tank on the resident's wheelchair. Staff interviews confirmed that oxygen tubing, humidifier bottles, and storage bags should be changed and dated, but the items observed were not dated.
Medication Refrigerator Temperature Logs Not Maintained
Penalty
Summary
Drugs and biologicals were not stored in locked compartments under proper temperature controls because the facility failed to ensure refrigerator temperatures were accurately checked and recorded. During observation of the medication room, the temperature log for the station 4 medication room refrigerator was kept in a binder outside the medication room at the nurses station, and multiple days in November and December 2025 had no recorded temperature checks. The refrigerator contained liquid Ativan and insulin medications. In a separate observation of the medication room named TU, there were no temperature check log sheets in the medication room or on the refrigerator, and an old binder at the nearby nurses station contained previous logs with no initials added for November or December. Staff interviews confirmed that refrigerator temperatures should be checked daily or every 24 hours and that the logs should be initialed, but the required checks and documentation were not being completed as observed.
Failure to Accommodate Religious Dietary Restrictions
Penalty
Summary
The facility failed to honor a resident's religious dietary preferences by not providing a suitable substitute meal when pork was served, despite documentation indicating the resident could not consume pork products. During a lunch meal service, the Dietary Manager initially prepared a tray containing breaded pork for the resident. After being informed by the Assistant Director of Nursing that the resident could not eat pork, the pork was removed, but the plate was returned with only rice and green vegetables and no substitute entrée. The resident was then offered cold cereal as a substitute, which was not their preferred choice. The resident later expressed frustration, stating that pork is regularly served to them despite their religious restrictions and that they are not always aware of what substitutes are available. Record review showed that pork was frequently included in the facility's menu, and the resident's menu card clearly indicated a restriction against pork. Interviews with staff revealed that while a preference list is maintained and residents are expected to annotate substitutes, the kitchen staff did not always catch dietary restrictions, and suitable alternatives were not always prepared in advance. The resident, who is cognitively intact and has a diagnosis of liver cell carcinoma, reported feeling that their preferences and religious needs were not respected during meal service.
Failure to Follow Wound Treatment Order
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was deficient for Resident #28, who had no cognitive impairment, required assistance of two staff for bed mobility and transfers, was at risk for pressure ulcers, had a pressure ulcer present on admission, and had diagnoses including diabetes, high blood pressure, and anemia. The resident’s care plan directed wound care per treatment order, and the physician’s order required cleaning the coccyx with hypohalous acid, applying barrier cream to the peri wound, applying collagen powder to the wound bed, and leaving the wound open to air daily. During observation, RN A cleaned the coccyx with hypohalous acid, removed gloves, washed hands, reapplied clean gloves, applied collagen powder to the wound bed, and left the wound open to air, but did not apply the ordered barrier cream to the peri wound. RN A stated the treatment order should be followed and acknowledged not realizing the barrier cream had not been applied. The DON and Administrator both stated that all medication and treatment orders should be followed as written by the physician, and the DON stated the barrier cream should have been applied to the resident’s peri wound.
Nurse Aide Training and Certification Not Completed Within Required Timeframe
Penalty
Summary
The facility failed to ensure that nurse aide A completed a nurse aide training program within four months of employment. The census was 67, and the facility did not provide a policy regarding nurse aide training. Review of nurse aide A's employee file showed a hire date of 4/21/25 and no documentation that the aide had completed a nurse aide training program. During interview, nurse aide A stated he/she had not passed the knowledge portion of the CNA test, was working only as an NA, was unsure when the test would be taken again, and was not aware of the requirement to be certified within four months of hire. The DON and Administrator both stated they were not aware the aide had been working at the facility more than four months and were unsure why the aide was still working there; the Administrator also stated the aide should have completed a nurse aide training program by now.
Failure to Monitor Antibiotic Use and Maintain Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an infection prevention and control program that included an antibiotic stewardship program with antibiotic use protocols and a system to monitor antibiotic use. The facility’s Antibiotic Stewardship policy, dated December 2016, stated that antibiotic stewardship was intended to monitor antibiotic use in residents and include training, orientation, and education of staff, and that antibiotic usage and outcomes would be collected on a facility-approved surveillance tracking form. However, the facility did not provide complete antibiotic stewardship documentation showing ongoing monthly surveillance and monitoring, including protocols to optimize treatment of infections, procedures to reduce adverse events from unnecessary or inappropriate antibiotic use, a facility-wide system to monitor antibiotic use and resistance data, designated staff accountable for stewardship, access to pharmacists or others with antibiotic stewardship experience, implementation of practices to improve antibiotic use, regular reporting to relevant staff, or education of staff and residents. Review of the facility’s 802/Resident Matrix showed only one resident receiving antibiotics, and that same resident was the only one noted with an infection, even though there were four active infections in the building requiring antibiotics. Review of the Infection Surveillance binder for 2025 showed no surveillance or monitoring for January through August, no completed McGeer’s Criteria checklists, and incomplete monthly logs: the September log had no infectious organisms, cultures, x-ray results, or resolved dates; the October log listed only four infectious organisms for UTIs at the beginning of the month and none for the remaining four UTIs, with no resolved dates for the last nine residents affected; the November log had no infectious organisms listed for any of the 13 residents; and the December log showed one resident on antibiotics for a skin infection, one for an upper respiratory infection, one for an eye infection with no organism or antibiotic listed, and a fourth resident listed with no further details. During interviews, the ADON/IP stated the facility followed provider preference for when to begin antibiotics and could not provide written antibiotic stewardship protocols, saying the facility just goes by what the provider wants. The DON said written protocols should exist on a shared computer drive but was not sure, and the Administrator said written protocols for antibiotic stewardship should exist and be followed.
Unqualified Infection Preventionist
Penalty
Summary
The facility failed to designate a qualified Infection Preventionist responsible for the Infection Prevention and Control Program. The facility’s policy stated that the Infection Preventionist serves as the coordinator of the infection prevention and control program, is generally best as a registered nurse, and must complete the required CDC Infection Preventionist training course. Record review showed the current Infection Preventionist had completed only modules 1 through 15 of the 23-module CDC-required course and no course completion certificate was provided. During interviews, the ADON and Infection Preventionist said she was not sure how to obtain further documentation beyond the 15 module certificates and did not know her sign-on for the CDC site. The DON stated the person responsible for Infection Prevention should have Infection Preventionist certification, and the Administrator said the Infection Preventionist should be certified and that the new MDS coordinator was certified but the current Infection Preventionist was not.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
Facility staff failed to administer pain management medication as ordered for a resident with moderately impaired cognition and multiple diagnoses, including pain, debility, anxiety, depression, and lung disease. The resident's physician had prescribed pregabalin 150 mg by mouth three times daily for pain, and the resident's care plan included both scheduled and PRN pain medications. Review of the medication administration record for April showed multiple missed doses of pregabalin on specific dates, with no documentation that the medication was given. During interviews, the resident reported not receiving pregabalin as prescribed during the last two weeks of April and experiencing pain while waiting for the medication. The ADON was unable to explain the gaps in administration and noted that the pharmacy was waiting for the physician to sign the order, while the Administrator confirmed that medications are expected to be administered as ordered. Facility policy requires implementation of the medication regimen as ordered and immediate provider contact if pain is not controlled, but these procedures were not followed, resulting in unnecessary pain for the resident.
Facility Fails to Maintain Sanitary Kitchen and Proper Food Storage
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen environment, as evidenced by observations of grease and grime on condiment baskets, recipe menu books, and food carts. The kitchen floors were sticky, and garbage and debris were found on the floor and food storage racks. The Dietary Manager acknowledged that cleaning tasks were assigned to staff, but the cleaning lists were not strictly followed, leading to unsanitary conditions. Additionally, the facility did not ensure that food preparation surfaces were cleaned and sanitized before use, as expected by the Administrator. The facility also failed to properly store and label food items. Observations revealed undated and unlabeled food items in the refrigerator, including applesauce, meat in marinade, and various soups and gravies. Spices were also found to be opened and undated, and some food items were stored directly on the floor. The Dietary Manager and staff were aware of the requirement to date and label food items, but this was not consistently done, leading to potential food safety risks. Furthermore, the facility did not adequately monitor refrigerator and freezer temperatures, as logs were found to be incomplete or missing. The Dietary Manager admitted to having only one thermometer in use, and the temperature logs for several days were blank. The Administrator expected temperatures to be checked daily on each shift, but this was not consistently done. Additionally, the dishwasher was not properly maintained, with logs not updated and the machine not cleaned as required. The Dietary Manager and staff were aware of the need to test and log the dishwasher's sanitizer levels, but this was not consistently performed.
Deficiencies in Resident Care and Dignity
Penalty
Summary
The facility failed to respect the rights of four residents, leading to deficiencies in care and dignity. One resident, who was severely cognitively impaired and required total assistance for all activities of daily living, was observed with a lack of oral care, resulting in dry, cracked lips and a buildup of secretions in the mouth. The care plan for this resident did not address grooming or oral care needs, and staff interviews revealed a lack of knowledge about oral care supplies. Another resident, who was not cognitively intact and had a history of urinary tract infections, was observed with a dirty urinal placed next to their food and drinks, compromising their dignity and hygiene. A resident who was cognitively intact but required assistance for personal hygiene and mobility reported long wait times for toileting assistance, leading to embarrassing incontinence accidents. The resident expressed frustration with the lack of timely assistance, particularly during nighttime hours, which was attributed to staffing shortages. Interviews with staff confirmed that residents should be taken to the bathroom before meals and checked every two hours, but the resident's experience indicated these protocols were not consistently followed. Additionally, another resident with intact cognitive skills but significant physical impairments reported waiting over an hour and a half for staff to respond to call lights. The resident noted that staff shortages on weekends exacerbated the issue. Interviews with staff and the facility's administration revealed discrepancies in the expected response times for call lights, with the administrator and DON stating that call lights should be answered within a few minutes, yet the resident's experience suggested otherwise.
Failure to Address and Communicate Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council members, as reported by seven of the eight residents who participated in a group meeting. The facility's policy for recording and investigating grievances, revised in April 2017, outlines a process for investigating and resolving grievances, but the facility did not follow through with this process. The resident council minutes from meetings held in April, May, and June 2024, documented various concerns such as inconsistent ice water delivery, issues with food quality, and inadequate response times from staff. However, these minutes did not indicate how the concerns were addressed or if they were resolved to the residents' satisfaction. During interviews, residents expressed that they did not receive any follow-up on their concerns voiced during the resident council meetings and were unaware of how to fill out a grievance or who to contact. The Activity Director mentioned that resolutions were discussed in subsequent meetings but were not documented in the minutes. The Director of Nursing expected that residents' concerns would be addressed and documented in the following meeting, but this was not done. This lack of communication and documentation had the potential to affect all 68 residents in the facility.
Facility Fails to Timely Reimburse Residents' Funds Post-Discharge
Penalty
Summary
The facility failed to properly manage and reimburse residents' personal funds after discharge, affecting nine out of 17 sampled residents. The facility did not have a policy on refunds, and the Resident Rights Policy indicated that residents have the right to manage their financial affairs and that the facility must act as a fiduciary for residents' funds. The facility's Interim Aged Analysis Report showed negative balances for several discharged residents, indicating that refunds were not issued in a timely manner. Checks for these refunds were delayed, with some requests submitted to the corporate office but not processed promptly. Interviews with the Business Office Manager and Administrator revealed that the facility had a 30-day timeframe to return funds for Medicaid residents and a five-day timeframe for private pay residents. However, the Business Office Manager noted delays in processing refund requests, with some requests not submitted or processed due to previous management issues. The Administrator expected timely returns of funds, but the facility's actions did not align with these expectations, leading to the deficiency in managing residents' financial affairs.
Failure to Document and Clarify Code Status for Residents
Penalty
Summary
The facility failed to clarify and document the code status of six residents, which is a critical aspect of respecting residents' rights to make decisions about their treatment preferences. The facility's Advance Directive Policy requires that advance directives be respected and documented in accordance with state law and facility policy, including obtaining physician orders for Do Not Resuscitate (DNR) or Full Code status. However, the review revealed that the code status was not documented in the medical records or care plans for several residents, and there were no corresponding physician orders. For Resident #63, the face sheet and physician orders lacked a code status, despite the resident's complex medical history, including cognitive impairment and chronic conditions. Similarly, Resident #6's care plan indicated a DNR status, but there was no corresponding physician order, and the electronic medical record showed conflicting information. Resident #18's care plan indicated a Full Code status, but the electronic medical record and code status book showed a DNR status, highlighting inconsistencies in documentation. Other residents, such as Resident #29 and Resident #33, also had discrepancies between their care plans, physician orders, and electronic medical records regarding their code status. Resident #22 had a signed OHDNR order, but the physician order was missing from the resident's POS. Interviews with the Director of Nursing and the Administrator confirmed that the facility's practice should include having a physician order for each resident's code status, which should be reflected on the face sheet and care plan, but this was not consistently done for the sampled residents.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for Resident #23 and in common areas on the 200 and 300 halls. Resident #23, who was readmitted from the hospital with infected hardware from hip repair and had a history of multi-drug resistant organisms, was observed multiple times in an unkempt room with dirty floors, trash, and linens on the floor. The resident's call light was often out of reach, and the resident was found without adequate bed linens, shivering in a cold room. Staff failed to ensure the call light was accessible and did not offer assistance or bed linens during tray delivery. The facility's common areas also showed significant deficiencies. Observations revealed missing wood chunks and varnish on handrails, missing paint on resident room doors, and a strong odor of urine in the 300 hall. The kitchen ceiling had chipping paint, and drywall patches were unsanded and unpainted. The dining room had exposed food trays with flies, and several rooms had sticky floors, strong odors of urine, and missing paint from walls. Maintenance issues were noted, including a black spot on the floor from a shower leak and difficulties in matching wall paint colors for repairs. Interviews with staff highlighted challenges in maintaining cleanliness and addressing maintenance issues. The housekeeping supervisor mentioned a lack of a floor tech and no current schedule for stripping and waxing floors, while the maintenance director noted ongoing pest control issues and difficulties in matching paint colors. A CNA reported that strong odors of urine were due to inadequate incontinent care and infrequent bed checks. These observations and interviews indicate systemic issues in maintaining a clean and safe environment for residents.
Failure to Inform Residents on Grievance Procedures
Penalty
Summary
The facility failed to ensure that residents were informed about how to file a grievance, which is a violation of their rights. The review of the resident rights documentation indicated that federal regulations guarantee residents certain rights, including the right to voice grievances without fear of discrimination or reprisal. The facility is required to make information on how to file a grievance available to residents and establish a grievance policy to ensure prompt resolution of grievances. However, during a group interview, all eight residents in attendance expressed that they were unaware of how to fill out a grievance or who to contact for assistance. The resident council minutes from April to June did not show any discussion on how to file grievances, focusing instead on other rights such as confidentiality, privacy, respect, and communication. Interviews with the Activity Director and the Director of Nursing revealed that grievance forms were available at nurse's stations and in front of the Activity Director's office, but it was assumed that residents knew this information. This lack of awareness among residents indicates a failure in the facility's responsibility to educate and inform them about their grievance rights and procedures.
Failure to Develop Individualized Care Plans
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for three residents, leading to unmet needs and preferences. Resident #18, who was cognitively intact and dependent on a wheelchair, required substantial assistance with bathing due to multiple sclerosis and other conditions. However, the care plan did not include the resident's shower preferences, resulting in showers being provided less frequently than desired. The resident expressed dissatisfaction with the frequency of showers, which were scheduled twice a week but often delayed due to staffing issues. Resident #43, also cognitively intact and dependent on a wheelchair, required assistance with personal hygiene and grooming. The care plan did not address the resident's preferences for daily shaving and nail care, leading to irregular grooming practices. The resident reported irritation from the facility's razors and overgrown nails, which were not consistently addressed. Observations confirmed the resident's facial hair and nail condition, and interviews with staff revealed a lack of awareness and documentation regarding the resident's grooming preferences. Resident #34, with severely impaired cognition and advanced dementia, was on hospice care and required total assistance for all activities of daily living. The care plan lacked specific interventions for comfort care, grooming, oral care, repositioning, and skin integrity. Observations showed the resident with poor oral hygiene and unmet care needs, while interviews with staff indicated a lack of knowledge about care plans and oral care supplies. The facility's failure to update and individualize care plans resulted in inadequate care for these residents.
Medication and Procedure Administration Deficiencies
Penalty
Summary
The facility failed to ensure that staff followed professional standards in administering medications and performing procedures, affecting several residents. One resident did not receive the correct dosage of Flonase nasal spray as prescribed, with only one spray administered in each nostril instead of the required two. The Certified Medication Technician (CMT) did not instruct the resident to administer the correct dosage, despite acknowledging the need to follow the physician's order. Another resident experienced improper administration of eye drops, where the CMT allowed the tip of the eye dropper to touch the resident's eyelashes, contrary to the facility's policy. Additionally, the resident applied lacrimal pressure for only eight seconds, whereas the policy required one minute. This deviation from the procedure was acknowledged by both the CMT and the Director of Nursing (DON). The facility also failed to obtain a physician's order for blood sugar checks for one resident, and the Licensed Practical Nurse (LPN) did not allow the alcohol to dry completely before obtaining blood sugar readings for two residents. Furthermore, another resident received an incorrect dosage of Tylenol, with two tablets administered instead of the prescribed one. The CMT involved admitted to not following the physician's orders, and the DON confirmed the expectation to adhere to the prescribed dosage.
Deficiencies in Resident Hygiene and Grooming Due to Inadequate Care
Penalty
Summary
The facility failed to provide adequate care for residents who were unable to perform activities of daily living (ADLs) independently, resulting in deficiencies in personal hygiene and grooming. Observations revealed that staff did not provide complete perineal care for several residents, including not cleaning all necessary areas and using the same area of a wipe for different parts of the body. This affected multiple residents who were dependent on staff for toileting and personal hygiene due to conditions such as paraplegia, Alzheimer's disease, and multiple sclerosis. Additionally, the facility did not ensure that residents received showers as scheduled, with some residents receiving significantly fewer showers than planned. This was partly due to staffing shortages, as shower aides were often pulled to work on the floor, leaving residents without the necessary hygiene care. Residents expressed dissatisfaction with the infrequency of showers, and some reported feeling embarrassed due to oily hair and inadequate cleanliness. The facility also failed to provide regular shaving and nail care for residents, with documentation showing that these tasks were often not completed during scheduled shower days. Residents reported preferences for daily shaving and expressed discomfort with the facility's shaving methods, which sometimes caused skin irritation. The lack of consistent grooming and hygiene care was attributed to insufficient staffing and inadequate scheduling, leading to unmet resident needs and dissatisfaction.
Improper Transfer Techniques and Inadequate Supervision
Penalty
Summary
The facility failed to ensure proper techniques were used to reduce the possibility of accidents or injuries during resident transfers. Specifically, staff did not lock residents' wheelchairs during transfers, did not close the base of lift legs during movement, and performed transfers with only one staff member present when two were required. These deficiencies affected three residents, including one who was cognitively intact and dependent on a wheelchair, another with moderately impaired cognition and multiple physical impairments, and a third with memory problems and dependency on staff for all activities of daily living. For Resident #31, staff used a mechanical lift to transfer the resident from a recliner to a toilet and back to a wheelchair. During this process, the lift's legs were locked when they should have been free to roll, and the wheelchair was not properly locked, leading to potential instability. Staff members involved were unaware of the correct procedures, indicating a lack of training or adherence to facility policies. Resident #6, who required substantial assistance and had multiple diagnoses including cerebral palsy and hemiplegia, was transferred using a Hoyer lift by a single CNA, contrary to the care plan that required two staff members. This was reportedly due to staffing shortages, with staff acknowledging they often performed transfers alone. For Resident #25, staff locked the brakes on the mechanical lift during a transfer, which was against the manufacturer's guidelines, further demonstrating inconsistencies in following proper procedures.
Failure to Maintain Resident Hydration
Penalty
Summary
The facility failed to maintain the hydration status of five residents by not providing fresh ice water or offering thickened fluids as required. Observations revealed that Resident #1, who was cognitively impaired and at risk for dehydration due to a urinary tract infection, did not have fluids within reach on multiple occasions. Despite being on a puree diet with nectar thick liquids, the resident was often found without any liquids in their room, indicating a lack of adherence to the care plan that required encouragement of fluid intake. Resident #10, who was cognitively intact but required assistance for daily activities, reported that their water cup was sometimes filled only once a day, and there were days when it was not filled at all. Observations confirmed that the resident's ice water was refilled only upon request, and the water cup was often less than a quarter full. This neglect in providing adequate hydration was contrary to the care plan, which required staff to prompt fluid intake with meals and in between. Other residents, such as Resident #25, who was severely impaired and dependent on staff for all activities, were also found without the necessary thickened fluids in their rooms. Interviews with staff revealed a lack of consistent practice in offering fluids every two hours, as expected. Resident #63, with a history of urinary tract infections, was observed with untouched beverages and no water available, while Resident #58 expressed a desire for more frequent ice water refills, which were not consistently provided. These observations and interviews highlight a systemic issue in the facility's hydration management practices.
Expired Medications Found in Facility
Penalty
Summary
The facility failed to discard expired medications and biologicals stored within the medication room, as observed during a survey. The facility's policy for the storage of medications was undated and did not address the handling of expired medications. During an observation and interview, it was found that the central supply cabinet contained an unopened bottle of Calcium 600 mg with Vitamin D supplement expired since June 2024, an unopened bottle of Zinc Sulfate 220 mg expired since March 2024, and a box of Bisacodyl Suppositories expired since November 2022. The Assistant Director of Nursing (ADON) indicated a belief that the Certified Medication Technician (CMT) was responsible for checking expired medications, which should be destroyed and not used. In an interview, the Administrator stated that either Medical Records or the CMT should check for expired medications every Tuesday, and there should not be expired medications in the room. Staff had been trained to check expiration dates when pulling medications.
Deficiencies in Meal Preparation and Dietary Preferences
Penalty
Summary
The facility failed to ensure that meals were served to meet the nutritional needs and preferences of residents, as evidenced by several deficiencies observed during the survey. Staff did not prepare food according to the registered dietician-approved recipes, failed to follow dietary preferences, and did not post a list of available menu substitutions for residents. This affected five of the seventeen sampled residents. For instance, Resident #22, who is allergic to dairy products and whey, reported that their allergies were not noted on their meal ticket, and their dietary preferences were not addressed. Additionally, Resident #21 expressed that they did not always receive the meals they ordered, and Resident #48 was unable to have cranberry juice with all meals as requested, with the facility only offering juice at breakfast. Resident #31 noted the absence of salt and pepper, which used to be provided with meals. Furthermore, Resident #32 expressed frustration during a resident council meeting about inconsistencies between the menu and the meals served, such as being served breaded chicken nuggets instead of BBQ chicken thighs as listed on the menu. Observations in the kitchen revealed that staff did not measure ingredients or follow recipes when preparing meals, such as quick oats, farina, and pancakes. The dietary manager admitted to not using a formal assessment tool for determining food preferences and acknowledged that the a-la-carte menu was not posted in the dining room. The dietician expected staff to follow menus and complete dietary preference assessments upon admission and annually, but these expectations were not consistently met.
Deficiency in Food Service Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. Observations and interviews revealed that hot food was not served at the appropriate temperature, and burnt food was provided to 10 out of 17 sampled residents. The facility's policy required food to be stored, prepared, distributed, and served in accordance with professional standards for food service safety, including maintaining specific temperature ranges for different types of food. However, the facility did not adhere to these standards, as evidenced by the lack of temperature logs for July and the failure to document food temperatures during meal service. Multiple residents reported receiving cold meals, with some describing the food as tough or burnt. For instance, one resident mentioned receiving burnt bacon and cold food, while another complained about the difficulty in cutting and chewing cold meat. Additionally, residents expressed dissatisfaction with the taste of the food, noting that it was sometimes overcooked or undercooked. The dietary staff did not consistently check or document food temperatures, and there were instances where burnt food, such as pancakes and baked goods, was served to residents. Interviews with staff members, including dietary aides and nurse aides, confirmed that there were frequent complaints from residents about cold and burnt food. The dietary manager acknowledged that food temperatures should be checked multiple times during meal service, but this was not consistently done. The facility's failure to maintain proper food temperatures and serve palatable meals resulted in a deficiency in providing quality care to the residents.
Inadequate Infection Control and Precautions
Penalty
Summary
The facility failed to implement proper infection prevention measures for several residents, as observed during a survey. Three residents were not placed on enhanced barrier precautions despite having conditions that warranted such measures. Resident #34, with severe cognitive impairment and a gastric feeding tube, had no care plan addressing the risk of multidrug-resistant organism (MDRO) infections or the use of personal protective equipment (PPE). Similarly, Resident #63, who had a urinary catheter and a history of repeated urinary tract infections, also lacked a care plan for MDRO infection risk and PPE use. Resident #23, with a history of MDRO infections and impaired cognition, was not identified for enhanced precautions, and staff were not alerted to the necessary PPE for care. The facility's staff demonstrated a lack of awareness and understanding of enhanced barrier precautions. Interviews with nursing assistants revealed that they were unsure about which residents required enhanced precautions and what PPE should be used. This lack of knowledge extended to the Director of Nursing and the Assistant Director of Nursing, who were also uncertain about the current criteria and recommendations for enhanced precautions. This indicates a systemic issue in the facility's infection control practices and staff training. Additionally, the facility failed to maintain proper hand hygiene practices during resident care. An observation of Resident #58's care showed that a certified nursing assistant did not wash hands between glove changes while providing care for a resident with a urinary catheter. This was contrary to the facility's hand hygiene policy, which emphasizes handwashing as a primary means to prevent healthcare-associated infections. The deficiency in hand hygiene practices further highlights the facility's failure to adhere to infection prevention protocols.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, specifically lacking a comprehensive antibiotic stewardship program. The program was supposed to include protocols for optimizing infection treatment, reducing adverse events from inappropriate antibiotic use, and implementing a system to monitor antibiotic usage and resistance data. However, the facility did not provide documentation of ongoing monthly surveillance and monitoring, nor did it have designated staff accountable for overseeing antibiotic stewardship. The facility's revised Antibiotic Stewardship policy from December 2016 outlined the need for monitoring antibiotic use and educating staff, but these measures were not effectively implemented. During interviews, the Director of Nursing, who started in May, admitted to being unaware of who previously managed infection prevention and was unsure of the current antibiotic usage and monitoring data. The antibiotic tracking book was found to be lacking in information. The Administrator acknowledged the importance of antibiotic stewardship but noted that the Director of Nursing was new to her role and now also responsible for managing infection control and antibiotic stewardship. This lack of clarity and accountability contributed to the deficiency in the facility's antibiotic stewardship program.
Consistent Delays in Meal Service
Penalty
Summary
The facility failed to serve meals according to scheduled meal times, affecting one of 17 sampled residents and potentially impacting all residents in the community. The facility's policy required timely distribution of meals and snacks, but observations showed significant delays in meal service. For instance, lunch service on multiple days was delayed, with the first tray served 24 minutes after the posted meal time and the last tray served 39 minutes late. Hall trays were also delayed, with the first cart leaving the kitchen 55 minutes after the scheduled time. Interviews with staff, including the Dietary Manager and Certified Nurse Aides, confirmed that meals were consistently served late, sometimes by up to two hours. Resident #22, who had intact cognitive skills but required assistance for meals due to paraplegia and other health conditions, reported that their food was often late. The Dietary Manager was unaware of the consistent delays, although they acknowledged that meal service took longer when residents had a-la-carte orders. The facility's dietician and administrator both expected meal service to be completed within one hour, but this expectation was not met. The consistent delays in meal service were observed and reported by multiple staff members, indicating a systemic issue within the facility's meal distribution process.
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 214 citations issued within 25 miles in the last 12 months — including the 4 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 Excelsior Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspire Senior Living Excelsior Springs | 0.4 mi | ★★★★★ | 21 | 0 |
| Lawson Manor & Rehab | 5.6 mi | ★★★★★ | 4 | 0 |
| Norterre | 11.6 mi | ★★★★★ | 1 | 0 |
| Liberty Health And Wellness | 11.6 mi | — | 0 | 0 |
| Avalon View Health And Wellness | 13.5 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.