Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chadwick Community Care Center during CMS and state inspections, most recent first.
Failure to provide required ADL care for a resident included missed oral care, nail care, and facial grooming. A CNA acknowledged not completing oral hygiene and grooming, while the resident reported needing help brushing her teeth, having long nails digging into her skin, and wanting facial hair trimmed. Observation found extensive plaque on the teeth, long chin hair, and nails leaving a deep impression in the contracted hand; an LPN confirmed the findings and noted the resident was cognitively intact.
The facility failed to follow comprehensive care plans for two residents. An LPN did not follow the wound care plan for a resident with diabetes and HTN heart disease by cleansing the wound but not patting it dry before applying betadine, as ordered. Another resident with an ADL self-care deficit reported that staff did not consistently provide needed oral care, nail care, or grooming assistance, despite the care plan directing one-person assistance for dressing, grooming, personal hygiene, and oral hygiene.
An LPN failed to follow ordered procedures during medication administration and wound care for two residents. One resident’s PEG tube medications were given without flushing between each medication, and the tube clogged during administration. For another resident with an intact blister on the left heel, the LPN cleansed the wound but did not pat it dry before applying betadine as ordered; the DON confirmed the order was not followed.
Failure to Secure Indwelling Urinary Catheter: A resident with an indwelling urinary catheter and moderate cognitive impairment was observed without a leg strap securing the catheter during foley care. CNAs confirmed the strap was not in place, and the DON stated staff are expected to apply the leg strap per the plan of care and orders for catheter care and tubing secured each shift.
Unnecessary Narcan Order on Medication List: A resident had an active Narcan order despite no opioid medications being ordered. The only sedative on the MAR was clonazepam for anxiety, and the DON confirmed Narcan would not reverse clonazepam and that the order had likely been selected in error during a batch submission for provider signature. The resident had paroxysmal atrial fibrillation and a BIMS score of 7, indicating severe cognitive impairment.
Failure to Communicate Meal Choices and Alternatives: A resident who was cognitively intact stated he did not know alternate meals were available and was not aware of what foods were being served each day. He reported that when he told CNAs he did not like the meal, he sometimes received something else and other times did not, and no menu was posted in his room. Staff interviews showed CNAs only sought alternatives after a tray was refused, while the DON stated residents should be informed of meal options before trays are served.
Infection prevention and control guidelines were not followed during medication administration for a resident receiving meds via PEG tube. An LPN placed a syringe stopcock plunger on a bare bedside table that had not been disinfected, then used the same plunger after it contacted the table when the resident’s tube became clogged. The LPN and DON both confirmed the bedside table should have been disinfected or the contaminated equipment replaced before use. The resident had a history including peritoneal abscess and moderate cognitive impairment.
A resident with severe cognitive impairment and a history of wandering was discharged after going on therapeutic leave with family, but neither the resident nor their representative received a required bed-hold notice or clear communication about discharge status, appeal rights, or the process for returning. Facility staff confirmed that bed-hold notifications were not provided for therapeutic leave, and the resident's family experienced confusion regarding medication, discharge, and the removal of a wander guard.
A resident with significant neurological impairments and total dependence for ADLs did not receive perineal care according to the care plan, which required two-person assistance. Instead, a CNA provided care alone, contrary to the documented interventions. Facility leadership and nursing staff confirmed that the care plan was not followed during this incident.
A CNA failed to provide perineal care according to policy for a resident with neurological impairments, neglecting to clean all required areas and improperly handling a feeding pump, which only nurses are authorized to operate. Facility staff confirmed the care was not performed correctly and that the resident was unable to participate in a mental status interview.
A resident on Enhanced Barrier Precautions did not receive perineal care in accordance with infection control protocols. A CNA failed to wear a gown, perform hand hygiene, use a barrier for supplies, or change gloves as required, and did not properly clean the perineal area. Facility staff confirmed these actions did not meet established infection prevention standards.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised through a kitchen door that lacked a wander guard alert system. Despite wearing a wander guard bracelet, the resident was able to leave undetected, as staff did not immediately notice the absence and the door was not properly secured. The resident was found approximately one mile away after crossing a busy highway, highlighting a failure in supervision and environmental safety controls.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and untimely incontinent care for residents. A resident experienced frequent delays, with observations noting a strong odor of urine and saturated briefs. Another resident reported long wait times for call light responses, with staff often failing to return. A third resident reported long wait times, particularly during the night shift, and a CNA confirmed staffing shortages. The DON and Administrator stated expectations for timely care, but observations indicated systemic staffing issues.
The facility failed to honor the rights of two residents who requested bedrails for assistance with mobility. Despite their requests, the facility removed all bedrails, citing state regulations and a restraint-free policy. The residents' needs and choices were not assessed, leading to a violation of their rights.
A resident receiving oxygen therapy at 2 L/min was found without a dated tubing and a humidifier, contrary to facility policy and physician orders. The resident, with a history of respiratory issues, had been hospitalized twice for shortness of breath. Staff interviews confirmed the oversight, highlighting the risk of infection and dryness due to non-compliance with weekly tubing changes and humidifier use.
A resident with moderate cognitive impairment and a history of stroke, diabetes, and heart disease experienced delays in receiving incontinent care. Despite activating the call light, staff either turned it off without providing care or delayed in responding. Observations showed the resident's brief was often saturated with urine, and the wheelchair was wet due to leakage. The facility had only one CNA for 12 residents, contributing to the delay, despite expectations for timely care set by the DON and Administrator.
Failure to Provide Required ADL Care
Penalty
Summary
The facility failed to consistently provide necessary ADL care for one resident, including daily oral hygiene, routine nail care, and regular shaving of facial hair. Facility policy stated that residents unable to perform ADLs independently would receive services necessary to maintain good nutrition, grooming, and personal and oral hygiene. During survey observations and interviews, a CNA assigned to the resident for the prior two days acknowledged failing to provide oral care and grooming, including shaving, but stated he could do it if the State Agency wanted him to. The resident stated that she wanted her teeth brushed daily but could not remember the last time staff brushed them because she needed help to do so. She also reported that staff did not often cut her nails and that the nails on her contracted hand were long and digging into her skin, and she wanted the hair under her chin trimmed regularly. Observation showed long nails on the contracted hand leaving a deep impression in the skin, facial chin hair that was long, gray, and curled like a beard, and an extremely large amount of plaque buildup on the teeth. An LPN confirmed the chin hair had not been shaved in quite some time, the nails were long and could cause further injury if not cut, and the teeth had extensive plaque buildup and needed to be brushed. The resident had diagnoses including unspecified osteoarthritis and a BIMS score of 15, indicating she was cognitively intact.
Failure to Follow Comprehensive Care Plans for Wound Care and ADL Assistance
Penalty
Summary
The facility failed to implement a comprehensive care plan related to ADL care and wound care for two residents. The facility policy on Comprehensive Person Centered care planning stated that a comprehensive, person-centered care plan with measurable objectives and timetables is developed and implemented for each resident. For Resident #60, the care plan directed staff to cleanse the wound site, pat it dry, apply skin preparation and barrier cream, and cover it with a dry dressing daily and as needed. During an observation of wound care, an LPN cleansed the wound with wound cleanser but did not pat it dry before applying betadine, which was not consistent with the physician order or the care plan. The LPN later stated he was not aware he had failed to pat the wound dry and acknowledged he did not follow the care plan. The DON stated staff are expected to follow the comprehensive care plan because it informs staff of the care required. For Resident #78, the care plan identified a potential ADL self-care deficit and directed staff to provide one-person assistance with dressing, grooming, personal hygiene, and oral hygiene with substantial to maximal assistance. During interview, the resident stated she wanted her teeth brushed daily but could not remember the last time staff brushed them because she requires staff assistance. She also stated staff do not often cut her nails, that the nails on her contracted hand were long and digging into her skin, and that she wanted them trimmed. She further stated she disliked the hair under her chin and requested that staff keep it trimmed regularly. The RN and MDS nurse stated the care plan is the plan of care for staff to follow and that nurses and CNAs are expected to follow it.
Failure to Follow Ordered Medication Administration and Wound Care Procedures
Penalty
Summary
The facility failed to follow standards of practice during medication administration and wound care for two residents. For Resident #8, who had an admission diagnosis that included peritoneal abscess and a BIMS score of 11 indicating moderate cognitive impairment, an LPN administered multiple medications through a PEG tube without flushing with water between each medication. During the observation, the tube became clogged and the nurse used a syringe plunger to push the medications after gravity flow stopped. The resident’s active order required the feeding tube to be flushed with 60 cc of water before and after medication administration, 15 cc between medications, and medications to be diluted with 5 cc of free water. For Resident #60, who had diagnoses including Type 2 Diabetes Mellitus without complications and Hypertensive Heart Disease without Heart Failure and a BIMS score of 13 indicating cognitive intactness, an LPN performed wound care on an intact blister to the left heel. The wound was cleansed with wound cleanser, but the nurse did not pat the wound dry before applying betadine as ordered. The active physician order required the wound to be cleansed with wound cleanser, patted dry, betadine applied daily, and covered with a dry dressing as needed. The DON stated the wound should have been patted dry prior to betadine application.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure an indwelling urinary catheter was secured with a leg strap for one resident with a catheter. The resident had diagnoses including Neuromuscular Dysfunction of the Bladder and an MDS BIMS score of 10, indicating moderate cognitive impairment. The facility policy for Catheter Care, Urinary, stated to ensure the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. During an observation and interview of foley catheter care, the resident’s pajamas were removed and a leg strap to secure the catheter was not in place. Two CNAs confirmed there was not a leg strap securing the catheter. One CNA stated the resident should have a leg strap and that it is used to prevent the catheter from pulling out, while the DON stated CNAs should apply a leg strap during care and that staff are expected to follow the plan of care and apply the leg strap. The resident had physician orders for catheter care each shift and to observe for placement of a catheter leg strap with tubing secured each shift.
Unnecessary Narcan Order on Medication List
Penalty
Summary
The facility failed to ensure that Resident #5’s drug regimen was free from unnecessary drugs when an active order for Narcan Nasal Liquid 4 mg/0.1 mL remained on the medication list despite the resident having no opioid medications ordered. The Narcan order directed staff to spray alternating nostrils every two minutes as needed for signs and symptoms of overdose, including unresponsiveness, shallow breathing, and cyanosis, with instructions to notify the MD and EMS immediately. Record review showed the only sedative medication ordered for the resident was clonazepam 0.5 mg, with an active dose of 0.25 mg by mouth every 12 hours for anxiety disorder. The record review and interview established that Narcan would not reverse the effects of clonazepam, and the DON confirmed the resident did not have any opioids ordered. During interview, the DON stated she needed to review Narcan’s pharmacologic action to determine whether it would reverse clonazepam, then confirmed it would not benefit the resident if unresponsiveness occurred from clonazepam use. She stated the order was likely selected in error when a nurse submitted a batch of orders for provider signature and acknowledged that the order did not apply to the resident. The resident’s admission record showed a diagnosis of paroxysmal atrial fibrillation, and the MDS ARD of 01/06/2026 showed a BIMS score of 7, indicating severe cognitive impairment.
Failure to Communicate Meal Choices and Alternatives
Penalty
Summary
The facility failed to provide alternative menu choices and failed to ensure meal preference options were communicated for one resident. Resident #70 stated he sometimes did not like the food he was served, did not know alternate meals were available, and said that when he told CNAs he did not like the meal, sometimes they brought something else and other times they did not. He also stated he was not aware of what foods were being served daily and wanted to know what was being served. On a later interview, he still did not know what foods would be served that day, and observation of his room showed there was no menu posted in the room. The Dietary Manager stated menus were posted on each hall, CNAs asked residents at lunch and notified kitchen staff of resident choices, and culinary meetings were held on Fridays with about 35 residents attending, although she confirmed not all residents attended. A CNA assigned to Resident #70 stated she passed breakfast and lunch trays, went to the kitchen to ask about alternatives only after residents refused the tray, and did not inform residents of alternative lunch or dinner options in advance because she did not know them until she asked dietary staff. The DON stated menus were posted near the dining room and on meal carts so staff could inform residents of alternative meals, and that her expectation was for CNAs to inform residents of meal options before trays were served. Resident #70's record showed an admission date of 07/18/2022, diagnoses including hypertensive heart disease without heart failure and hyperlipidemia, and an MDS ARD of 10/20/2025 with a BIMS score of 15, indicating he was cognitively intact.
Infection Control Lapse During PEG Tube Medication Administration
Penalty
Summary
Infection prevention and control guidelines were not followed during medication administration for Resident #8, who was receiving medications via a percutaneous endoscopic gastrostomy tube. During observation, the LPN removed the stopcock plunger from the feeding tube syringe and placed it on top of the plastic container it came in. While medication was being administered, the plunger slid off the container onto the bare bedside table, which had not been disinfected before medication preparation. When the resident’s feeding tube became clogged, the LPN used the same stopcock plunger to push the medication through the tube. The plunger was not disinfected after it contacted the bedside table and was placed directly back into the syringe for use in administering medication into the resident’s feeding tube. During interview, the LPN confirmed the plunger had been resting on the bedside table and stated that proper practice would have required disinfecting the bedside table before medication administration or discarding the contaminated syringe and stopcock and obtaining a new one. The DON also stated the bedside table should have been disinfected or a clean barrier used, and that once the plunger contacted the table, a new syringe should have been obtained or the equipment disinfected before use. Resident #8’s record showed an admission date of 08/15/2023, diagnoses including peritoneal abscess, and an MDS BIMS score of 11 indicating moderate cognitive impairment.
Failure to Provide Bed-Hold Notice and Discharge Communication
Penalty
Summary
The facility failed to provide a required bed-hold notice to a resident and their representative when the resident went out on therapeutic leave, as required for Medicaid beneficiaries. The facility did not have a policy for issuing bed-hold notifications for therapeutic leave, and staff interviews confirmed that such notices were only given when a resident was admitted to a hospital for more than 24 hours, not for therapeutic leave with family. The Executive Director, Business Office Manager, and other staff acknowledged that bed-hold notifications were not provided in these circumstances, and the Executive Director later recognized this as an oversight. The resident involved had a history of schizophrenia and wandering, with a severely impaired cognitive status as indicated by a BIMS score of 03. The resident frequently went on therapeutic leave with family, as documented in progress notes and facility records. On the date in question, the resident left with family for therapeutic leave and did not return. The family and resident representative were not informed of a discharge at the time of departure, nor were they provided with information about bed-hold policies, appeal rights, or the resident's ability to return to the facility. Interviews with the resident's representative and family revealed confusion and lack of communication regarding the resident's discharge status, medication supply, and the process for returning to the facility. The representative reported not understanding the appeal process and not receiving timely or adequate notification about the resident's discharge or bed-hold rights. Additionally, the facility did not remove the resident's wander guard upon discharge, and there was no follow-up from the social worker regarding the resident's care after leaving the facility.
Failure to Follow Care Plan for Dependent Resident During Perineal Care
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident who was observed for activities of daily living (ADL) care, specifically during perineal care. The resident's care plan, initiated on 10/2/24, indicated that the resident was incontinent of bladder and bowel and required incontinent checks and care every two hours and as needed, with two-person assistance due to total dependence. However, during an observation on 9/16/25, a CNA provided perineal care to the resident without the required two-person assistance as specified in the care plan. Interviews with the CNA, Executive Director, and Director of Nursing confirmed that the care plan was not followed during the provision of care. The CNA acknowledged not using two-person assistance, and both the Executive Director and Director of Nursing stated that the expectation is for CNAs to follow the care plan and provide proper care. The resident involved had significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview, indicating a high level of dependency and vulnerability.
Failure to Provide Proper Perineal Care and Unauthorized Handling of Feeding Pump
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide perineal care according to the facility's policy and accepted standards for a resident with significant neurological impairments, including hemiplegia, hemiparesis, dysphasia, and aphasia. During the observed care, the CNA used wipes to clean the resident's groin area but did not separate the labia or clean each side and the center thoroughly, nor did he clean the rectal area. The CNA also placed the resident's feeding pump on hold, an action that facility policy reserves for nurses only. The CNA acknowledged not following proper procedure and attributed the lapse to nervousness. Interviews with facility staff, including the RN Unit Manager, Executive Director, and Director of Nursing, confirmed that the CNA did not perform perineal care correctly and was not authorized to operate the feeding pump. The facility's policy requires thorough cleaning of the entire perineal area and mandates that only nurses handle feeding pumps. The resident involved was unable to participate in a mental status interview, as indicated by a BIMS score of 00, and had been admitted with multiple neurological diagnoses.
Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to provide perineal care in accordance with infection prevention and control protocols for one of two residents observed. During the observation, a CNA gathered supplies and entered the resident's room, which was under Enhanced Barrier Precautions (EBP), without donning a gown as required. The CNA placed supplies directly on the table without a barrier, did not perform hand hygiene before, during, or after care, and did not change gloves during the procedure. The CNA also failed to separate the labia to clean each side and the center individually, did not clean the rectal area, and placed soiled wipes and briefs on the bed instead of in a designated bag. After completing care, the CNA removed gloves and exited the room without washing or sanitizing hands. Interviews with facility staff, including the CNA, RN Unit Manager, Executive Director, DON, and Infection Preventionist, confirmed that the CNA did not follow established protocols for EBP, hand hygiene, and perineal care. Staff acknowledged that the CNA's actions constituted cross-contamination and did not meet the facility's expectations for infection control. The CNA admitted to not wearing a gown, not washing hands, and not following proper perineal care procedures, attributing the lapse to nervousness and oversight. The resident involved had a history of significant medical conditions, including hemiplegia, hemiparesis, dysphasia, and aphasia following cerebrovascular disease, and was unable to complete a mental status interview. Facility records and policy reviews indicated that staff were trained and expected to follow EBP and hand hygiene protocols, but these were not adhered to during the observed incident.
Failure to Prevent Elopement of High-Risk Resident Due to Inadequate Supervision and Environmental Controls
Penalty
Summary
The facility failed to provide adequate supervision to a resident identified as an elopement and wandering risk, resulting in the resident exiting the facility unsupervised. The resident, who had a diagnosis of Schizophrenia and severe cognitive impairment as indicated by a BIMS score of 4, was last seen in the dining room by staff. Despite being equipped with a wander guard bracelet, the resident was able to leave the facility through a kitchen door that was not equipped with a wander guard alert system, unlike other facility exits. The door had a keypad lock, but it was accessible from the dining area and not properly secured to prevent resident exit. Staff did not immediately notice the resident's absence. The resident's walker was left in the dining room, and staff initially assumed the resident had returned to his room. It was only after a phone call from the resident's family and subsequent checks that staff realized the resident was missing. A facility-wide elopement alert was then announced, and staff began searching the premises and surrounding area. The resident was located approximately one mile from the facility, having crossed a busy four-lane highway, and was returned after being unsupervised for about two hours. Interviews with staff and family confirmed that the resident had a history of exit-seeking behavior and had previously expressed a desire to go home. Staff had observed the resident attempting to open exit doors on multiple occasions. The facility's policy required staff to report any resident attempting to leave or suspected of being missing, but in this instance, the resident was able to leave undetected due to the lack of a wander guard system on the kitchen door and insufficient supervision in the dining area.
Removal Plan
- RN #2 performed a head-to-toe assessment with the resident's daughter, Executive Director, and DON present. There were no visible physical injuries.
- A 100% audit of all Wander/Elopement Risk residents were assessed for placement and proper functioning with no adverse findings.
- All the facility's entrance and exit door's alarm systems were checked. All the alarms were functioning properly.
- Resident #1 checked for wander guard placement and properly working. His wander guard was intact and working properly.
- Head-to-toe assessment of Resident #1 completed by the Unit B Manager and DON. There were no negative findings.
- Resident #1 was interviewed by the Unit B Manager. No negative statements were made by the resident.
- Upon Resident #1's return he was placed on 1:1 location monitoring x (times) 72 hours then tapered down to every 15 minutes then every 30 minutes then every hour. The Unit Manager, DON, and Social Services will determine when the resident may be removed from 1:1. The resident was placed on 24 hours charting for the nurses to document and notifying the MD/NP of any significant changes in the resident physical or mental status.
- A keypad lock was placed on the kitchen entrance door in the dining room by the Housekeeping Supervisor. The Housekeeping Supervisor replaced the old door handle on the kitchen door next to Unit-B with a keypad. The code will be given to dietary workers and key staff.
- The Maintenance Supervisor contacted Systronic Alarms Systems on installing a wander guard alarm on the kitchen door leading to the loading dock. A representative from the company will be at the facility.
- Resident #1 was moved closer to the nurses station. He moved from B 118P to B 108P. The Elopement Wander guard book reviewed. The Elopement Book was correct. A 100% check of the Wander/Elopement Risk were assessed for placement and proper functioning.
- The Dietary Workers on shift during the time of the incident received 1:1 Educational In-Services on Exit Doors in the kitchen and written corrective counseling by the Executive Director.
- Educational In-services for the facility's staff conducted by the Staff Development/Executive Director were initiated and included: a) Exit Doors in the kitchen b) Resident's Rights c) Abuse Prevention and Reporting d) Abuse and Neglect e) Residents expression to go home f) Missing Resident/Elopement.
- The Unit B Manager re-schedule Resident #1's eye appointment. Resident's appointment is scheduled as a follow-up consult visit to rule out retinal vein occlusion with macula edema to the left eye.
- Resident #1's care plan and pain assessment up-dated. Social Services Director preformed a Trauma Screen.
- The facility prepared a formal letter to mail to each resident's representative. The letter requests that during visits, if the resident expresses wish to leave the facility or return home, the family should inform nurse management, the Executive Director, or Social Services.
- We had a Family Meeting with Resident #1's daughter. The daughter did not express any concerns about her father's care or safety with the facility.
- Nursing will review 24 hour progress notes on the following week day and/or Monday following the weekend for any resident's voicing wanting to go home or exhibits exit seeking behavior to ensure proper intervention are in place.
- A QAPI was implemented with an emergency QA meeting reviewing Resident #1's incident.
Inadequate Staffing Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by delayed responses to call lights and untimely incontinent care for three residents. Resident #48 experienced frequent delays in receiving care, with observations noting a strong odor of urine and saturated briefs. The resident reported that CNAs often turned off call lights without returning promptly, and the facility was observed to have only one CNA attending to 12 residents on the hall. The Director of Nurses and an LPN acknowledged the delay, attributing it to staffing shortages. Resident #87 also reported long wait times for call light responses, with staff often failing to return after initially acknowledging the call. This resident, who was cognitively intact, expressed frustration with the consistent delays across all shifts. Similarly, Resident #23 reported long wait times, particularly during the night shift, and a CNA confirmed that the facility was often short-staffed, with nurses not assisting CNAs. The Director of Nurses and the Administrator both stated expectations for timely care, but the observations and interviews indicated a systemic issue with staffing levels and response times.
Failure to Honor Resident Choice for Bedrails
Penalty
Summary
The facility failed to honor the rights of two residents, who expressed a desire to have bedrails for assistance with turning and bed mobility. Resident #54, who was cognitively intact, reported wanting bedrails to maintain some independence, but was informed by staff that state regulations prohibited their use. Similarly, Resident #78, who had moderate cognitive impairment and required assistance with mobility, expressed frustration over the removal of his bedrails, which he used for turning assistance. Both residents were told that the state regulations were the reason for the removal of bedrails, and their requests for bedrails were not assessed or honored. The facility's management confirmed that all bedrails were removed from residents' beds, citing state regulations and the facility's restraint-free policy as reasons. However, it was acknowledged that the removal of bedrails without assessing individual resident needs or choices was a violation of residents' rights. The facility did not have a specific bedrail policy in place, only a restraint policy, which contributed to the oversight in addressing the residents' requests and needs for bedrails.
Failure to Follow Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper oxygen therapy for a resident, as evidenced by not following physician orders or facility policies. During an observation, it was noted that a resident was receiving oxygen at 2 liters per nasal cannula without a date on the tubing and without a humidifier attached. The resident had a history of shortness of breath and acute respiratory failure with hypoxia, and had been hospitalized twice due to shortness of breath. The facility's policy required oxygen tubing to be changed and dated weekly, and a humidifier to be used if needed to prevent dryness in the nasal area. Interviews with staff, including an LPN and the Director of Nurses, confirmed the oversight. The LPN acknowledged the absence of a date on the tubing and the lack of a humidifier, stating that these omissions could lead to infection issues. The Director of Nurses also confirmed that the resident should have had a humidifier attached to the oxygen delivery system to maintain moisture in the nasal area and that the tubing should be changed weekly to prevent bacterial growth. The physician's orders for the resident specified continuous oxygen at 2 L/min and weekly tubing changes, which were not adhered to.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care for a resident, leading to a deficiency in care. The resident, who has a history of cerebral infarction, type 2 diabetes mellitus, and hypertensive heart disease, was observed to have a moderate cognitive impairment and required substantial assistance with toileting and personal hygiene. On multiple occasions, the resident's call light was activated, indicating a need for assistance, but staff either turned off the light without providing care or delayed in responding. The resident expressed frustration over the long wait times for care, which occurred across different shifts. Observations revealed that the resident's incontinent brief was often soiled and saturated with urine, and the resident's wheelchair was also wet due to leakage. Interviews with staff, including CNAs and the DON, confirmed that there was only one CNA available for 12 residents on the hall, which contributed to the delay in care. Despite the facility's policy and the expectations set by the DON and the Administrator for timely care, the resident continued to experience delays in receiving necessary assistance, resulting in a strong odor of urine in the resident's room and hallway.
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Illustrative
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Illustrative
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pleasant Hills Community Living Center | 0.4 mi | ★★★★★ | 2 | 1 |
| Woodlands Rehabilitation And Healthcare Center | 4.3 mi | ★★★★★ | 12 | 0 |
| Methodist Sepcialty Care Center | 4.5 mi | ★★★★★ | 1 | 0 |
| Willow Creek Retirement Center | 4.9 mi | ★★★★★ | 9 | 0 |
| Compere Nh Inc | 5 mi | ★★★★★ | 0 | 0 |
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