Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Tsali Care Center during CMS and state inspections, most recent first.
Administrator and DON failed to ensure EMR code status was correctly ordered and verified, and failed to oversee audits for accuracy. The audit tool used by Medical Records and Admissions staff only checked for Advance Directives, requested code status on the clinical consent form, and MOST forms, but did not verify that DNR orders were entered or that code status was updated correctly in the EMR for affected residents.
The facility’s QAPI committee failed to maintain an effective quality oversight process. The revised QAPI policy did not address data collection and analysis, adverse event monitoring, or feedback, and the Administrator confirmed those elements were omitted. The facility also did not complete any PIPs during the year, and although concerns were discussed in QAPI and Monday meetings, there was no formal PIP or documentation of data tracking and analysis. For repeated deficiencies cited in prior surveys, staff received education, but there was no monitoring or auditing of the repeat issues and no policy changes for the repeated F 578 concern.
Failure to Document Informed Consent for Prescribed Medications: The facility did not document that four residents were informed in advance of the risks and benefits of prescribed meds, treatment alternatives, or their right to choose preferred options. The affected residents included one with Parkinsonism, DM2, HF, and moderate cognitive impairment receiving multiple meds including quetiapine PRN, insulin, and cardiac meds; one with HF, depression, DM2, anxiety, and psychosis receiving fluoxetine, hydroxyzine, olanzapine, trazodone, and Lantus; one cognitively intact resident with acute respiratory failure, psychosis, manic episode, and DM2 receiving quetiapine, Ozempic, Lantus, Eliquis, and other meds; and one cognitively intact resident with schizoaffective disorder, PTSD, depression, bipolar disorder, and DM2 receiving gabapentin, Ozempic, risperidone, and duloxetine. The DON confirmed the missing documentation.
A facility failed to assess residents for safe self-administration and bedside storage of medications/biologicals, while medicated cough drops, Zinc Oxide ointment, Anesep wound cleanser, and Betadine scrub were left unsecured at the bedside for multiple residents. One resident with CHF and dysphagia was self-administering cough drops without an assessment or MD order, while other residents with diabetes, dementia, impaired skin integrity, and ESRD had open medication or wound-care products left in their rooms without the required IDT review or physician authorization.
Advance directives and code status were not properly documented for multiple residents. Several residents had forms indicating they had executed advance directives or would provide copies, but no copies were available in the chart, and one resident's record showed conflicting code status documentation: MOST, clinical agreement, and a physician order indicated DNR, while the monthly order sheet and EMR banner showed Full Code. The resident stated she did not want CPR, and staff confirmed the charted Full Code status did not match her wishes.
A facility failed to protect resident privacy and confidentiality when PHI was left uncovered and visible on a diabetic treatment cart in a day room, including vital signs and appointment details for multiple residents. The facility also failed to provide privacy when a CNA took an oral temperature for a resident with dementia in a common area while other residents were present, despite the DON stating privacy was expected during care.
Failure to Timely Resolve Resident Grievance About Ants in Room: A cognitively intact resident with AFib, cerebrovascular disease, and asthma reported ants in her bed and mattress, and staff confirmed ants were present in the room and on the mattress. Staff cleaned the room and linens, but the resident said the mattress was not replaced right away and she slept on it for about a week while the ants continued. The resident’s daughter later contacted administration, and the facility policy required grievances to be addressed immediately or within seven business days if not resolved right away.
Unsecured medication and treatment carts left unattended. An LPN left a diabetic treatment cart unlocked with lancets, cleansing wipes, and a pressurized spray inside, and another LPN left a medication cart unlocked in a day room where residents and staff were present. In a separate observation, an LPN left a medication cart unlocked during a med pass, and a Lidocaine 5% patch was found unsecured on top of a medication cart in the nurse station. The DON confirmed the medication should have been locked inside the cart.
Staff failed to follow infection control practices during laundry, catheter care, and dining. A laundry aide wore PPE while moving through hallways and common areas after sorting dirty laundry, a resident’s catheter bag and tubing were left on the floor with urine visible, and CNAs did not consistently perform hand hygiene while serving and assisting multiple residents, handled meal plates by the inner rim, and touched a garbage lid with an ungloved hand before continuing resident care.
Failure to Document and Offer Flu and Pneumonia Immunizations: The facility did not ensure that residents were educated and given the opportunity to accept or decline influenza and pneumonia vaccines. Records for several residents showed missing pneumonia documentation, and one resident’s consent form documented only COVID-19 and influenza consent. The ICP stated the immunization program had been inconsistent and that declination documentation was not available for multiple residents.
Two residents were not provided with dignified care, as one was brought out to visit family with uncombed hair, twisted clothing, and improperly worn socks, while another was left with visible chin hairs after a shower, despite facility policy requiring grooming and shaving to be offered. Staff failed to ensure proper grooming and respectful treatment, resulting in a deficiency related to residents' rights to dignity and self-determination.
A resident lost the ability to perform ADLs without a documented medical reason. The facility did not ensure that the decline in ADL performance was clinically unavoidable, as required by regulations.
Failure to Provide Bathroom Access Accommodation: A resident with obesity, acute respiratory failure, psychosis, mania, and DM2 was cognitively intact, dependent for ADLs, and required a one-person assist for transfers. He reported injuring a finger while trying to maneuver his WC through a tight bathroom doorway to reach the sink, and said a smaller WC had been discussed but not provided. Therapy staff were unaware of the injury and confirmed no WC had been ordered; the DON and Administrator were later notified that the resident could not enter or exit the bathroom, but no additional accommodations had been offered.
PRN antipsychotic order lacked stop date and diagnosis. A resident with Parkinsonism, DM2, insomnia, BPH, and HF had a PRN quetiapine order for agitation that started without an end date, and the record did not show a supporting psychiatric or mood disorder diagnosis. Nursing notes and observations showed the resident was often sleepy, restless, or agitated, and staff documented mixed effectiveness of the medication. An RN stated the PRN antipsychotic was ordered after the resident reportedly became physically aggressive, and she knew PRN antipsychotics required a stop date and diagnosis.
Failure to document a skin tear on the comprehensive MDS for a resident with PVD, DM2, vascular dementia, and encephalopathy. During observation, the resident had a visible open, moist skin tear on the lower left leg/shin, but the MDS listed skin as intact. The MDS coordinator and RN wound care nurse were unaware of the injury, and the record contained no physician or nursing documentation acknowledging or treating the skin tear.
A resident with acute respiratory failure, obesity, and type 2 DM had prior documentation of psychosis and a manic episode, and was prescribed Seroquel. Staff, including the SW and MDS coordinator, verified the resident was not referred for PASRR Level II after the new qualifying MH diagnosis was identified, despite the facility policy requiring an updated PASRR screen when SMI, IDD, or RC is discovered after the initial Level I.
A resident with diagnoses including delusional disorders, PVD, diabetes, and a BKA had a PASRR Level I that stated no further screening was needed. After that screening, the medical record documented delusional parasitosis, and the MDS later listed delusional disorders, but no PASRR Level II was completed. The SW confirmed the new qualifying mental health diagnosis was received after the initial PASRR and before admission, requiring an updated Level I and Level II.
The facility failed to develop and/or implement comprehensive, person-centered care plans for three residents. One resident with Parkinsonism and cognitive impairment had behavioral care needs, but a CNA interacted in an argumentative manner and did not follow the care plan during an observed encounter. Another resident with PTSD had no trauma-informed interventions in the care plan despite a history of sexual trauma and reported triggers with unfamiliar men. A third resident with hemiplegia/hemiparesis had no restorative-focused goals or interventions for ROM or bed mobility despite needing substantial assistance with ADLs and transfers.
Failure to Arrange Ordered Consults and Evaluate Possible Insect Bites: A resident with persistent pruritus had a physician order for a dermatology consult, but the consult was not arranged and no specialist visit was documented. Another cognitively intact resident reported ants in her bed and bites on her back and arm; nursing notes described papules and itching, but the record lacked a documented physician assessment of the suspected insect bites. A third resident with dysphagia and diet complaints had an RD request for SLP evaluation, but no SLP assessment was documented.
Missed Scheduled Showers for Resident Preferring Female CNA: The facility failed to ensure a cognitively intact resident with AFib, cerebrovascular disease, and asthma received showers at least twice weekly as scheduled. The resident required partial/moderate assistance with bathing and reported difficulty getting showers when the female CNA was unavailable or called in sick, since she preferred a female caregiver. Charting showed several bathing intervals of 7 days, and the DON stated showers were scheduled for twice weekly with a female available for female residents.
A resident with encephalopathy, DM2, vascular dementia, PVD, and glaucoma had fragile lower-leg skin with swelling, dry skin, scabs, and an open moist skin tear on the left shin after showering. Staff did not document the fragile skin or skin tear in wound assessments, and the care plan and progress notes lacked interventions to prevent friction-related injury during personal care; the RN was unaware of the open area and the DON acknowledged the skin fragility but did not provide a treatment or prevention plan.
A resident with hemiplegia/hemiparesis, impaired cognition, and dependence for ADLs had worsening weakness and limited bed mobility, but no PT, OT, or restorative nursing orders were in place to maintain or improve ROM. The resident reported not receiving exercises or bed mobility training, the care plan lacked restorative interventions, and the resident was not enrolled in the restorative nursing program despite staff acknowledging she could benefit from it.
The facility failed to consistently implement fall prevention measures for two residents with repeated falls. One resident with severe cognitive impairment and walker use had his call light and walker out of reach, no fall mat, and multiple recent falls; another resident with gait impairment and hallucinations had repeated unwitnessed falls, with the bed not in the lowest position and no fall mat or reminder signs present. The facility also failed to assess and document safe smokeless tobacco use for a resident who kept chewing tobacco at her bedside, and no tobacco safety evaluation was found in the record.
A resident with ESRD receiving hemodialysis three times weekly had incomplete dialysis coordination and documentation. Pre- and post-dialysis weights, VS, and vascular assessments were not documented on several occasions, dialysis hand-off forms were incomplete or missing, and nursing notes did not explain missed dialysis treatments or show communication with the dialysis center or provider. An LPN and the DON described expected pre/post dialysis assessments, access checks, weights, and documentation of missed treatments.
A resident admitted with PTSD, schizoaffective disorder, depression, and diabetes did not have a documented trauma-focused or culturally competent assessment in the medical record. The resident said she was unaware of her behavioral health diagnosis and wanted someone to talk to about feeling sad, while the SW acknowledged knowing the resident had a history of sexual trauma and was triggered by unfamiliar men, including a new male CNA, but had not completed a trauma assessment or documented this information.
Failure to coordinate dental services for two residents. One resident with impaired cognition had no upper teeth and broken, darkly colored lower teeth with likely caries, but staff did not know how dental appointments were scheduled and the DON confirmed the resident had not been seen by a dentist. Another resident reported losing her upper dentures and needing replacement, but after an unsuccessful trip to a dental office because she was in a wheelchair, staff did not reschedule with the provider that usually sees wheelchair patients.
A resident with a recent lower limb amputation and diabetes was being transferred from a facility van when, due to an unsecured wheelchair cushion, the individual slid out of the chair and landed on the surgical stump. The cushion, meant to prevent skin breakdown, was not properly buckled, which allowed it to slide out with the resident. The incident resulted in significant pain and required ambulance transport and hospital treatment for wound dehiscence. Staff interviews and documentation confirmed the cushion was not secured at the time of the incident.
A resident was denied visitation with his wife after she was suspected of carrying a parasite, despite no evidence of infestation being found by staff or pest control. The wife was banned from the building and property, and the resident was not allowed to meet her outside or receive food she brought. Staff interviews confirmed the ban was enforced based on unsubstantiated concerns, and the facility's own policies regarding visitation rights were not followed.
A resident with a traumatic amputation and diabetes was given a 48-hour discharge notice, followed by a 30-day notice, both lacking required information about the appeals process. The facility's actions did not comply with policy or regulatory requirements for discharge notices.
A resident with a traumatic amputation and Type 1 Diabetes Mellitus, along with the resident's representative, did not receive required notifications of care plan meetings. The Social Service Director relied on an automated system that failed to send notifications, and neither the resident nor the representative received notice or copies of care plans prior to a recent meeting. Facility policy required such notifications and documentation, but these steps were not followed.
A resident with multiple chronic conditions and existing pressure ulcers did not receive daily wound care and dressing changes as ordered by a physician. Despite updated orders from a consulting podiatrist for daily dressing changes, nursing staff continued to provide care only three times a week for about one week. The oversight was discovered after the resident's wounds worsened and concerns were raised by the resident's spouse and outside providers.
A resident with multiple chronic conditions and a known allergy to contrast dye did not receive three ordered doses of prednisone prior to an angiogram because the medication order was not transcribed onto the MAR. The omission was discovered after the resident’s wife inquired, and staff confirmed the medication had not been administered as required by facility policy.
A nurse failed to properly disinfect a blood glucose monitor after use on a resident with diabetes, wiping the device for only five seconds instead of the required one-minute wet time as specified by facility policy and the disinfectant instructions. The device was then returned to the insulin cart without adequate disinfection.
The facility failed to serve hot meals to residents eating breakfast in their rooms, affecting all 55 residents. Complaints were documented over several months, with residents expressing dissatisfaction with cold food. A test tray evaluation confirmed that breakfast items were served at temperatures below what is considered hot. The Administrator expected staff to assist in serving hot food, but this was not achieved.
A facility failed to ensure coordinated care and communication for a resident requiring dialysis. The resident was taken to a dialysis center without a scheduled appointment, resulting in no available chair. There was a lack of communication regarding the resident's condition, weight monitoring, and nutritional status. The facility did not document pre and post dialysis weights, and there was no assessment by the Registered Dietitian. Staff interviews revealed a lack of communication with the dialysis center, and the facility's policy for coordination and communication was not followed.
A resident with multiple diagnoses, including neuropathy, did not receive prescribed pain medications, leading to unmanaged pain rated as eight out of ten. Despite the resident's complaints, staff failed to assess and address the pain adequately, with incomplete pain assessments and lack of communication. The facility's policy on pain management documentation and reporting was not followed.
The facility failed to issue Notice of Medicare Non-Coverage (NOMNC) forms to 12 residents who no longer qualified for Medicare Part A. The [NAME] Specialist, unaware of her responsibility, did not send any NOMNC notices. The Administrator confirmed the oversight, acknowledging that the facility's policy requiring NOMNC delivery at least two days before service termination was not followed.
The facility's assessment failed to involve direct care staff or residents, lacked a detailed staffing plan for each unit and shift, and did not address resources for grandfathered smoking residents. Additionally, staff competencies and training requirements were not clearly documented.
The facility failed to maintain a functioning wash temperature gauge on the dish machine, affecting all residents. Observations showed the gauge consistently registered below the required 150 F, and staff had not used temperature strips for accurate readings. Maintenance was unaware of the issue until the survey, despite previous repairs in January. The facility's policy required daily checks, which were not effectively conducted.
The facility did not address resident grievances about cold food, as documented in Resident Council Meeting Minutes. Despite regular complaints from residents about late and cold food trays, particularly for meals delivered to rooms, no effective follow-up or resolution was communicated. The Activity Director forwarded these concerns to the Administrator and Dietary Manager, but residents reported no changes or feedback, leading to ongoing dissatisfaction.
The facility failed to ensure that residents were given the opportunity to formulate advance directives. A resident with a heart attack diagnosis had no Living Will on file despite indicating its formulation. Two residents with severe cognitive impairment had no documentation of advance directives or opportunities to formulate them. Another resident, who was cognitively intact, also lacked advance directives. Staff interviews revealed inadequate follow-up and oversight in the admission process regarding advance directives.
A facility reported a medication error rate of 16.13%, exceeding the acceptable 5% threshold. Errors included improper administration of insulin by an LPN and RN, who failed to prime insulin pens, and incorrect application of eye ointment and drops by a medication aide. The DON confirmed these errors, highlighting deviations from prescribed methods.
A resident with severe cognitive impairment and infections was left undressed in bed and during transfer to a shower chair, wearing only a pull-up diaper. The resident expressed a desire to be dressed, but staff did not assist, leaving him undressed after an incontinence episode before breakfast. The DON confirmed that residents should be dressed after such episodes, highlighting a failure to uphold the resident's right to dignity.
A resident did not receive a quarterly financial statement as required by facility policy. Despite being cognitively intact and his own responsible party, the resident confirmed not receiving the statement, and facility records lacked documentation of its delivery. The [NAME] Specialist was unable to verify the delivery, and the Administrator expected compliance with the policy, but no evidence was found in the records.
A facility failed to provide a safe and clean environment for a resident, as a worn and soiled mattress and an unclean slipper pan were found in the resident's room. The DON acknowledged that the CNAs should have reported the mattress's condition and ensured its replacement, and that the slipper pan should have been discarded and replaced.
A facility failed to notify a resident and their representative of the reasons for hospital transfers on two occasions. The resident, with severe cognitive impairment, was transferred due to a suspected stroke and a complicated UTI. Required documentation was not maintained, and interviews with staff confirmed the absence of necessary transfer notices in the resident's medical record.
A resident with severe cognitive impairment was transferred to the hospital due to a suspected stroke, but the facility failed to provide written notification of its bed hold policy. The facility's procedure mandates that a copy of the bed hold policy be sent with the resident, but this was not done, as confirmed by the Administrator.
A facility failed to submit a referral for a Level 2 PASSAR evaluation for a resident with an expired Level 2 PASSAR. The resident, admitted with major depressive disorder, anxiety disorder, PTSD, and type 2 diabetes, was receiving orthopedic aftercare. The Social Worker confirmed the oversight, unaware that Level 2 approvals could be short-term and expire.
The facility failed to update care plans for two residents after falls and changes in condition. One resident with severe cognitive impairment and a history of falls did not have their care plan revised after multiple falls. Another resident, admitted with acute pyelonephritis and MRSA, experienced a fall and a decline in function, yet their care plan did not reflect the need for two-person assistance during transfers. The facility's policy on safe lifting was not followed, contributing to the deficiencies.
A resident with severe cognitive impairment and recent fall history reported right arm pain and immobility, which CNAs failed to report to the LPN. The OT noticed the issue and sought further evaluation. Training records showed incomplete documentation for one CNA, indicating a deficiency in communication and training protocols.
Failure to Verify EMR Code Status Orders and Audit Accuracy
Penalty
Summary
The facility's Administrator and DON failed to identify that there was no physician order in the EMR to correctly identify all residents' code status, and failed to provide oversight of staff audits of residents' EMR code status to ensure the audits were accurate. The deficiency was identified through document review, interview, record review, and policy review, and was cited as having the potential to affect 72 of 72 residents in the facility. During interviews, the Administrator could not initially provide the audit tools used to monitor code status and later stated the tool had been completed by Medical Records and Admissions staff. Review of the audit tool showed that new admissions were checked for Advance Directives and requested code status on the clinical consent form, but it did not include verification that orders were received for DNR wishes for one resident or that code status was updated and correct in the EMR for two residents. The Administrator later stated she had not previously reviewed the audit tool and had not audited the audits for accuracy, and the Medical Records staff member stated she only checked for Advance Directives, requested code status on the clinical consent form, and MOST forms, and did not verify that code status was ordered or included on the profile screen.
QAPI Committee Failed to Maintain Effective Oversight of Repeated Deficiencies
Penalty
Summary
The facility’s QAPI committee failed to maintain an effective ongoing quality assessment and assurance process related to repeated deficient practices cited during the recertification and complaint surveys. The report states that the committee did not ensure its policy addressed data collection and analysis, data and adverse event monitoring, and feedback. During interview, the Administrator confirmed that these elements were missing from the revised QAPI policy because the information had been left out. The facility also did not conduct any PIPs during the year, and the management team only discussed concerns during QAPI meetings and cross-functional Monday meetings without starting a formal PIP or documenting tracking and analysis of data for one. In addition, for repeated deficiencies cited in prior surveys, staff received education, but there was no monitoring or auditing of the repeat deficiencies and no policy changes in place for the repeated F 578 issue. The report also notes that the committee’s policy required it to help departments develop and implement plans of correction and monitoring approaches, track active plans of correction, and advise administration of needed policy or procedural changes, but these processes were not maintained for the cited deficiencies.
Failure to Document Informed Consent for Prescribed Medications
Penalty
Summary
The facility failed to ensure that residents were informed in advance of the risks and benefits of prescribed medications, the treatment alternatives, and the option to choose the preferred treatment for four of five sampled residents. Resident #7 was admitted with diagnoses including Parkinsonism, type 2 diabetes, insomnia, benign prostatic hyperplasia, and heart failure, and had moderate cognitive impairment. Physician orders showed the resident was receiving multiple medications, including quetiapine PRN for agitation, empagliflozin, paroxetine, insulin, sitagliptin, acetaminophen, carbidopa-levodopa, MiraLAX, tamsulosin, metoprolol, losartan, isosorbide mononitrate, furosemide, and atorvastatin. The medical record contained no documentation that the resident or the resident’s representative had been provided the required information or had consented to the medications. Resident #1 had diagnoses including heart failure, depression, type 2 diabetes, anxiety, and unspecified psychosis, and had mild cognitive impairment. Orders included fluoxetine, hydroxyzine, olanzapine, trazodone, propranolol PRN, and Lantus. Resident #4 was cognitively intact and had diagnoses including acute respiratory failure, unspecified psychosis, manic episode, and type 2 diabetes; orders included quetiapine, Ozempic, Lantus, Eliquis, hydrocodone-acetaminophen, NovoLog, gabapentin, and Jardiance. Resident #8 was cognitively intact and had diagnoses including schizoaffective disorder, bipolar type; PTSD; depression; bipolar disorder; and type 2 diabetes; orders included gabapentin, Ozempic, risperidone, and duloxetine. For Residents #1, #4, and #8, the record also lacked documentation that the resident or representative had been informed of the risks and benefits, treatment alternatives, or had consented to the prescribed medications. The DON confirmed the facility did not have this documentation for these residents.
Unsecured medications and biologicals left at bedside without required self-administration assessment
Penalty
Summary
The facility failed to assess residents for safe self-administration and storage of medications and biologicals, and several items were left unsecured at the bedside. Surveyors observed medicated cough drops, Zinc Oxide topical ointment, Anesep antimicrobial skin and wound cleanser, and Betadine Gluconate 4% Solution Antiseptic Surgical Scrub left at the bedside for four sampled residents. The facility’s Medication Self-Administration and Storage policy required an interdisciplinary team assessment and, when appropriate, a physician order before bedside medication storage or self-administration. Resident #17, who had diagnoses including type 2 diabetes mellitus, unspecified sequelae of cerebral infarction, and impaired skin integrity, had an open four-ounce tube of Zinc Oxide topical ointment on the bedside table during multiple observations. The medical record showed no interdisciplinary assessment of the resident’s ability to safely self-administer or store medications/biologicals at the bedside and no physician order for bedside self-administration or storage. RN #1 confirmed the ointment had been left in the room for CNA use during personal care, and RN #2 verified the resident had not been assessed for safe self-administration or storage. Resident #18, who had diagnoses including encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral disturbance, peripheral vascular disease, and glaucoma, had an open eight-ounce spray bottle of Anesep Antimicrobial Skin and Wound Cleanser on the bedside table during repeated observations. Resident #45, who had diagnoses including a non-pressure chronic ulcer of the left foot, viral intestinal infection, and end stage renal disease with hemodialysis, had an open and partially used bottle of Betadine Gluconate 4% Solution Antiseptic Surgical Scrub on the over-bed table, with no physician order for bedside self-administration or storage. Resident #21, who had congestive heart failure and dysphagia and was moderately cognitively impaired on the MDS, had three bags of cough drops on the bedside dresser and stated she had been self-administering them for weeks without assessment or notification to nursing staff; RN #2 and the DON confirmed no self-administration assessment or physician order had been completed.
Advance directives and code status were not properly documented in resident records
Penalty
Summary
The facility failed to ensure that advance directives were readily available in resident records or that appropriate advance directives were in place for six of 23 residents reviewed. Resident #16, who was admitted with diagnoses including type 2 diabetes mellitus and encephalopathy and was moderately cognitively impaired, had an Advance Directive and Code Status Acknowledgment of Receipt form indicating she had chosen to formulate and issue advance directives and that a guardianship letter existed, but no advance directives or guardianship letter were readily available in the medical record. Resident #17, who was cognitively intact and admitted with osteoarthritis and heart failure, also had a form indicating she had chosen to formulate and issue advance directives and would provide a copy to the facility, but no copy was available in the record. Resident #34, who was cognitively impaired and admitted with chronic obstructive pulmonary disease and degenerative disease of the nervous system, had a form indicating she had chosen to formulate and issue advance directives, but no copy was readily available in the medical record. Resident #51, who was cognitively impaired and admitted with dementia and hallucinations, had the same documentation on file, but no advance directive was available. Resident #66, who was cognitively intact and admitted with major depressive disorder and type 2 diabetes mellitus, also had a form stating she would provide a copy of her advance directives to the facility, but no copy was present in the record. Resident #27, who was cognitively intact and admitted with type 2 diabetes, major depressive disorder, anxiety disorder, and adjustment disorder with depressed mood, had documentation showing a MOST form and Clinical Care Agreement indicating DNR status, and a physician order dated [DATE] also reflected DNR. However, the monthly physician order sheet documented Full Code with a start date of [DATE], and the electronic medical record banner also showed Full Code. The record contained no documentation supporting Full Code status and no verbal or written order for Full Code. During interview, the resident stated she did not want CPR, and staff interviews confirmed nursing staff relied on the EMR banner for code status and that the documented Full Code status did not match the resident's wishes.
Privacy and PHI Left Exposed During Care
Penalty
Summary
The facility failed to keep resident personal and medical records private and confidential when PHI was left uncovered and visible on top of the [NAME] neighborhood’s diabetic treatment cart in the resident day room. During observation, a clipboard with a Vital Signs Chart dated July 28, 2025 was seen on the cart with blood pressure, temperature, pulse, respiration, and/or pulse oximetry results for Residents #15, 44, 58, and 71. An 8 x 11-inch sheet labeled "HAVE THEM READY BY THIS TIME!! WEEK OF 07/28/25-08/01/25" was also visible and contained the full names and clinical appointment details for Residents #1, 8, 10, 18, 23, 24, 32, 45, and 61. The documents were uncovered and highly visible to passersby and the public, and an LPN later returned to the day room and performed tasks on top of the uncovered clipboard and appointment sheet without covering or hiding the PHI. The facility also failed to provide privacy during a temperature check for Resident #51, who was admitted with diagnoses including dementia and abnormalities of gait and mobility. A CNA was observed taking an oral temperature for the resident in the common area while nine other residents were present. Staff interviews showed differing views about whether vital signs could be taken in common areas, but the DON confirmed that privacy was expected when care was provided, including vital sign monitoring. The facility policy titled Resident Rights for Senior Services stated that residents have the right to personal privacy and confidentiality of their personal and medical records.
Failure to Timely Resolve Resident Grievance About Ants in Room
Penalty
Summary
The facility failed to resolve a grievance timely for one resident who was cognitively intact and admitted with diagnoses including unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma. The resident reported waking up to ants all over her bed and stated the ants were in the mattress. She said staff tried to get the ants up, but she continued to see ants for seven days and slept on the same mattress during that time. She also stated the facility would not change the mattress when she first reported the problem. Staff interviews confirmed ants were found in the resident’s room and on the mattress. A housekeeper reported seeing a trail of ants across the room and stated the room was cleaned, linens were changed, and the mattress was later changed out. An LPN confirmed staff were aware of ants in the room and that the room was deep cleaned. A CNA stated ants were getting on the mattress and that staff wiped it down, but the ants returned. The resident’s daughter reported the resident called her about the ants and later said they were still in the bed and biting her; she also stated she contacted facility administration and was told to file a complaint. The facility policy required complaints to be addressed immediately or, if not resolved immediately, reviewed and addressed within seven business days, but the mattress was not replaced until after the daughter contacted the Administrator.
Unsecured medication and treatment carts left unattended
Penalty
Summary
Staff failed to keep medication and treatment carts secured when they were unattended. During multiple observations, a diabetic treatment cart was left unlocked and unattended, including a top drawer containing lancets, chemical cleansing wipes, and a pressurized can of Febreze spray. On one occasion, an LPN returned to the medication cart parked next to the treatment cart, completed a task, and left the treatment cart unlocked. When informed, another LPN stated the treatment cart should be kept locked. A medication cart in the day room was also observed unlocked, unattended, and accessible to residents and staff, with CNAs present in the area and the cart not within the line of sight of licensed clinical staff. The LPN later acknowledged she had not locked the cart and said she knew better than to step away without locking it. During another medication pass observation, an LPN again left the medication cart unlocked while unattended and then locked it only after noticing. In a separate observation, a Lidocaine 5% patch was left unsecured on top of a medication cart in the nurse station while the nurse was in and out of the area and absent when a restorative aide entered. The DON confirmed the medication should have been locked inside the cart, and the facility policy stated medication carts and supplies are to be locked or attended by authorized persons.
Infection Control Failures During Laundry, Catheter Care, and Dining
Penalty
Summary
The facility failed to ensure staff appropriately donned and doffed PPE when providing laundry services. During an observation and interview, a Laundry Aide was seen wearing an N95 face mask, face shield, gown, and gloves while walking around the Laurel Unit, touching the nurse station door, and later opening a porch door with a gloved hand while looking for staff. He stated he had put on the PPE before sorting dirty laundry and was still wearing the same PPE while moving through hallways and common areas. The DON confirmed PPE should be removed in an appropriate container inside the room before exiting and should not be worn in hallways or common areas. The facility policy stated gowns, gloves, and face masks should be discarded into the appropriate receptacle in the room where the task was performed. The facility also failed to keep an indwelling catheter bag and tubing off the floor for Resident #21, who was admitted with flaccid neuropathic bladder and a history of UTI. During two observations, the resident’s catheter bag was partially or fully in a privacy bag on the floor, and the catheter tubing was on the floor with clear yellow urine visible. An RN stated the bag and tubing should be off the floor to prevent infection, and the DON stated the expectation was that urinary catheter tubing and bags should not be on the floor. In addition, during a dining observation, CNA staff did not consistently perform hand hygiene while serving and assisting multiple residents, handled meal plates with thumbs on the inner edge of the plate rims, did not clean hands between contact with different residents, and one CNA lifted a garbage lid with an ungloved hand before continuing resident care. The DON stated staff were expected to wash or sanitize hands frequently, especially before, after, and between resident contact, when passing trays, and after touching multiple surfaces.
Failure to Document and Offer Flu and Pneumonia Immunizations
Penalty
Summary
The facility failed to ensure residents were educated and given the opportunity to accept or decline influenza and pneumonia immunizations in accordance with the CDC Adult Immunization Schedule for four residents reviewed for immunizations. Resident #21 had diagnoses including MRSA, UTI, heart failure, and DM type 2, and the record showed influenza vaccine administration on 10/11/23 but no documentation of a pneumonia vaccination. Resident #23 had diagnoses including COPD, DM type 2, and ESRD, and the record showed influenza vaccine administration on 10/11/04 and a pneumonia vaccination on 11/02/18. Resident #45 had diagnoses including cardiovascular disease, infection, MRSA, and hypertension, and the record showed no documentation of a pneumonia vaccination. Resident #71 had diagnoses including CAD and urinary retention, and the record showed a pneumonia vaccination on 12/13/19. Further review of the medical records for Residents #21, #23, and #71 showed no Vaccine Consent Form documenting that the residents were provided education, offered, and/or administered the appropriate vaccinations. For Resident #45, the Vaccine Consent Form dated 1/9/25 documented consent for COVID-19 and influenza vaccines, but there was no documentation for pneumonia vaccination. The Infection Control Preventionist stated that while she was on leave, the staff member responsible for immunizations had not been consistent with the facility's immunization program, that she could only locate two of the five residents' information and it was not complete, and that the facility did not have vaccination declination documentation for Residents #21, #23, #45, and #71. The facility policy stated that all residents would be offered influenza, pneumonia, and COVID-19 vaccinations unless medically contraindicated or already immunized, and that written consent or documented verbal consent should be obtained prior to administration.
Failure to Provide Dignified Care and Proper Grooming
Penalty
Summary
Two residents were not treated in a manner that promoted their dignity and quality of life. One resident, who was cognitively impaired and dependent on staff for activities of daily living, was observed by his representative to have been brought out of his room with uncombed hair, twisted clothing, and socks put on incorrectly. The representative also reported that the certified nurse aides assigned to assist the resident displayed unprofessional behavior, such as rolling their eyes and making dismissive comments during the transfer process. Documentation confirmed that a grievance was filed regarding this incident, and the facility's own records indicated that the resident was not properly groomed or dressed when brought out to visit with family. Another resident, who was cognitively intact and required staff assistance with bathing and grooming, was found to have visible, unshaven chin hairs of varying lengths after a documented shower. The resident stated that she was supposed to be shaved on shower days but was neither shaved nor asked if she wanted to be shaved during her most recent shower. A certified medication aide confirmed that residents should be offered shaving with each shower and acknowledged that the resident's appearance was not consistent with this expectation. Both incidents were in direct violation of the facility's policy, which requires that all residents be treated with respect and dignity, and that care be provided in a manner that maintains or enhances their quality of life. The failure to ensure proper grooming and respectful treatment during care activities led to a deficiency in upholding residents' rights to dignity and self-determination.
Failure to Prevent Unnecessary Loss of ADL Abilities
Penalty
Summary
Residents experienced a loss in their ability to perform activities of daily living (ADLs) without a documented medical reason. The facility failed to ensure that residents maintained their highest practicable level of functioning in ADLs, as required, unless a decline was clinically unavoidable due to a medical condition. This deficiency was identified through surveyor observation and review of resident records, which did not provide evidence of a medical justification for the decline in ADL performance.
Failure to Provide Bathroom Access Accommodation
Penalty
Summary
The facility failed to ensure Resident #4 was provided appropriate DME that allowed access to the bathroom. Resident #4 was admitted with diagnoses including obesity, acute respiratory failure, unspecified psychosis, manic episode, and type 2 diabetes. His quarterly MDS showed he was cognitively intact, dependent for ADLs, and required a one-person assist for transfers. During observation and interview, the resident stated he had smashed the pointer finger on his left hand a couple of months earlier while trying to self-propel his wheelchair through the bathroom threshold to reach the sink. He reported that his wheelchair could barely fit through the doorway and that it was a very tight fit, and he pointed out dark marks on the wall that he said were from his wheelchair wheels. He also stated he had asked for a band-aid and that PT had ordered a smaller wheelchair about three weeks earlier, but he had not heard anything further about it. During interview, the COTA verified that a wheelchair had not been ordered for the resident, that therapy services ran from 03/07/25 through 07/16/25, and that the resident was non-ambulatory due to hip pain. She stated she was unaware the resident had injured his finger and said that if the wheelchair did not fit through the door, a bedside commode should be provided to accommodate the resident's needs. The PTA stated she was unaware the resident injured his finger due to the tight fit of his wheelchair through the bathroom threshold. The Administrator, DON, and Administration staff #6 were later notified that the resident injured his finger when entering the bathroom with his wheelchair, and the Administrator was aware the resident was unable to enter and exit the bathroom, but no additional accommodations had been offered. The facility policy stated residents have the right to reasonable accommodation of their needs and preferences.
PRN antipsychotic order lacked stop date and supporting diagnosis
Penalty
Summary
The facility failed to ensure that an as-needed quetiapine fumarate order for one resident had a stop date and a supporting diagnosis for use. Resident #7 was admitted with diagnoses including Parkinsonism, type 2 diabetes, insomnia, benign prostatic hyperplasia, and heart failure. The admission MDS showed the resident was moderately cognitively impaired, had verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and rejected care during the look-back period, but did not have any psychiatric or mood disorder diagnoses. The MDS also showed recent use of antianxiety, antidepressant, and hypnotic medications. The physician’s orders included quetiapine fumarate 25 mg, 0.5 tablet by mouth as needed for agitation, with a start date of 07/29/25 and no end date written for the PRN antipsychotic order. Nursing documentation showed the medication was administered on multiple occasions, with one note stating the administration was ineffective and another noting no documentation of effectiveness. Additional notes described the resident as restless, uncomfortable, and receiving PRN melatonin and ibuprofen for insomnia and leg pain, while also being provided one-on-one supervision and fall mats. During observations, the resident was seen falling asleep while sitting in a recliner, yelling out for help while attempting to get up, and later sitting in the dayroom with two staff members while falling asleep in his wheelchair. Staff interviews indicated the resident’s medications were being adjusted to balance anxiety and behaviors without over-sedating him, and one RN stated the PRN antipsychotic was ordered after the resident reportedly put his hands around a CNA’s neck. The RN also stated she knew PRN antipsychotics required a 14-day stop date and a diagnosis for use, but the order in the record did not include an end date or documented supporting diagnosis.
Failure to Document Skin Tear on MDS
Penalty
Summary
Facility staff failed to identify and document a skin tear injury on the comprehensive MDS for one resident reviewed for skin integrity. The resident was admitted with diagnoses including peripheral vascular disease, type 2 diabetes mellitus, vascular dementia without behavior, and encephalopathy. The comprehensive MDS dated [DATE] indicated the resident’s skin was intact and did not note any skin tears, abrasions, or open wounds/injuries. During an observation and interview on 07/29/25 at 2:41 PM, the resident was sitting in a recliner with both legs elevated, and a two-centimeter reddened, open, moist skin tear was visible on the lower left leg/shin. The resident’s lower legs were also described as dry with dark pin-head size scabs. On 07/30/25 at 1:00 PM, the MDS Coordinator confirmed the assessment reflected intact skin and stated she was not aware of the skin tear. Review of the resident’s medical records, including progress notes, wound assessment, and physician notes, revealed no documented doctor or nurse treatment orders or acknowledgment of the injury. The RN wound care nurse confirmed weekly skin assessments were completed but was not aware of and did not document the skin tear.
Failure to Complete PASRR Level II After New Mental Health Diagnosis
Penalty
Summary
The facility failed to complete a PASRR Level II review when Resident #4 developed a new qualifying mental health diagnosis. Resident #4 was admitted with diagnoses including acute respiratory failure, obesity, and type 2 diabetes, and a quarterly MDS showed the resident was cognitively intact, dependent with ADLs, and required one-person assist for transfers. Review of prior MDS documentation showed diagnoses of unspecified psychosis not due to a substance or known physiological condition and manic episode, unspecified. During interviews, the resident denied behavioral health or mental health concerns and stated the mood was stable. The Social Worker stated she was unaware why the resident received the psychosis diagnosis and verified the resident was not referred for PASRR Level II. The MDS coordinator later verified the medical record supported a bipolar diagnosis and that the resident was prescribed Seroquel, and the Social Worker acknowledged the resident should have been referred for PASRR Level II. The facility policy stated that if a resident is discovered to have SMI, IDD, or RC after the Level I screen, the facility must call the PASRR contractor to perform an updated Level I.
PASRR Screening Not Updated for Resident With Mental Health Diagnosis
Penalty
Summary
The facility failed to ensure accurate completion of the PASRR Level I screening and failed to obtain a PASRR Level II referral for a resident with a mental health diagnosis. Resident #5 was admitted with diagnoses including delusional disorders, a history of left below-the-knee amputation, peripheral vascular disease, and diabetes. The resident’s PASRR Level I Assessment, dated 12/05/24, stated that the individual did not meet the federal definition for mental illness or mental retardation and that no further PASRR screening was required unless there was a significant change in status. However, the resident’s medical record later documented a new diagnosis of delusional parasitosis disorder prior to admission, with provider notes dated 12/20/24 and 12/24/24 referencing the diagnosis. The resident’s MDS with an ARD of 01/02/25 listed a diagnosis of delusional disorders, and the resident was not assessed for PASRR Level II. During interview and record review, the social worker confirmed that the diagnosis of delusional parasitosis was received after the PASRR Level I was completed and before admission to the facility, and stated that this qualifying mental health diagnosis would require an updated PASRR Level I and a PASRR Level II. The facility policy stated that if a resident is discovered to have SMI, IDD, or RC after the Level I was performed, the facility must call the PASRR contractor to perform an updated Level I, and that the Social Worker or admission and Marketing Director or designee is responsible for ensuring the PASRR level is obtained and documented.
Incomplete Care Plans for Behavioral Health, Trauma, and Restorative Needs
Penalty
Summary
The facility failed to ensure staff developed and/or implemented comprehensive care plans with person-centered interventions for three residents reviewed. One resident was admitted with Parkinsonism and insomnia and was moderately cognitively impaired, had verbal behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, rejected care during the look-back period, and required substantial to maximal assistance with personal care and mobility. His care plan included interventions for resistive care, yelling out, impaired cognitive function, and aggressive behavior, but during an observation he was in his room with a CNA who spoke to him in an argumentative tone while he was trying to stand. The CNA made repeated comments about the resident cussing, threatening to knock her out, and not wanting her to touch him, then left the room. Another staff member later observed the resident yelling for help while trying to get up, and he was then placed in his wheelchair and became calm and cooperative. The DON confirmed the CNA failed to implement the resident’s care plan. A second resident was admitted with schizoaffective disorder, bipolar type; PTSD; depression; and type 2 diabetes. Her care plan did not contain specific interventions addressing her PTSD diagnosis, triggers, or measures to prevent retraumatization while receiving care. The resident was observed in her room and stated she was not aware of a behavioral health diagnosis and denied talking to anyone about her mood, though she also said she sometimes felt sad and would like to talk to someone. The SW stated no social history or trauma assessment had been completed, and reported the resident had a history of sexual molestation, was a registered sex offender, and had been triggered by men she did not know, including a new male CNA. The SW confirmed this information was not listed in the care plan. A third resident was admitted and later readmitted with hemiplegia and hemiparesis following cerebrovascular disease affecting the left non-dominant side, morbid obesity, spinal stenosis, and chronic respiratory failure. Her MDS showed moderately impaired cognition, dependence on staff for ADLs, and substantial assistance needed for bed mobility and transfers. Her comprehensive care plan revised on 07/21/25 had no focus, goals, or resident-centered interventions to address maintenance or prevention of decreased ROM and bed mobility related to her hemiplegia and hemiparesis. The DON and an RN confirmed staff were expected to ensure care plans were accurate and reflected resident care needs. The facility policy on restorative nursing care stated the program is designed to help residents achieve and maintain optimal self-care and independence, and that residents may be referred when functional decline or maintenance needs are identified.
Failure to Arrange Ordered Consults and Evaluate Possible Insect Bites
Penalty
Summary
The facility failed to ensure a dermatology consult was arranged for a resident with persistent itching. The resident was admitted with diagnoses including type 2 diabetes, major depressive disorder, anxiety disorder, and adjustment disorder with depressed mood, and was cognitively intact. She reported ongoing itching from head to toe that interfered with sleep and stated she wanted to see a dermatologist. The physician’s initial assessment documented a history of itching in the scalp and throat and noted itching of the skin without rash. A physician order was written for a dermatology consult for itching and a history of eczema, but the medical record did not show that an appointment with a dermatologist or allergist had been arranged or that the resident was seen. Staff interviews showed the consult order was supposed to be placed in a folder for transportation staff, but the order was not given to the staff member responsible for scheduling outside appointments, and the appointment had not been made until later. The facility also failed to ensure assessment and treatment were completed for a resident who reported possible insect bites. The resident, who was cognitively intact and admitted with diagnoses including unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma, stated that ants were found in her bed and that she developed bites on her upper back, neck, and left arm. Nursing documentation described a rash or papules on the left shoulder/back with itching, and hydrocortisone cream was applied. A skin/wound note described small, slightly red papules in a scattered cluster pattern and stated the resident believed the area was related to bug bites, but there was no further documentation of assessment by the physician in the record. Staff interviews confirmed ants had been seen in the resident’s room and on her mattress, and the resident’s daughter provided photographs showing multiple distinct raised papules on the resident’s upper back, shoulder, and arm. The facility further failed to ensure a speech and language evaluation was arranged for a resident with dysphagia and diet concerns. The resident was moderately cognitively impaired and had an order for a regular diet with mechanical soft ground texture. The resident told staff she did not like the consistency of the meat and said she had been told by the RD that she would have an SLP evaluation regarding a diet change, but no one had followed up. The RD documented that the resident continued to complain about her diet and requested to speak with the SLP to downgrade her diet, and the plan was to request SLP to speak with the resident. However, the medical record contained no SLP documentation showing that the evaluation occurred, and interviews with the NP, SLP, DON, and RD confirmed there was no documentation of an SLP assessment or waiver related to the resident’s diet preference.
Missed Scheduled Showers for Resident Preferring Female CNA
Penalty
Summary
The facility failed to ensure showers were provided at least twice a week as scheduled for one resident, Resident #66, who was admitted with diagnoses including unspecified atrial fibrillation, cerebrovascular disease, and moderate persistent asthma. The quarterly MDS indicated the resident was cognitively intact, had no mood or behavior symptoms, did not resist or refuse care, and required partial/moderate assistance with showering and bathing. During interview, the resident stated she had trouble getting showers twice a week, especially on nights when both a male and female CNA were scheduled, because the female CNA was sometimes unavailable or called in sick and she preferred a female CNA. She stated this happened about once a week. Review of the ADL bathing charting for May, June, and July 2025 showed multiple instances where bathing occurred seven days apart rather than twice weekly. CNA #1 stated the resident was scheduled for showers on Wednesday and Saturday nights and was particular about shower time and which CNAs assisted her. The DON stated the resident was scheduled for showers every Thursday and Sunday night before bed and that when a male CNA was working, a female was always scheduled to provide showers for female residents who preferred a female caregiver; if the female CNA called in, the nurse or CMA would provide bathing assistance. The facility policies stated residents' bathing preferences would be honored and that each resident would receive appropriate treatment and services to maintain ADLs.
Failure to Address Fragile Skin and Skin Tear During Care
Penalty
Summary
Facility staff failed to identify, treat, and implement measures to prevent friction-related skin tear injuries during showering or personal care for a resident with fragile skin. The resident was admitted with diagnoses including encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral disturbance, peripheral vascular disease, and glaucoma. During an observation, the resident was sitting in a recliner with both legs elevated; his ankles were swollen, the skin on his lower legs was dry with dark pin-head size scabs, and there was a two-centimeter reddened, open, moist area on the left lower leg/shin. The resident’s sister stated the injury was a skin tear that occurred when staff showered him after admission and said she had told staff the resident’s skin was thin and should be patted dry rather than rubbed. Review of the resident’s wound assessments for July 2025 showed no documented evidence or description of fragile/thin skin, skin tears, or other lower-leg injuries. The resident’s progress notes and care plan also contained no evidence of interventions to prevent skin irritation, abrasions, or tears related to fragile skin or friction. Nursing progress notes dated 07/13/25 documented scabs on the lower extremities with different forms of healing, but there was no indication of a wound treatment plan for healing or protection. The RN confirmed weekly skin assessments had been completed but was not aware of the open/moist skin tear on the lower left leg/shin, and the DON acknowledged the resident’s leg skin was fragile and subject to skin tears/friction-related injuries during care, but did not provide evidence of a plan to treat the open wound or prevent worsening.
Failure to Provide Restorative Services for ROM and Mobility
Penalty
Summary
Facility staff failed to provide or re-evaluate appropriate restorative treatment and services to maintain or improve range of motion (ROM) and mobility for one resident with hemiplegia and hemiparesis following cerebrovascular disease, morbid obesity, spinal stenosis, and chronic respiratory failure. The resident’s MDS showed moderately impaired cognition, dependence on staff for ADLs, and substantial assistance needs for bed mobility and transfers. During observation and interview, the resident stated her arms and legs were weaker than when she arrived, that she could no longer help turn herself in bed, that staff now used a lift to get her up, and that she wanted to at least help turn herself in bed. She also stated she had not received exercises for her arms or legs and had not been shown bed exercises. The medical record contained no physician or rehabilitation orders for PT, OT, or restorative nursing program services to promote, attain, or maintain the resident’s highest practicable ROM and bed mobility. The care plan had no focus, goals, or resident-centered interventions addressing restorative care for ROM or bed mobility, and the resident was not enrolled in the restorative nursing program. PT staff confirmed the resident had only a few therapy visits and was discharged due to refusal to participate, but also stated the resident could benefit from rehab services and had not been referred to restorative nursing. The restorative nursing director acknowledged the resident’s diagnoses, limited ROM and mobility, and lack of rehabilitation services could make her a candidate for restorative nursing services, but the resident had never been referred to, evaluated by, or enrolled in the program.
Falls Prevention and Tobacco Use Assessment Deficiencies
Penalty
Summary
The facility failed to ensure fall prevention interventions were resident-centered, practicable, and consistently implemented, and failed to provide adequate supervision to prevent falls for two residents with a history of multiple falls. One resident had diagnoses including encephalopathy, type 2 diabetes mellitus, vascular dementia without behavioral disturbance, peripheral vascular disease, and glaucoma, and his MDS showed severely impaired cognition, walker use, bilateral lower extremity impairment, and partial assistance needs. During observation, his call light was out of reach, his walker was across the room, and no fall mat was present; he stated he could get up by himself and go to the bathroom, while his sister reported he had fallen several times in the short time he had been in the facility. Records showed three falls after admission, and staff confirmed the resident had fallen multiple times and that the call light and walker should have been within reach, with a reminder sign also expected at the bedside. A second resident had diagnoses including abnormalities of gait and mobility and hallucinations, and the quarterly MDS showed intact cognition with ambulation and partial assistance needs. She stated she had fallen several times since admission and described hallucinations that led her to try to get animals she saw. Observations showed her bed was not in the lowest position, no fall mat was next to the bed, and no precaution reminder signs were visible in the room. The incident report documented four unwitnessed falls within two months, and staff confirmed the resident had a history of falling and that the bed should have been in the lowest position with a fall mat in place when she was in bed. The facility also failed to document assessment and safety education for the use of smokeless tobacco and failed to offer nicotine cessation alternatives for a resident who used chewing tobacco. The resident was alert, extremely hard of hearing, and visually impaired, and her natural teeth were badly stained. Chewing tobacco was observed in a medicine cup in the day room, and staff confirmed it belonged to her. Review of the medical record found no smoking evaluation to determine safe use of tobacco products, and the DON confirmed the resident used chewing tobacco at her bedside and had not been evaluated for safe use because the facility was non-smoking.
Incomplete dialysis coordination and documentation
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for one resident who required hemodialysis three days per week. The resident was admitted with end stage renal disease, cerebral infarction, hemiplegia and hemiparesis affecting the right dominant side, contracture of the right hand, and adult failure to thrive. Review of the July 2025 MAR showed that pre- and post-dialysis weights, vital signs, and/or vascular assessments were not documented on 07/16/25, 07/21/25, and 07/30/25. The July 2025 Dialysis/SNF Hand-Off communication reports were incomplete or not completed on 07/09/25, 07/14/25, 07/18/25, 07/21/25, 07/23/25, 07/25/25, 07/28/25, and 07/30/25. Nursing notes also lacked documentation on 07/11/25 and 07/16/25 to explain why the resident missed dialysis, and there was no documentation of communication with the dialysis center or notification of the physician regarding the missed treatments. During interviews, an LPN stated that pre-dialysis assessment and completion of the dialysis communication form were expected, while the DON stated that nursing staff were expected to perform pre- and post-dialysis assessments, check dialysis access, obtain weights, contact the provider for missed dialysis visits, communicate with the dialysis center, and document missed visits in the resident's chart.
Failure to Assess PTSD-Related Needs and Triggers
Penalty
Summary
The facility failed to assess the needs of a resident with a history of PTSD for one of twenty-three sampled residents. The resident was admitted with diagnoses that included schizoaffective disorder, bipolar type; PTSD; depression; and type 2 diabetes. Review of the admission MDS showed mild cognitive impairment, a PTSD diagnosis, no behaviors during the seven-day look-back period, and independence with ADLs. The medical record did not contain a specific assessment addressing the resident’s PTSD-related needs, triggers, or measures to help minimize triggers and prevent re-traumatization. During observation and interview, the resident was fully dressed and reclined in bed, later observed dressed and playing music while getting ready to walk. She stated she was not aware of her behavioral health diagnosis, denied talking to anyone about her mood, and said, "Sometimes I feel sad and would like to talk to someone." The SW stated she had not completed a social history or trauma assessment, but knew the resident personally and was aware the resident had a history of sexual trauma and was triggered by men she did not know. The SW confirmed the resident had recently been triggered by a new male CNA, that the DON was informed so the resident was not assigned that CNA, and that this information was not documented in the medical record. The facility policy stated that residents admitted with PTSD should receive person-centered treatment and services and that staff should ask about triggers and cultural preferences.
Failure to Coordinate Dental Services for Two Residents
Penalty
Summary
Facility staff failed to assess residents’ dental care needs and did not assist with coordinating, scheduling, or rescheduling routine or emergency dental evaluations for two of three residents reviewed. One resident, admitted with diagnoses including acute osteomyelitis of the left ankle and foot, heart failure, and Alzheimer’s disease, had moderately impaired cognition, required substantial/maximal assistance with oral hygiene, and had obvious or likely cavities or broken natural teeth on the MDS. During observations, this resident had no upper teeth and the bottom teeth were broken, darkly colored, and appeared to have caries. The resident stated he had upper dentures that he did not wear and confirmed poor bottom teeth. A CNA stated the resident had upper dentures but would not wear them, confirmed dental caries on the bottom row of teeth, and was unaware of any dentist visit. The LPN stated she did not know how residents were scheduled for dental appointments or how to ensure a resident was seen by a dentist, and the DON confirmed the resident had not been seen by a dentist. Another resident stated she had lost her upper dentures during transfer and needed replacement top dentures because she had trouble eating without her upper plate. She also stated she had been taken to a dentist but was told she could not be seen because she was in a wheelchair. The SW confirmed the resident had requested help replacing her upper denture plate, and the SC stated the resident was transported to Affordable Dentures but could not be seen because she was unable to transfer from her wheelchair for an X-ray and the dentist who usually sees wheelchair patients was out that week. Nursing progress notes documented that the resident was taken to Affordable Dentures and was not seen for that reason. The SW later confirmed the unsuccessful appointment and stated the appointment should have been rescheduled with the dentist that usually sees patients in wheelchairs at Affordable Dentures.
Failure to Secure Wheelchair Cushion Leads to Resident Fall During Van Transfer
Penalty
Summary
A deficiency occurred when a resident with a recent below-knee amputation and a history of Type 1 Diabetes Mellitus was not safely transferred from a facility van. The resident, who was cognitively intact, returned from a medical appointment and was being assisted by a staff van driver. During the transfer, as the wheelchair was being maneuvered down the ramp, the resident leaned forward and slid out of the wheelchair, landing on his recently operated stump. The cushion, which was intended to prevent skin breakdown, was not properly secured to the wheelchair and slid out with the resident. Multiple staff interviews confirmed that the cushion's securing strap was not buckled, allowing it to move from its position due to the smooth surfaces of both the cushion and the wheelchair seat. The incident resulted in the resident experiencing significant pain and requiring ambulance transport to the hospital, where he was diagnosed with a fall from the wheelchair and dehiscence of the surgical wound on his stump. Facility documentation and staff interviews consistently indicated that the failure to properly secure the wheelchair cushion directly contributed to the resident's fall during the transfer process.
Failure to Honor Resident Visitation Rights Due to Unsubstantiated Infestation Concerns
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of his choosing, specifically restricting a cognitively intact resident from seeing his wife. The resident's wife was banned from entering the facility after reporting that she had been bitten or stung by something in the resident's room, which led the administrator to suspect she might have a parasite. The administrator required her to obtain medical clearance before returning. Despite no evidence of bugs or infestation being found by staff, pest control, or housekeeping, the ban remained in place for approximately two weeks. During this period, the resident's wife was not allowed to visit inside or outside the facility, and staff prevented the resident from meeting her outside or receiving food she brought. Staff interviews confirmed that the ban was enforced due to concerns about a possible infestation, but no actual infestation was identified. The resident and his wife both reported that she was threatened with arrest for trespassing if she did not leave the property when attempting to deliver food. Staff, including CNAs, LPNs, and the Social Service Director, acknowledged awareness of the ban and confirmed that no bugs were found on the resident, his wife, or in the room. The Social Service Director and DON stated that the resident should have been allowed to visit with his wife outside, but this did not occur. The facility's pest control company confirmed that no additional services were requested and that bed bugs would not die out without treatment. The facility's own resident handbook states that visitation rights will be honored unless they infringe on the rights of others, but there was no evidence that this was the case.
Failure to Provide Proper Discharge Notice and Required Information
Penalty
Summary
A cognitively intact resident with a history of complete traumatic amputation to the left lower leg and Type 1 Diabetes Mellitus was admitted to the facility and continued to receive services, including physical therapy. On one occasion, the resident was issued a 48-hour discharge notice by the Assistant Administrator without an explanation or inclusion of information regarding the appeals process. Later the same day, a 30-day discharge notice was provided, also lacking the required information about the appeals process. Both notices instructed the resident to remove all personal belongings and vacate the room by the specified dates. Interviews with the resident and the Assistant Administrator confirmed that the discharge notices did not contain all the information required by regulation, specifically omitting details about the appeals process. Review of facility policy and the resident's contract agreement indicated that a 30-day notice is required except in emergencies, and that all applicable federal and state regulations must be followed. The facility failed to provide the resident with a proper discharge notice containing the necessary information and appropriate notice period as required.
Failure to Notify Resident and Representative of Care Plan Meetings
Penalty
Summary
The facility failed to ensure that a resident and the resident's representative received notification of care plan meetings, as required by facility policy. The resident, who was cognitively intact and admitted with a complete traumatic amputation to the left lower leg and Type 1 Diabetes Mellitus, reported not receiving any notice of care plan meetings prior to March 2025. The resident's wife also stated she had never received notice of a care plan meeting, despite specifically requesting to be invited at the time of admission. Both the resident and his wife confirmed they were not notified of any care plan meetings before March, nor did they receive copies of any prior care plans. Interviews with facility staff revealed that the Social Service Director (SSD) was responsible for setting up care plan meetings and notifying residents and their representatives. The SSD indicated that the automated notification system through the electronic medical record (ClinNEX in Point Click Care) had not been functioning, resulting in the lack of notification for the resident and his wife. The Assistant Administrator and Director of Nursing confirmed that it was expected for care plan meetings to be set up by personal phone call, mail, or hand delivery if the resident was their own representative. Review of facility policy confirmed the requirement to notify residents and their families or responsible parties of care plan meetings and to maintain records of such notifications.
Failure to Provide Daily Wound Care as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple comorbidities, including heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, did not receive wound care and dressing changes as ordered by the physician. The resident was admitted with existing pressure ulcers and deep tissue injuries, and the wound care orders were updated several times by consulting specialists, including instructions for daily dressing changes. Despite these orders, the facility continued to provide wound care only on Monday, Wednesday, and Friday for approximately one week, rather than daily as required by the most recent physician orders. The failure to update and implement the correct wound care orders was identified through a review of the Treatment Administration Record (TAR), interviews with nursing staff, and communication with the resident's spouse and outside providers. The wound care nurse was responsible for transcribing new orders to the TAR but did not update the frequency of dressing changes after receiving new instructions from the podiatrist. This oversight was confirmed by both the wound care nurse and the Director of Nursing, who acknowledged that the orders were not correctly changed and implemented for about one week. During this period, the resident's wounds were noted to be worsening, with increased size and depth, as documented by the consulting podiatrist. The resident's spouse raised concerns about the lack of daily dressing changes, which prompted further investigation and ultimately led to the discovery of the error. The facility's policy required that provider orders be reviewed and followed prior to providing wound care, but this was not done in this instance, resulting in the resident not receiving the prescribed daily wound care.
Failure to Administer Ordered Pre-Procedural Medication for Allergy Prevention
Penalty
Summary
A resident with a history of heart failure, peripheral vascular disease, type 2 diabetes mellitus, and end stage renal disease, and known allergies to iodine and contrast dye, was scheduled for an angiogram. Pre-procedure instructions required the resident to receive three doses of prednisone to prevent an allergic reaction due to the known allergy. The instructions were communicated to nursing staff, and the orders were to be transcribed onto the Medication Administration Record (MAR). However, the order for the three doses of prednisone was not transcribed onto the MAR, and there was no documentation that the resident received any of the required doses prior to the procedure. The omission was discovered when the resident’s wife inquired about the medication, and staff confirmed that no order for prednisone was present in the system. As a result, the resident did not receive the prescribed pre-procedure medication as required by the facility’s policy for safe and timely medication administration.
Improper Disinfection of Glucometer After Use
Penalty
Summary
A deficiency occurred when a registered nurse failed to properly disinfect a blood glucose monitor after use on a resident with Type 2 Diabetes Mellitus who was moderately cognitively impaired. During observation, the nurse was seen wiping the glucometer with an Oxivir TB wipe for only five seconds before placing it back in the insulin cart, despite stating that the required wet/contact time for disinfection was one minute. The nurse confirmed that the glucometer was not cleaned and disinfected for the full required time. The facility's policy and the disinfectant manufacturer's instructions both specify that reusable items, such as glucometers, must be cleaned and disinfected between residents with a one-minute wet time and allowed to air dry.
Facility Fails to Serve Hot Meals to Residents
Penalty
Summary
The facility failed to ensure that food and beverages were served at an appetizing temperature for residents who ate breakfast in their rooms, potentially affecting all 55 residents. An anonymous complaint and Resident Council Meeting Minutes from February to July 2024 revealed ongoing concerns about food trays being delivered late and cold. Specific complaints were documented in the meeting minutes, with residents expressing dissatisfaction with the temperature of their meals, particularly breakfast. During a confidential interview, a resident confirmed that breakfast was consistently cold and unappetizing, with no reheating offered. On October 17, 2024, a test tray evaluation was conducted following complaints of cold food. Observations began at 9:00 a.m., and a calibrated thermometer was used to measure food temperatures. The test tray revealed that waffles, scrambled eggs, sausage patty, and spiced apples were all served at temperatures below what is considered hot, with readings ranging from 68 to 90 degrees Fahrenheit. CNA #1 confirmed that the food items did not taste hot, and no residents requested reheating. During an interview, the Administrator stated that all staff should assist with passing trays and expected residents to receive hot food.
Failure in Coordinated Dialysis Care and Communication
Penalty
Summary
The facility failed to ensure coordinated care and communication for a resident requiring dialysis services. Resident A, who was admitted with multiple diagnoses including End Stage Renal Disease, was taken to a dialysis center without a scheduled appointment, resulting in no available chair for treatment. There was a lack of communication between the facility and the dialysis center regarding the resident's condition, weight monitoring, nutritional status, and changes in status. The facility did not have new orders for dialysis upon the resident's admission, and there was no documentation of communication with the dialysis center to schedule treatments. The medical record review revealed that the facility did not document pre and post dialysis weights for Resident A, nor was there an assessment by the Registered Dietitian. The Director of Nursing admitted that the facility relied on the dialysis center to notify them of weight changes and was unaware of the process for nutritional assessments. The Certified Dietary Manager stated that nutritional assessments should occur within 48 hours of admission, but the facility did not monitor dialysis weights. Additionally, there was no documentation of monitoring the resident's AV fistula, and the facility continued to monitor a PD catheter that was no longer in use. Interviews with staff indicated a lack of communication and coordination with the dialysis center. The facility previously used a daily communication sheet, which was discontinued at the dialysis center's request, and no alternative communication method was implemented. The facility's policy required coordination and communication with the dialysis center, including monitoring weight changes and nutritional care, but these were not followed, leading to inadequate care for Resident A.
Failure in Pain Management for a Resident
Penalty
Summary
The facility failed to manage pain effectively for a resident, identified as Resident #159, who was admitted with multiple diagnoses including hemiplegia, anxiety disorder, and neuropathy. The resident's care plan included interventions for pain management, such as administering medications as ordered and monitoring their effectiveness. However, the facility did not administer prescribed pain medications, including Tylenol and Hydro/apap, as needed for pain relief. The medication administration record (MAR) and narcotic sheet indicated that the resident did not receive any of the prescribed pain medications, and there was no documentation of refusals or administration. The resident reported experiencing significant pain, rated as eight out of ten, and stated that he had not received any pain relief. Despite the resident's complaints, the staff, including LPNs and medication aides, failed to assess and address the resident's pain adequately. The resident's pain assessments were incomplete, and there was a lack of communication and documentation regarding the resident's pain and the effectiveness of pain management interventions. The resident expressed a preference for Hydrocodone, but the facility did not provide education or document the refusal of alternative pain management options such as the Lidocaine patch. Interviews with staff revealed a lack of coordination and communication regarding the resident's pain management. The Director of Nursing (DON) acknowledged that the resident's pain was a concern and confirmed that the resident did not receive the prescribed Hydro/apap during the ordered timeframe. The Medical Director (MD) noted that the resident was experiencing post-stroke pain and was on Gabapentin for neuropathic pain. The MD intended to explore other pain management options after reviewing the resident's medical record. The facility's policy required documentation and reporting of pain assessments and interventions, which were not adequately followed in this case.
Failure to Issue Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) form to 12 residents who no longer qualified for Medicare Part A, despite having days remaining. This deficiency was identified through interviews and a review of facility documents and policies. The [NAME] Specialist, who began working at the facility on 08/05/24, admitted to not sending any NOMNC notices and was unaware of her responsibility to do so. The Administrator confirmed that the [NAME] Specialist was responsible for sending out these notices and was unaware that they were not being sent. The facility's policy requires that the NOMNC be delivered at least two calendar days before Medicare-covered services end, but this was not adhered to for the 12 residents involved.
Inadequate Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to conduct a comprehensive facility-wide assessment, which is essential for determining the necessary resources to care for residents effectively during both routine operations and emergencies. The assessment, revised and updated in 2024, was completed by the Administrator, the Director of Nursing, the Medical Director, and a Governing Board Member, but did not involve direct care staff or solicit input from residents, their representatives, or family members. This lack of involvement from key stakeholders could lead to an incomplete understanding of the facility's needs. Additionally, the staffing plan outlined in the assessment was inadequate as it did not specify staffing needs for each unit, shift, or weekends, nor did it consider changes in the resident population. The facility also failed to address the resources required for residents who were grandfathered for smoking. Furthermore, the assessment did not clearly state staff competencies and required training, as the documentation for annual education, orientation checklists, and competency checklists was incomplete or missing. The Administrator admitted to being unaware of the updated requirements for the Facility Assessment and acknowledged the need to plan for grandfathered smoking residents and streamline staff training.
Dish Machine Temperature Gauge Malfunction
Penalty
Summary
The facility failed to ensure the dish machine in the dietary department had a functioning wash temperature gauge, affecting all 56 residents. During an observation and interview, it was noted that the wash cycle gauge on the dish machine consistently registered below the required minimum temperature of 150 degrees Fahrenheit, with readings of 146 F and 144 F. The Assistant Dietary Manager (ADM) confirmed that the machine's instructions required a minimum wash temperature of 150 F and acknowledged that the wash temperature never reached this minimum. The ADM also stated that maintenance had previously serviced the machine for not reaching the required temperature. Further investigation revealed that maintenance had not been informed of the issue until the day of the observation. The ADM admitted that staff had not been using temperature strips to verify the wash temperature and had been relying on the faulty gauge for documentation. A review of the dish machine temperature logs from February to August 2024 showed that the wash temperature only met the minimum requirement on a few occasions. Additionally, a work order from January 2024 indicated previous issues with the machine's temperature, which were addressed by replacing parts and verifying the temperature. The facility's policy required daily maintenance checks of the temperature gauges, which were not effectively carried out, leading to the deficiency.
Failure to Address Resident Grievances on Cold Food
Penalty
Summary
The facility failed to address grievances voiced by residents regarding cold food, as documented in the Resident Council Meeting Minutes from February 2024 through July 2024. The minutes revealed consistent complaints about food trays being delivered late and cold. Despite these concerns being raised regularly, there was no evidence of effective follow-up or resolution. The Activity Director, responsible for documenting and forwarding these concerns, indicated that the minutes were sent to the Administrator and the relevant Department Head, such as the Dietary Manager, but no feedback or corrective action was communicated back to the residents. During a group interview conducted in August 2024, six alert and oriented residents confirmed that meals were frequently cold, particularly breakfast and lunch. They expressed frustration that despite raising these issues in meetings, no changes were made, and they were not informed of any plans to address the problem. The residents noted that the issue was specific to meals delivered to rooms, not those served in the dining room. The lack of response and action from the facility staff contributed to the ongoing dissatisfaction among the residents regarding the quality of their meals.
Failure to Provide Opportunity for Advance Directives
Penalty
Summary
The facility failed to provide residents with the opportunity to formulate advance directives, as evidenced by the cases of four residents. Resident #33, who was cognitively intact, had signed a form indicating the formulation of a Living Will and Do Not Resuscitate order, but no Living Will was found in the records. Resident #31, with severe cognitive impairment, had no advance directives or documentation indicating an opportunity to formulate them. Similarly, Resident #112, also with severe cognitive impairment, had a form with only initials and no indication of advance directives, and no documentation of an opportunity to formulate them. Resident #9, who was cognitively intact and his own responsible party, also had no advance directives or documentation of an opportunity to formulate them. Interviews with facility staff revealed a lack of follow-up and oversight in ensuring that advance directive documentation was completed and that residents were provided the opportunity to formulate them. The Social Worker indicated that the Admission Coordinator was responsible for handling advance directives during the admission process. However, the Admission Coordinator admitted to not following up to ensure all documents were obtained and completed, resulting in the deficiency noted in the report.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with a reported rate of 16.13% due to five medication errors out of 31 opportunities. On one occasion, an LPN administered 12 units of LISPRO Insulin to a resident without priming the insulin pen, which is necessary to ensure the full dose is delivered. The LPN admitted to not being aware of the need to prime the pen. Similarly, an RN administered 22 units of FIASP Insulin to another resident without priming the pen, acknowledging awareness of the requirement and the potential for the resident not receiving the full dose. Additionally, a medication aide incorrectly administered Erythromycin Eye Ointment and Refresh Eye drops to a resident. The aide applied a drop of ointment instead of a ribbon along the lower eyelid and failed to administer the Refresh eye drops to the right eye, while administering two drops instead of one to the left eye. The DON confirmed the errors, noting the correct method for administering the ointment and the eye drops as per the physician's orders.
Failure to Ensure Resident Dignity by Dressing After Incontinence
Penalty
Summary
The facility failed to uphold the resident's right to a dignified existence by not ensuring that a resident was dressed appropriately. Resident #112, who had severe cognitive impairment and was diagnosed with acute pyelonephritis and MRSA infection, was observed in bed with only a cover pulled up to his chin and wearing only a pull-up diaper. The resident expressed a desire to be dressed, stating that his clothes were dirty, but he had clean shirts available in his closet. Despite this, staff did not assist him in getting dressed. Further observations revealed that Certified Nurse Aides (CNAs) #3 and #4 transferred the resident to a shower chair while he was still undressed, wearing only an incontinence brief. CNA #3 admitted to leaving the resident undressed after an episode of incontinence before breakfast, as she planned to take him to the shower afterward. The Director of Nursing confirmed that the expectation was for residents to be dressed after such episodes and not left undressed for meals. This failure to dress the resident after an incontinence episode and before breakfast was a violation of the facility's Resident Rights, which emphasize the right to a dignified existence and reasonable accommodation of needs and preferences.
Failure to Provide Quarterly Financial Statement to Resident
Penalty
Summary
The facility failed to provide a quarterly statement of personal funds to a resident, identified as Resident #9, who was cognitively intact and his own responsible party. The resident was readmitted to the facility and had not requested or appointed another representative to receive his personal fund statements. During interviews, Resident #9 confirmed that he did not receive the quarterly statement dated June 30, 2024, and expressed a desire to know the balance in his account. The facility's policy required that resident fund statements be sent out quarterly, but there was no documentation in the medical or financial records to confirm that the statement was delivered to Resident #9. The [NAME] Specialist #1, who had been in her role for two weeks, was unable to verify whether the quarterly statement was provided to Resident #9. She only had a sticky note indicating that the statement was hand-delivered, but it lacked a delivery date or the name of the person who delivered it. The Administrator expected that quarterly statements be provided to residents or their representatives, but the facility's records did not reflect compliance with this expectation. An email from the Social Worker to the Administrator suggested that the resident received the trust statement, but this was not corroborated by the records available at the time of the survey.
Failure to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for a resident, as evidenced by a worn and soiled mattress and an unclean slipper pan. During an observation, a resident's mattress was found to have a large, discolored, and dirty area, indicating significant wear and lack of cleanliness. Additionally, a slipper pan in the resident's bathroom contained brown residue and was improperly stored on top of a package of briefs. The Director of Nursing acknowledged that the Certified Nursing Assistants should have reported the condition of the mattress and ensured it was replaced, and that the slipper pan should have been discarded and replaced.
Failure to Notify Resident of Hospital Transfer Reasons
Penalty
Summary
The facility failed to provide timely notification to a resident, their representative, and the ombudsman regarding the reasons for the resident's transfer to the hospital. This deficiency was identified for one resident who was transferred to the hospital on two separate occasions. The resident, who had severe cognitive impairment, was initially transferred due to symptoms indicative of a stroke and later for a complicated urinary tract infection. In both instances, there was no documentation in the resident's medical record indicating that written notice of the reasons for the hospital transfers was provided to the resident or their representative. Interviews with facility staff, including the Medical Records clerk, Administrator, and Director of Nursing, revealed that the necessary transfer documentation was not maintained in the resident's electronic medical record. The facility's procedures and policies required that a Nursing Home Notice of Transfer/Discharge form be completed and included in the resident's medical record, but this was not done. The forms available did not have a section to specify reasons for hospital transfers, and no copies of the required notices were found for the resident's hospitalizations.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide a resident with written notification of its bed hold policy during a transfer to the hospital. This deficiency was identified for one resident out of a sample of three. The resident, who had severe cognitive impairment, was initially admitted to the facility with acute pyelonephritis and MRSA infection. On a particular day, the resident exhibited symptoms of a suspected stroke, prompting immediate medical intervention and transfer to the hospital via airlift. Upon review of the resident's electronic medical record, it was found that there was no documentation indicating that the resident or their representative received a written notice of the facility's bed hold policy at the time of transfer. The facility's procedure for hospital transfers explicitly requires that a copy of the bed hold policy be sent with the resident. During an interview, the Administrator confirmed that this protocol was not followed in the case of the resident's transfer.
Failure to Submit Referral for Level 2 PASSAR Evaluation
Penalty
Summary
The facility failed to submit a referral for a Level 2 PASSAR (Pre-Admission Screening and Resident Review) evaluation for a resident with an expired Level 2 PASSAR. The resident was admitted with diagnoses including major depressive disorder, anxiety disorder, post-traumatic stress disorder, and type 2 diabetes mellitus, and was receiving orthopedic aftercare following a surgical amputation. The resident's Level 2 PASSAR was initially approved for short-term admission and had expired. There was no evidence in the medical record that the facility had submitted a referral for another Level 2 evaluation to extend approval beyond the expiration date. During an interview, the Social Worker confirmed that the resident's Level 2 PASSAR had expired and admitted she had not submitted a request for another evaluation. She was unaware that Level 2 approvals could be short-term and have expiration dates.
Failure to Update Care Plans After Falls and Changes in Condition
Penalty
Summary
The facility failed to revise the care plan for two residents after significant events, leading to deficiencies in their care. Resident #51, who had severe cognitive impairment and a history of falls, experienced multiple falls while in the facility. Despite being identified as high risk for falls, the care plan was not updated to address the falls on two specific occasions, nor were new interventions implemented to prevent further incidents. The MDS Coordinator confirmed that the care plan was not revised following these falls. Resident #112, who was admitted with acute pyelonephritis and MRSA infection, also experienced a fall that was not adequately addressed in the care plan. After a significant change in condition, including a fall that resulted in a decline in function and mobility, the care plan still indicated that the resident required assistance from only one person for transfers. However, observations showed that two CNAs were needed to transfer the resident safely, indicating a discrepancy between the care plan and the resident's actual needs. The MDS Coordinator acknowledged that the care plan was not updated to reflect the resident's fluctuating abilities and the need for additional assistance. The facility's policy on safe lifting and moving of residents was not adhered to, as evidenced by the manual lifting of Resident #112 without the use of mechanical aids or proper techniques. The policy requires ongoing assessment and documentation of residents' transfer needs, which was not done in these cases. This failure to update care plans and follow established policies contributed to the deficiencies identified by the surveyors.
Failure to Report Change in Resident's Condition
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) were competent in reporting changes in a resident's condition, specifically for Resident #112. This resident, who had severe cognitive impairment and was dependent on assistance for transfers, reported right arm and shoulder pain and an inability to move the arm. Despite these complaints being observed by CNAs #3 and #4, the change in condition was not reported to the Licensed Practical Nurse (LPN) #1. The resident had a history of a recent fall, which was not initially linked to the current symptoms by the CNAs. The Occupational Therapist (OT) #2, upon noticing the resident's condition, sought out the Director of Rehab and the nurse to report the issue and inquire about an x-ray. LPN #1 confirmed that no report of the resident's condition had been made to her prior to the OT's intervention. The facility's training records showed that CNA #4 had received orientation training, but there was no documentation for CNA #3's training or competencies. This lack of documentation and failure to report the resident's condition highlights a deficiency in the facility's training and communication protocols.
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Illustrative
What surveyors actually found near you
We read the 18 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cherokee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mountain View Manor Nursing Center | 8.1 mi | ★★★★★ | 0 | 0 |
| Vero Health & Rehab Of Sylva | 9.9 mi | ★★★★★ | 7 | 0 |
| Skyland Care Center | 9.9 mi | ★★★★★ | 0 | 0 |
| Maggie Valley Health And Rehabilitation Center | 13.9 mi | ★★★★★ | 4 | 0 |
| Autumn Care Of Waynesville | 18.5 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.