Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Sunset Drive - A Prospera Community during CMS and state inspections, most recent first.
Dishwashers in the main kitchen and on the Edgewater unit failed to reach the required 160°F rinse temperature needed to sanitize dishware. Surveyors observed temperatures below standard using an irreversible registering thermometer and a color-indicator test strip, and facility staff confirmed the rinse cycle did not meet requirements.
A resident with ESRD on hemodialysis, CHF, DM, and depression experienced significant weight loss while the facility failed to document multiple post-dialysis weights, complete a comprehensive dietary assessment, or implement nutritional interventions. Staff confirmed the resident frequently refused meals after dialysis, and the EHR lacked several weights needed for nutritional monitoring despite a physician order to compare dry post-dialysis weights.
Emergency suction machines were not kept ready for use on 4 of 4 resident care units. Staff found machines boxed, unassembled, or difficult to locate in the clean utility room, and one nurse stated the last time she tried to use a suction machine, it did not work. An RN and other staff confirmed that unpacking or locating the equipment would delay response during an emergency.
Housekeeping and environmental cleanliness were not maintained consistently in resident rooms and common areas. Surveyors observed dust, food crumbs, debris, sticky and wet floors, odors, unemptied trash, and soiled briefs left on a wheelchair and scooter seat. Residents and a family member reported that bathrooms and trash were not being cleaned or emptied regularly, and an admin staff member stated staff were expected to clean rooms as needed and remove trash to the soiled utility room.
The facility failed to keep several resident care plans current with changing needs and treatments. A resident with wounds and a fluid restriction had outdated wound, infection, and fluid details in the care plan; another resident's skin treatment order changed from Triad to Calmoseptine but the care plan was not updated; one resident's diuretic therapy was not reflected; another resident's care plan missed current incontinence and toileting needs; one resident's care plan still listed a pressure ulcer when no open areas were present; and another resident's mobility and transfer status did not match observed care, including a two-person pivot transfer instead of ambulation with a FWW.
The facility failed to keep the main laundry room free of hazards for 2 of 2 dryers. Surveyors observed lint buildup on the back of the dryers, including the top, openings, gas lines, and inside the machine openings, with gas dryer flames visible through the openings. Laundry staff stated no one cleans behind the dryers and that they only clean the floor and what they can reach.
Insufficient nursing staffing led to delayed call light response and missed or delayed care for multiple residents. A resident’s family reported long waits for assistance and a ventilator issue, another resident missed showers because there were not enough staff to provide two-person care, and other residents reported long delays for bathing, linen changes, and toileting. Call light reports showed waits up to 45 minutes, and staff confirmed the unit was short-staffed with only one CNA for 33 residents during part of a shift.
Staff failed to follow infection control precautions during resident care, including improper glove changes, missed hand hygiene, and failure to use required PPE and EBP. During toileting, transfers, and other hands-on care, CNAs removed and reapplied gloves without hand hygiene, touched their own face while gloved, and handled equipment and room items without cleaning their hands. Other residents with C. difficile, chronic wounds, or indwelling devices did not have required EBP or TBP measures in place, and staff entered rooms without the required gown, gloves, mask, or soap-and-water handwashing.
Failure to protect residents from abuse occurred when one resident, who returned from an outing intoxicated, kissed another resident in the hallway. The other resident had dementia and severely impaired cognition. A CNA observed the incident, both residents were redirected, and the on-call nurse and DON were notified. An admin staff member confirmed the sexual incident.
MDS coding was inaccurate for 3 sampled residents. One resident had a Stage 3 pressure injury documented in the record, but staff relied on limited wound documentation and coded the skin item inconsistently. Another resident’s MDS failed to code Eliquis as an anticoagulant under high-risk drug classes. A third resident had a chest vest/harness in use while seated in a wheelchair, and staff determined it was not a restraint and said the MDS was coded correctly.
Failure to provide ordered bathing assistance: Three residents who needed staff help with bathing did not receive care as planned. One resident with quadriplegia and immobility syndrome missed scheduled showers despite a care plan for 2-person assist and a physician order for baths three times weekly, with staff noting they could not spare enough aides. Another resident with dialysis, weakness, and pain received mostly sponge baths, had matted hair, and staff could not identify the last shower or bed bath. A third resident with a fractured femur and chronic pain reported not having had a bath since admission and was only using wet wipes.
Failure to follow ordered daily weights and reweighing requirements affected two residents with CHF. One resident had edema and a significant weight loss noted on MDS review, but staff missed multiple ordered daily weights and did not reweigh after a 10-pound loss and an 11-pound gain. Another resident with a daily weight order also had missed weights on five of eight days reviewed.
A resident with a PEG tube, dysphagia, and a vitamin deficiency had a care plan for 100% nutrition and hydration via enteral feeding, but the eMAR showed numerous missed tube feeding and water flush administrations, including scheduled bolus and continuous feeds. The facility could not provide a nutritional or dietary assessment, and an admin nurse confirmed there was no documented information regarding the missed administrations.
A resident with vascular dementia, anxiety, and hallucinations was admitted on olanzapine, but the record lacked an AIMS assessment on admission. Facility policy required an RN to complete the AIMS for residents admitted on antipsychotics, and a nurse manager confirmed the assessment was not done.
Medications and creams were not securely stored for two residents. One resident who was cognitively intact had multiple creams and ointments, plus a medication cup, left on a bedside table without a self-administration assessment or MD order to keep them there. Another resident who was not approved for self-administration had noon meds left in cups on a windowsill, and the resident said he would take them later; an RN confirmed the resident was not approved to self-administer.
Failure to maintain a clean, comfortable, and homelike environment was cited after surveyors observed multiple resident rooms and bathrooms with dirt, dust, food debris, residue, sticky floors, scuff marks, a soiled toilet, and fecal matter on a bathroom floor. Residents and a family member reported poor housekeeping, urine odors, garbage buildup, and rooms not being consistently cleaned, and an environmental staff member confirmed the housekeeping dept was short staffed.
Failure to notify a resident’s guardian of an unplanned discharge. The resident left the facility AMA and did not return, but staff did not immediately inform the guardian as required by facility policy. Record review showed the resident had a guardian over the person, finances, and property, and the guardian later confirmed she was not called when the resident left.
Failure to investigate a reported lift fall and spinal injury: A resident with intact cognition and transfer assistance needs said she was dropped from a mechanical lift and later had a T8 compression fracture. The family reported the fall and pain to staff, but staff denied the incident, did not believe it occurred, and no investigation was conducted.
Failure to use wheelchair footrests for a resident seated in a wheelchair. A CNA transported the resident back to his room to assist with dressing, but did not place the footrests on the wheelchair or cue the resident to raise his legs and feet, and the resident's legs and feet bounced along the floor.
Failure to provide respiratory care consistent with professional standards occurred for a resident with interstitial lung disease, chronic respiratory failure with hypoxia, and dependence on supplemental O2. The record showed the resident’s baseline need for 3 to 4 L/min, but staff did not clarify the post-hospital O2 order or include respiratory problems and interventions in the care plan. The resident later developed SOB with O2 sats as low as 76% on 2 L, and was transferred to the ER after staff noted the O2 did not seem to be working.
Failure to follow infection control standards occurred when staff did not fully use EBP during resident care and did not disinfect shared equipment after use. A CNA cared for a resident requiring EBP without wearing a gown during toileting and perineal care, and during care for another resident, a CNA handled a radio with gloved hands and returned it to a pocket without disinfecting it after leaving the room.
A resident with a history of wandering and identified elopement risk, who was cognitively intact and using a wander guard, followed a visitor out the front door when the door alarm sounded. The receptionist observed the resident leaving and notified a nurse, who then went to the front entrance, but during this delay the resident walked off the premises toward a nearby gas station. A CNA saw the resident walking in the street with a walker and later found the resident inside the gas station purchasing cigarettes, after which the resident was returned to the facility. Facility camera footage confirmed the time the resident left and returned, demonstrating that staff did not provide adequate supervision or timely response to the door alarm to prevent the elopement.
Two residents with histories of behavioral issues physically assaulted other residents, one after a wheelchair collision and another during a meal, resulting in physical abuse of residents with cognitive impairments. Both incidents were witnessed by staff and involved residents with documented behavioral risks.
Two residents requiring modified diets and direct or 1:1 supervision during meals were observed eating without the required staff supervision and with access to straws, despite physician orders and care plans specifying otherwise. Staff confirmed these orders were not followed during the observed mealtimes.
A deficiency was cited due to the facility's failure to keep an area free from accident hazards and to provide adequate supervision to prevent accidents. Surveyors observed environmental risks and insufficient oversight, resulting in unsafe conditions for residents.
Two residents dependent on staff for oral care did not consistently receive scheduled oral hygiene assistance as required by their care plans and facility policy. Documentation showed multiple missed instances of AM and PM oral care over several months, and an administrative staff member confirmed that staff were expected to provide this care as planned.
Multiple residents experienced significant delays in call light response, with some waiting from 25 minutes to over three hours for assistance. Observations, call light logs, and staff interviews confirmed that insufficient nursing staff led to unmet resident needs, including prolonged periods in soiled conditions and emotional distress, contrary to facility policy and expectations.
Staff did not administer medications within the required timeframe for multiple residents, with medications given more than one hour late on several occasions. The facility lacked a policy on timely medication administration, and an administrative nurse confirmed the expectation for medications to be given within one hour of the scheduled time.
A resident with quadriplegia and a right foot fracture was injured during van transport when staff failed to turn off the power to the individual's motorized wheelchair. While the van was moving, the resident accidentally activated the chair, causing it to move forward and the foot board to strike the chair in front, resulting in a foot injury.
The facility did not ensure accurate documentation and communication of advance directives for several residents. In one instance, a resident on comfort care was transferred to the ED with an incorrect POLST, and the error was only discovered after transfer. For four other residents, there was no documentation that code status discussions occurred with the residents or their representatives, despite physician orders being present. An administrative nurse confirmed that such discussions and documentation were expected but not completed.
Surveyors observed strong urine odors, dirty floors, stripped beds, dusty medical equipment, damaged furniture, and water-stained ceiling tiles affecting several residents. Staff interviews confirmed that maintenance requests for these issues were not documented as required by facility policy.
Several residents with diabetes and physician's orders for insulin did not have care plans updated to include monitoring and interventions for hypoglycemia and hyperglycemia, and a resident with a foot ulcer under enhanced barrier precautions lacked appropriate care plan documentation for EBP. An administrative nurse confirmed that staff did not update these care plans as required by facility policy.
Multiple residents requiring assistance with ADLs did not receive scheduled showers or baths as outlined in their care plans and physician orders, with some receiving only partial hygiene care or none at all. Residents reported feeling neglected and cited lack of staff as the reason for missed care, while staff interviews confirmed that scheduled hygiene services were not consistently provided. Documentation of care was inconsistent, and the facility could not provide a policy on bathing and personal hygiene.
Multiple residents reported that insufficient nursing staff led to long call light response times, missed showers, and delays in assistance, with some residents experiencing incontinence or waiting on the floor after a fall. Staff confirmed that bath aides were frequently reassigned, and other departments such as activities and dining were also short-staffed, resulting in unmet resident needs and complaints about cold food.
The facility did not ensure food was served at appetizing temperatures, as multiple residents reported receiving cold meals and staff failed to consistently monitor or record food temperatures. Dietary aides lacked education on temperature checks, and ongoing complaints were documented in resident council meetings, indicating a persistent issue with food not being served hot.
Staff did not consistently follow infection control standards, including Enhanced Barrier Precautions, during high-contact care for multiple residents with wounds, indwelling devices, or MDRO history. Lapses included not wearing gowns, improper glove use, inadequate hand hygiene, and failure to disinfect shared equipment and supplies after use.
Staff did not consistently place the call light within reach for a legally blind, non-ambulatory resident, leaving it on a chair at the foot of the bed after care was provided. The resident reported that staff frequently forgot to return the call light, despite her care plan specifying the need for accessible bedside items.
A resident with a guardian experienced a room change without receiving the required written notice or explanation, as confirmed by record review and staff interviews. Facility policy mandates that residents and their representatives be notified in writing before any room relocation, but this procedure was not followed.
A resident was observed with multiple medications and a tube of nystatin cream at the bedside without a completed assessment or physician's order for self-administration, as required by facility policy. An administrative nurse confirmed the omission of both the assessment and the order.
Two residents requiring assistance with personal hygiene experienced lapses in dignity when one was repeatedly observed with a soiled chest vest positioning device and visible residue on the face, while another was left exposed on the toilet with doors open and no staff present. Care plans for both residents indicated the need for staff assistance with these activities.
Two residents were unable to reliably access their personal food items stored in the facility's resident fridge. One resident's meals brought by family were reported missing when requested, and another resident faced barriers in accessing flavored coffee creamer due to staff availability and storage limitations. These actions did not support resident autonomy or choice as required.
Two residents with cognitive impairment were not adequately protected from potential sexual abuse when staff failed to follow care plan interventions and provide required supervision. One resident was found in another's room at night and admitted to kissing and holding hands, while another incident involved inappropriate physical contact in the dining room. Staff, including new dietary personnel, were unaware of necessary restrictions, leading to lapses in monitoring and supervision.
The facility did not report an incident involving two residents, where one entered another's room and engaged in physical contact, as potential abuse to the SSA, despite facility policy requiring such reporting.
A resident was hospitalized, and the facility did not provide the required written notice of transfer or bed-hold policy information to the resident, their representative, or the State Long Term Care Ombudsman, as mandated by facility policy.
A resident's required MDS assessments, including discharge, entry tracking, and significant change in status, were not transmitted to CMS within the mandated 14-day period. Multiple assessments were submitted several days late, as confirmed by record review and staff interview.
Staff failed to prime an insulin pen before administration for a resident, contrary to facility policy, and did not transcribe provider orders for continuous glucose monitoring for another resident. Additionally, lorazepam was administered to a resident without an active physician order after the previous order had expired.
Two residents who valued group and evening activities did not have access to scheduled evening programs, as activity calendars showed no such offerings and staff confirmed none were provided unless self-initiated. This was inconsistent with their care plans and documented preferences.
Staff did not implement restorative nursing and therapy services as outlined in the care plan for a resident with Parkinson's disease and severe contractures. The care plan required arm and leg exercises and the use of a stuffed animal in the hands, but observations showed no adaptive devices in place and staff interviews revealed a lack of awareness and documentation of the ROM program.
A resident with neuropathy, amputation, and chronic ulcers experienced ongoing severe pain due to the facility's failure to develop an effective pain management plan. The resident frequently required PRN oxycodone and reported inadequate relief from acetaminophen, yet the facility did not evaluate the pain regimen, notify the provider about frequent PRN use, or consider scheduled pain medications, resulting in unresolved pain and discomfort.
A resident did not have aspirin held as ordered by the physician before a scheduled surgery, due to inaccurate transcription and failure to follow the order. The medication was administered on days it should have been withheld, and this was confirmed by a nurse manager.
Dishwashers Failed to Reach Required Sanitizing Temperature
Penalty
Summary
The facility failed to ensure sanitization of dishware used to serve residents, staff, and visitors because the mechanical dishwashing machines in the main kitchen and on the Edgewater unit did not maintain the required hot water temperature during the rinse cycle. During the recertification survey, the survey team determined a potential Immediate Jeopardy situation when the dishwasher rinse cycle failed to reach 160 degrees Fahrenheit at plate level. Survey observations showed the Edgewater dishwasher measured 158 degrees Fahrenheit with an irreversible registering temperature indicator. On the main kitchen dishwasher, temperatures measured 148 degrees Fahrenheit and 146 degrees Fahrenheit, and later 150.9 degrees Fahrenheit with a different thermometer; a facility color-indicator test strip also showed the dishwasher failed to reach the appropriate temperature. Facility staff members verified that the temperature and test strip results were below requirements, and a dietary administrative staff member confirmed the rinse temperature did not reach 160 degrees Fahrenheit.
Failure to Monitor Dialysis Weights and Address Weight Loss
Penalty
Summary
The facility failed to maintain acceptable nutritional status for Resident #81, who had end stage renal disease, CHF, DM, depression, and dependence on renal dialysis. The resident had a physician order to collect weight at dialysis for accuracy and compare the dry post-dialysis weight for nutritional determinations, and the care plan identified the resident as at risk for nutritional problems and weight loss. Facility policy required accurate nutritional assessment, identification of residents at nutritional risk, and monitoring of weight, but the record showed the facility did not complete a comprehensive dietary admission assessment and did not implement nutritional interventions for the resident's weight loss. Review of the record showed weights of 121.0 lbs on admission, 122.0 lbs one week later, then 117.9 lbs pre-dialysis and 112.8 lbs post-dialysis on one date, followed by 112.9 lbs and 108.4 lbs on later dates, with a dialysis communication document listing a post-dialysis weight of 103.8 lbs. The EHR did not contain the resident's weight from June 14 through June 22 and from June 26 through July 9, including eight post-dialysis weights. Staff confirmed the resident received dialysis three days a week, that weights including dry weights were entered into the EHR, and that the resident frequently refused to eat after returning from dialysis. The resident's calculated weight loss from June 4 to July 3 was 14.21%.
Emergency Suction Machines Not Ready for Use
Penalty
Summary
Keep all essential equipment working safely was not maintained when the facility failed to ensure emergency suction machines remained in operating condition on 4 of 4 resident care units: Sunset, Edgewater, Grandview, and [NAME]. On the Edgewood unit, a nurse observed the emergency suction machine boxed and not assembled in the clean utility room, and the nurse stated that assembling it would slow response time during an emergency. On the Sunset unit, a staff member went to the clean utility room to find the suction machine, had to move boxes to locate it, and an unidentified nurse stated the last time she tried to use the suction machine, it did not work. On the [NAME] unit, a staff member went to the clean utility room but could not identify the box containing the emergency suction machine. On the Grandview unit, a staff member located the suction machine in the clean utility room, and the nurse confirmed that unpacking and setting it up would increase response time in an emergency. Two administrative staff members later confirmed that the location of the suction machines and/or the unassembled machines would not be helpful during an emergency.
Housekeeping and Environmental Cleanliness Lapses
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, homelike environment for residents on multiple days of survey. Review of the facility housekeeping policy stated that environmental cleaning is part of infection control and that standard or light cleaning should occur daily in occupied rooms, including emptying trash containers and sweeping and damp mopping hard surface flooring as needed. However, observations on 07/06/26 and 07/07/26 found dust on a fan in one resident room, no bedding on one resident’s bed while the resident was lying in bed watching TV, dust/debris and food crumbs on floors, sticky floors, water on the floor, food debris on an over-the-bed table, and an odor in another resident room. Similar findings were observed again on 07/09/26 in the unit kitchenette, where food debris, dust, a wet substance, and a sticky floor were present, and a dietary aide agreed the floor needed cleaning. Additional observations showed a garbage bag containing a soiled brief on a wheelchair seat in one resident room and on the seat of another resident’s electric scooter. A resident’s bathroom garbage was full of incontinence products, and the resident stated they had to ask for the trash to be emptied and had had a full trash bin since Friday. Another resident stated the bathroom had not been cleaned recently, and another stated the toilet was not cleaned regularly and that they sometimes cleaned it themselves. Other observations included a full garbage can, food crumbs and wrappers, a dried substance on the floor, and food particles and dust/debris on the floor and under a bed. A family member stated the kitchen floors were gross, and an administrative staff member stated the facility used a contracted cleaning company and expected staff to clean resident rooms as needed and take trash to the soiled utility room rather than leaving it in the room.
Care Plans Not Updated to Reflect Current Resident Status
Penalty
Summary
The facility failed to review and revise comprehensive care plans to reflect the current status of 6 of 25 sampled residents. Review of the facility policy stated that care plans are driven by identified resident issues, conditions, strengths, and needs, and must be revised as the resident's needs or status changes. Record review, observations, and staff interviews showed that several residents had current conditions or treatment needs that were not reflected in their care plans, including wound care, medication-related needs, toileting/incontinence needs, and mobility status. Resident #6 had current physician orders for dressing changes to the right buttock, weekly wraps to the right lower leg for a venous stasis ulcer, and a 1800 mL fluid restriction, but the care plan still listed a UTI, a 1500 mL fluid restriction, and a potential for pressure ulcer development without including the venous ulcer, treatment, or open area to the buttocks. Staff confirmed the buttock wound was a stage 2 pressure ulcer, the UTI had been completed, and enhanced barrier precautions were needed due to open wounds. Resident #8's care plan still referenced Triad paste even though the provider changed the order to Calmoseptine. Resident #12 had a current order for spironolactone three times daily related to hypertension, but the care plan did not include related problems, goals, or interventions. Resident #13's care plan did not identify incontinence or current toileting needs despite progress notes showing bladder incontinence, agitation related to inability to control the bladder, and staff assistance with soiled clothing and linens. Resident #80's care plan listed a documented pressure ulcer even though staff confirmed there were no open areas. Resident #119's care plan stated the resident ambulated with a front wheeled walker and required one-person assistance for toileting, but observation and nurse interview showed the resident was transferred by two nurses using a pivot transfer and did not ambulate with a front wheeled walker.
Laundry Room Lint Buildup on Dryers
Penalty
Summary
The facility failed to ensure the laundry room remained free of hazards for 2 of 2 dryers in the main laundry room. Review of the facility's Laundry Resource Packet on 07/09/26 stated that frequent cleaning, disinfecting, and inspections of the laundry room are crucial and that the equipment must be well maintained. During observation of the laundry room on 07/09/26 at 9:20 a.m. with laundry staff members #20 and #21, surveyors observed lint build-up on the back of the dryers, including on the top, around the openings at the top, on the gas lines, and inside the machines' openings, with the gas dryer flames visible through the openings. When asked about cleaning behind the dryers, staff stated that no one cleans behind the dryers and that they only clean the floor and what they can reach.
Insufficient Nursing Staffing and Delayed Response to Resident Needs
Penalty
Summary
The facility failed to ensure sufficient nursing staff and related services were available to meet residents’ needs for 3 of 25 sampled residents and 2 supplemental residents who required staff assistance. The facility policy on call lights stated residents should always have a method of calling for assistance and that call lights should be answered promptly. During the survey, a family member for Resident #8 reported staff did not answer call lights and said the resident had waited 2 hours for help with cares; the family member also reported the resident had called three times since admission because the ventilator was not attached. The call light report for this resident showed wait times up to 43 minutes. Resident #44’s record showed dependence on staff for showering/bathing, and a progress note documented the resident was upset after not getting a shower because there were not enough staff scheduled and both staff needed for the shower could not be pulled from the floor. The resident’s call light report showed wait times up to 45 minutes. Resident #81’s record showed substantial to maximum assistance was needed for showering/bathing, and the resident stated she did not know when she had last received a shower; a bath aide was unaware of the last shower or bed bath, and the documentation from June 10 through July 8, 2026 lacked documentation of refusals. Resident #106 stated he had not received a bath since admission and had been using wet wipes, and also reported bedding was only changed after he asked. Resident #116 reported call light response times ranged from five minutes to an hour, staff sometimes said they would return but did not, and she had been incontinent because of the long waits; her call light report showed response times of 21 and 27 minutes. Staff interviews also confirmed staffing concerns on the Edgewater unit, including one CNA for 33 residents from 6 a.m. to 7 a.m. after a call-in, while normal staffing was reported as four CNAs.
Infection Control Precautions Not Followed During Resident Care
Penalty
Summary
The facility failed to follow infection prevention and control standards for hand hygiene, glove use, enhanced barrier precautions (EBP), and transmission-based precautions (TBP) for multiple residents. Facility policies reviewed stated that hand hygiene must be performed before and after resident contact, after glove removal, and that soap and water must be used during care of residents with suspected or confirmed C. difficile. The policy also required clear signage for EBP and TBP, including gown and glove use for residents with chronic wounds or indwelling medical devices and contact precautions for residents with gastrointestinal illness. During observation of care for one resident, two CNAs performed toileting and transfer care, but after removing soiled gloves they reapplied new gloves and continued care without hand hygiene. One CNA also adjusted the side table and moved the resident’s scooter while still wearing soiled gloves, and later handled the lift and moved it out of the room after removing gloves without performing hand hygiene. The other CNA gathered the garbage bag, removed soiled gloves, and exited the room without hand hygiene. For another resident, a CNA assisted toileting, removed and reapplied gloves multiple times without hand hygiene, touched her own nose and face while wearing the same gloves, and continued resident care without hand hygiene between tasks. Additional findings showed that one resident with a right lower leg dressing and an open area on the buttocks had no EBP sign or PPE supplies outside the room, and an administrative nurse confirmed EBP had not been initiated. Another resident with recurrent C. difficile and a dialysis catheter had a contact precautions sign on the door, but a nurse entered without gown, gloves, or mask, then returned, donned a gown, delivered medication and water, removed the gown, and used hand sanitizer instead of washing hands with soap and water. A resident with an indwelling urinary catheter also had no EBP signage or PPE outside the room, and a nurse and CNA assisted with a full-body mechanical lift transfer without applying PPE during the high-contact care activity.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure residents remained free from abuse when Resident #43, who had intact cognition and was returned from an outing intoxicated and smelling of alcohol, kissed another resident, Resident #96. The facility policy stated that residents have the right to be free from abuse by anyone, including other residents. The final FRI dated 06/22/26 stated that Resident #43 returned from the outing intoxicated and kissed Resident #96. Resident #43's record documented that on 06/19/26 the resident returned intoxicated, was not the usual self, and was answering questions appropriately when the kissing incident occurred. Resident #96 had a diagnosis of dementia, severely impaired cognition on the MDS, and a progress note stated that a CNA saw Resident #96 being kissed by another resident while reaching her arms out to him in the hallway. Both residents were redirected, the on-call nurse was notified, and the DON was informed. An administrative staff member later confirmed that a sexual incident occurred between Resident #43 and Resident #96 on 06/19/26.
Inaccurate MDS Coding for Skin, Medication, and Restraint Items
Penalty
Summary
The facility failed to ensure accurate MDS coding for 3 of 25 sampled residents. For Resident #80, review of the medical record showed a Pressure Ulcer/Injury Evaluation History dated 03/18/26 identifying a Stage 3 pressure injury to the right plantar first digit, while the quarterly MDS identified one Stage 3 pressure ulcer. However, the medical record lacked additional documentation of a pressure ulcer, and an administrative nurse stated the resident had no open areas and that documentation after 03/25/26 did not support an active pressure injury. Another administrative nurse stated she did not confirm the presence of a pressure injury through interview or assessment and relied only on the active wound entry in the evaluation history, and agreed the MDS was coded incorrectly. For Resident #113, the medical record included a physician order for Eliquis 5 mg by mouth twice daily, but the quarterly MDS failed to code the anticoagulant under N0415 high-risk drug classes. For Resident #11, the quarterly MDS identified a trunk restraint used daily, and the record included diagnoses of epilepsy and seizures along with a physical device and/or restraint evaluation stating a harness and positioning aid were used to keep the resident upright in the wheelchair and prevent falling forward or to the side. Observation showed the resident unable to move arms and legs with a chest vest in place while seated in the wheelchair, and an administrative staff member confirmed the chest vest did not meet the definition of a restraint and that the MDS was coded correctly.
Failure to Provide Ordered Bathing Assistance
Penalty
Summary
The facility failed to ensure residents received the bathing assistance needed to maintain personal hygiene for three residents who required staff help with bathing. Review of the facility policy stated bathing was intended to ensure cleanliness, general hygiene, comfort, relaxation, and well-being, and to assist residents with personal care. The record for one resident with quadriplegia and immobility syndrome showed he was dependent on staff for showering/bathing, had a care plan for two staff assistance with total lift and bathing scheduled for Monday and Friday, and had a physician order for three baths per week. However, the bathing record showed only two showers and 12 sponge baths over the review period, and there was no documentation of refusals for the missed showers. A progress note stated the resident was upset about not getting a shower and that staff could not provide one because there were not enough staff on the shift to pull two staff off the floor. A second resident with dialysis, muscle weakness, and pain was assessed as needing substantial to maximum assistance with showering/bathing and had a care plan for one staff assist and at least one bed bath or shower each week. The bathing record showed one shower, one bed bath, and 16 sponge baths, while the resident stated he did not know when his last shower occurred and staff observed his hair was matted. A bath aide stated she was unaware of the resident’s last shower or bed bath and said the resident frequently refuses, but the record lacked documentation of refusals. A third resident with a fractured femur, chronic pain, and muscle weakness was assessed as needing partial to moderate assistance with bathing and had a care plan for staff assistance with showers, but the care plan did not specify how often showers should occur. The bathing record showed only sponge baths, and the resident stated he had not received a bath since admission and had been using wet wipes.
Failure to Follow Ordered Daily Weights and Reweighing Requirements
Penalty
Summary
The facility failed to provide care and services in accordance with physician's orders for Resident #80 and Resident #127. Resident #80 had diagnoses of congestive heart failure and edema, and a quarterly MDS identified a significant weight loss with a current weight of 195 pounds. The physician ordered daily weights, immediate reweighing if the weight was 5 pounds greater or lower than the previous weight, and provider notification if the weight changed by 3 pounds or more in one day or more than 5 pounds in a week. Review of the weight record and MAR showed the facility did not obtain daily weights on multiple days in April, May, June, and July. For Resident #80, the record also showed the facility did not reweigh the resident when the weight dropped from 205 pounds to 195.3 pounds on 06/18/26 and again when the weight increased from 195.3 pounds to 206.1 pounds on 06/19/26. An administrative nurse stated staff were expected to reweigh and document when weight loss or gain was 3 percent or greater, and another administrative nurse confirmed staff were expected to obtain weights as ordered. Resident #127, admitted on 06/25/26 with a diagnosis of congestive heart failure and a physician's order for daily weight, also had missed daily weights on five of eight days reviewed.
Missed Tube Feeding and Flush Administrations
Penalty
Summary
Failure to provide care and services to prevent nutritional deficits was identified for one resident with a feeding tube. The resident had diagnoses including a feeding tube and a vitamin deficiency, and the quarterly MDS identified intact cognition. The resident’s care plan stated that the resident had dysphagia with need for PEG tube feeding for 100% nutrition and hydration needs, vitamin deficiency, and an order for enteral feeding by feeding tube with NPO status. Review of the resident’s June 1 through July 7, 2026 eMAR showed multiple missed enteral feeding-related administrations, including flushes of 250 cc of additional water three times daily, half-carton bolus feeds with tolerance monitoring, continuous tube feeding at 50 mL per hour with water flushes before and after feedings, and three daily bolus feeds of Complete Peptide with water flushes before and after feeding. The facility was unable to provide a nutritional or dietary assessment for the resident, and an administrative nurse confirmed during interview that the facility could not provide documented information regarding the missed administrations.
Missing AIMS Assessment for Antipsychotic Use
Penalty
Summary
The facility failed to ensure one resident's medication regimen remained free from unnecessary drugs by not completing an Abnormal Involuntary Movement Scale (AIMS) assessment before and during antipsychotic use. Resident #80 was admitted in March 2026 with diagnoses of vascular dementia with anxiety and hallucinations and was receiving olanzapine 2.5 mg twice daily on admission, later decreased to daily at bedtime on 06/16/26. Review of the resident's record showed no AIMS assessment on admission. The facility policy titled Psychotropic Medications stated that if a resident is admitted on psychotropic medications and the medication is an antipsychotic, a registered nurse must complete the AIMS. During interview, a nurse manager confirmed staff failed to complete the AIMS assessment on admission.
Medications Left at Bedside Without Authorization
Penalty
Summary
Drugs and biologicals were not stored securely for 2 sampled residents. Facility policy titled Medication: Administration stated that medications should not be left at the bedside unless there is a specific physician order and the resident has been evaluated for self-administration. Review of one resident's record showed the resident was cognitively intact, but the record did not contain a self-administration assessment or a physician order to keep creams at the bedside. During observations on 06/06/26 and 06/07/26, two overflowing baskets of various creams and ointments were seen on a bedside table at the end of the bed, along with a medication cup containing a light pink creamy substance. Another resident's record showed a self-administration assessment dated 11/25/25 stating the resident was not approved for self-administration. Despite this, observations on 07/06/26 and 07/07/26 showed medications in cups on the windowsill, and the resident stated they were his noon medications and that he would take them later. During an interview on 07/08/26, a nurse confirmed the resident was not approved for self-administration of medications.
Failure to Maintain Clean Resident Rooms and Bathrooms
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for 4 of 14 sampled residents and 9 supplemental residents observed during survey. Review of the facility’s Environmental Cleaning Principles policy stated that environmental cleaning is an important part of infection control and emphasized frequent cleaning and disinfection of high-touch areas. During observations, multiple resident rooms and bathrooms were found with visible dirt, dust, food debris, residue, scuff marks, sticky flooring, and soiled surfaces, including a bathroom floor smeared with fecal matter, a soiled toilet, and a fall mat with dried liquid residue. Several residents and a family member reported that housekeeping services were not consistently provided or were inadequate. One resident reported a strong urine smell in the bathroom and said housekeeping had not cleaned the floor well, while another said the bathroom was not cleaned well and garbage piled up. A resident stated housekeeping had not cleaned much lately, and another reported the room and facility were not consistently maintained in a clean condition, with a family member cleaning the room on multiple occasions. A family member also stated the room was always dirty and the bed was not made until after 1:00 p.m. An environmental staff member confirmed the housekeeping department was short staffed.
Failure to Notify Guardian of Resident Discharge
Penalty
Summary
The facility failed to immediately notify Resident #19’s representative of the resident’s discharge after the resident left the facility and did not return. Review of the facility policy titled Notification of Change- R/S, LTC showed that the facility must immediately inform the resident representative when there is a decision to transfer or discharge the resident. Resident #19’s record identified family member #B as the resident’s guardian over the person, financial, and property effective 03/19/26. Progress notes documented that on 03/28/26 the resident left against medical advice and was not in her room when staff checked later that evening; staff called family member C, who stated, “My mom wants me to take care of her in our house,” and then ended the call. The note also stated the resident left AMA without notifying staff and without signing the sign-out sheet. During interview, family member B confirmed the facility did not call her when the resident left and did not return, and stated the administrative staff member and an unknown nurse had received the guardianship paperwork on 03/26/26.
Failure to Investigate Reported Lift Fall and T8 Compression Fracture
Penalty
Summary
The facility failed to thoroughly investigate a reported fall and injury for one resident who stated she had been dropped from a mechanical lift. The resident had intact cognition on the quarterly MDS and a care plan noting weakness, need for assistance with transfers, and transfer assistance with one person. The facility policy on Fall Prevention And Management required staff to notify the physician and resident representative and, if the resident was stable, begin an investigation after a fall. The FRI submitted to the state survey agency identified a moderate injury with compression to the T8 vertebrae and stated the resident reported being dropped from a mechanical lift, while staff denied the incident and no one was notified. Nursing notes documented that the family called the facility about the resident’s report of a fall from the sling of the lift and later reported severe pain all over, and the provider was informed that the resident said she had fallen and had no record of a fall or pain, prompting x-rays. During interview, a family member stated staff told her there were no reported falls and that the resident could not have fallen, and an administrative nurse stated the facility did not conduct an investigation because the fall did not seem real.
Failure to Use Wheelchair Footrests
Penalty
Summary
The facility failed to properly utilize assistive devices needed to prevent accidents and injury for Resident #2, who was observed seated in a wheelchair without footrests. The facility policy titled, Wheelchair, Use of, LTC, stated that foot rests should be lowered and the resident's feet placed on them to provide mobility with safety and comfort. During an observation on 05/27/26 at 9:10 a.m., an unidentified CNA brought Resident #2 back to his room to assist with dressing, but the CNA did not place the wheelchair footrests on the chair and did not cue the resident to raise his legs or feet. As the resident was transported, his legs and feet bounced along the floor.
Failure to Clarify Oxygen Orders and Monitor Respiratory Status
Penalty
Summary
Failure to provide respiratory care consistent with professional standards occurred for a resident with interstitial pulmonary disease, chronic respiratory failure with hypoxia, and dependence on supplemental oxygen. The resident was admitted from the hospital with documentation showing a baseline need for supplemental oxygen at about 3 to 4 L/min, and the inpatient pulmonary consultation recommended increasing oxygen to the maximum before exertion. The facility’s baseline care plan did not include problems, goals, or interventions related to the resident’s respiratory diagnoses, and the record did not show that staff clarified the physician’s orders regarding whether oxygen was required or at what flow rate after hospitalization. Progress notes showed the resident had shortness of breath while lying flat with oxygen saturation of 90% on room air, and later was visibly short of breath and anxious with oxygen saturation of 76% on 2 L. A CNA alerted the nurse to the resident’s shortness of breath, and the resident stated she had been crying most of the night; the night nurse had not reported the change. The resident was transferred to the emergency room by telephone order, and the record also noted that staff recalled the night nurse had placed the resident on a concentrator because the oxygen did not seem to be working. An administrative staff member confirmed staff failed to obtain a physician’s order for oxygen therapy and monitoring.
Failure to Follow EBP and Shared Equipment Infection Control Practices
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when the facility failed to follow infection control and prevention standards for 2 of 4 residents observed, including Resident #21 and Resident #8, who were identified as requiring Enhanced Barrier Precautions (EBP). The facility policy stated that EBP includes the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of multidrug-resistant organisms to staff hands and clothing. Resident #21's care plan stated the resident required EBP, including donning gown and gloves inside the resident room and performing hand hygiene. During observation, a CNA entered the room, performed hand hygiene, applied gloves, and transferred the resident to the toilet without putting on a gown. The CNA then changed the resident's wet brief and pants, provided perineal care, and transferred the resident back to the wheelchair. In a separate observation, two CNAs entered Resident #8's room with hand hygiene, gowns, and gloves for a full body mechanical lift transfer. After the transfer, one CNA reached into her pocket with a gloved hand, asked for assistance over the radio, placed the radio back into her pocket, and failed to disinfect the radio after exiting the resident's room.
Elopement Following Delayed Response to Door Alarm
Penalty
Summary
The facility failed to ensure adequate supervision and monitoring to prevent an elopement when a cognitively intact resident exited the building and went to a gas station across the street. The resident had a BIMS score of 13 and a care plan dated the same day as the incident that identified potential for elopement related to wandering aimlessly, with use of a wander guard to alert staff of the resident’s movements. On the day of the incident, the resident followed a visitor out the front door. The front door alarm beeped twice and the light flashed, and the front desk receptionist observed the resident leaving and called a nurse on Unit 2 to ask if a resident wearing an orange jacket and hat was expected. The nurse then walked down to the front door and went outside. During this time, the resident continued off facility property and proceeded toward the gas station across the street. A CNA saw the resident walking on the street with a walker toward the gas station. By the time staff reached him, the resident was inside the gas station purchasing cigarettes. Camera footage showed the resident left the facility at 4:37 p.m. and returned at 4:48 p.m. Staff interviews indicated that a wander guard had been placed on the resident earlier that day after he exited a secured courtyard, but the resident was still able to leave the building and reach the gas station before staff intervened. The facility did not respond immediately to the door alarm in a manner that prevented the resident from eloping from the building and grounds.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, resulting in two separate incidents of resident-to-resident physical altercations. In the first incident, a resident with vascular dementia, psychotic and mood disturbances, and anxiety, who was noted to have behavioral symptoms and a history of being short-tempered, struck another resident in the face after a minor collision between their wheelchairs. The resident who was struck had diagnoses including anxiety and metabolic encephalopathy, which can cause confusion and memory loss. The altercation occurred after the aggressor yelled at the other resident to move away and then made physical contact when the request was not met quickly enough. In the second incident, a resident with a history of violent behavior and a care plan noting prior physical altercations slapped another resident on the upper arm while both were seated at a dining table. The resident who was slapped had severe cognitive impairment due to dementia and anxiety. The incident was witnessed by a dietary aide, and the aggressor was identified as having intact cognition. Both incidents demonstrate a failure to prevent resident-to-resident abuse, as required by facility policy.
Failure to Follow Physician Dietary Orders and Supervision Requirements During Meals
Penalty
Summary
Facility staff failed to follow professional standards of practice and physician orders for two residents requiring specific dietary modifications and supervision during meals. For one resident, physician orders and care plans specified a soft and bite-sized texture diet, thin liquids with no straw, and direct supervision during meals. Observations showed the resident had access to beverages with straws and consumed meals without staff supervision, contrary to the prescribed orders. Supervisory staff confirmed these requirements were not met during the observed mealtime. For another resident, physician orders and care plans required a minced and moist texture diet, thin liquids with no straw, and 1:1 supervision during meals. The resident's meal ticket also indicated the need for 1:1 supervision. However, during observation, the resident was seen eating at a dining room table with no staff present to provide the required supervision. An administrative dietary staff member confirmed that staff presence was expected for this resident during meals, as per the dietary orders.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. Surveyors observed that the environment posed risks for accidents, and there was insufficient oversight to mitigate these hazards. The report specifically notes the lack of preventive measures and supervision necessary to maintain resident safety in the affected area.
Failure to Provide Scheduled Oral Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide necessary oral hygiene services to two residents who were dependent on staff for oral care. According to the facility's policy, residents unable to perform activities of daily living (ADLs), including oral hygiene, should receive assistance to maintain personal hygiene. Record review showed that one resident required assistance of one staff member for oral care every morning and at bedtime, with an increased frequency scheduled in July. Documentation revealed multiple instances where scheduled oral care was not completed, including missed AM and PM care over several days in May, June, and July, and no night or PRN oral care documented in July. A second resident, who required set-up assistance for oral care twice daily, also had missed AM and PM oral care on several days in July. During staff interviews, an administrative staff member confirmed the expectation that staff provide oral care as outlined in the care plans. The findings were based on review of facility policy, medical records, and staff interviews, demonstrating a failure to ensure that dependent residents received the necessary services to maintain oral hygiene.
Delayed Call Light Response Due to Insufficient Nursing Staff
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents who required staff assistance, as evidenced by multiple instances of delayed responses to call lights. Observations and call light logs showed that several residents waited between 25 minutes to over three hours for staff to respond after activating their call lights. For example, one resident's call light was activated at 7:52 p.m. and staff responded one hour and 30 minutes later, while another resident waited over three hours for assistance. These delays were confirmed by both direct observation and review of facility call light logs. A confidential staff member reported being consistently short-staffed, resulting in residents crying and remaining in soiled conditions due to the lack of timely assistance. An administrative staff member stated that the expectation was for call lights to be answered within 15-20 minutes, which was not met in these cases. The facility's own policy and assessment indicated that adequate staffing should be provided to ensure resident safety and well-being, but the documented delays and staff interviews demonstrated that this standard was not maintained for several residents.
Failure to Administer Medications Timely per Professional Standards
Penalty
Summary
The facility failed to follow professional standards of practice for timely medication administration for all seven sampled residents. Record review showed that staff administered medications more than one hour late on multiple occasions for each resident, with some residents experiencing late administration up to ten times within the review period. The facility was unable to provide a policy regarding timely medication administration. Reference to professional nursing standards indicated that non-time-critical medications should be administered within one hour before or after the scheduled time. An administrative nurse confirmed the expectation that medications be administered within this timeframe.
Failure to Turn Off Power to Motorized Wheelchair During Transport Results in Resident Injury
Penalty
Summary
A deficiency occurred when staff failed to ensure that the power control to a resident's motorized wheelchair was turned off during van transport. The resident, who had diagnoses including quadriplegia, immobility, and a right foot fracture, was seated in a motorized scooter that was locked and secured with seat belts. However, the power to the scooter remained on, and while the van was in motion, the resident accidentally activated the forward button, causing the chair to move forward. This movement resulted in the scooter's foot board striking the chair in front, which then caused injury to the resident's right foot. The incident was identified when the resident reported pain in his right foot upon arrival at a clinic, leading to an x-ray that showed a healing fracture in the first metatarsal head. The facility's investigation confirmed that the van driver did not turn off the power to the motorized wheelchair before transport, which directly led to the accident and injury.
Failure to Accurately Document and Communicate Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that residents' code status and advance directive wishes were accurately documented and communicated in the medical records for five residents. In one case, a resident who was on palliative care with a POLST indicating comfort measures only was transferred to the emergency department, and the incorrect POLST was sent with the resident. The error was only identified after the transfer, and the emergency department was notified of the mistake. Progress notes and interviews confirmed that the resident's updated POLST had been completed months prior, but the documentation and communication did not reflect the resident's current wishes at the time of the transfer. For four additional residents, the medical records contained physician orders regarding advance directives (either DNR or CPR), but there was no documentation that the facility had discussed code status with the residents or their representatives. In one case, the resident was not capable of making their own decisions and had a guardian, but there was still no evidence of discussion or documentation. An administrative nurse confirmed that staff are expected to discuss and document code status at admission and care conferences, but acknowledged that the required documentation was missing in these cases.
Failure to Maintain Safe, Clean, and Homelike Environment for Multiple Residents
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, comfortable, and homelike environment for several residents. Observations included strong urine odors in two residents' rooms, a sticky bathroom floor, a resident's bed stripped of all linens on two occasions, and a dirty floor with stains and debris. Additionally, an oxygen concentrator was found covered with dust, including the air intake and filter area, and wallpaper was missing or torn behind a resident's headboard, with dried food particles present on the floor. Another resident's overbed table had cracked, raised, and peeling laminate, and water stains were observed on ceiling tiles above the bed. Interviews with staff revealed that maintenance requests for these issues were not documented in the facility's maintenance binder, despite facility policy requiring immediate reporting of such concerns. Staff confirmed the poor condition of the overbed table and the presence of ceiling tile stains, as well as the lack of maintenance requests for the damaged wallpaper and other environmental deficiencies.
Failure to Update and Revise Care Plans for Residents with Diabetes and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and needs of several residents. Specifically, for six sampled residents and one supplemental resident with diagnoses including diabetes and physician's orders for insulin, care plans did not include monitoring for signs and symptoms of hypoglycemia and hyperglycemia, nor did they outline interventions to address these conditions. Additionally, one resident with a foot ulcer and enhanced barrier precautions (EBP) in place did not have EBP addressed in their care plan with appropriate problems, goals, or interventions. These omissions were confirmed by an administrative nurse during staff interviews and were not in accordance with the facility's policy requiring individualized, comprehensive care plans.
Failure to Provide Scheduled Bathing and Hygiene Assistance Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that several residents who required assistance with activities of daily living, specifically bathing and personal hygiene, received the necessary services. Observations and record reviews revealed that multiple residents did not receive scheduled showers or baths as outlined in their care plans and physician orders. For example, one resident was observed with long, dirty fingernails, and their records showed they received only one of four scheduled showers and one bed bath over a two-week period. Another resident, diagnosed with seborrheic dermatitis, received only three of eight scheduled baths in one month and two of four in the following two weeks, and reported not having a bath in over a week, feeling neglected, and experiencing worsening scalp conditions due to missed showers. Additional residents with conditions such as candidiasis, eczema, and severe dry skin also did not receive the required number of showers, with one resident receiving only half of the physician-ordered showers and no bed baths or refusals documented. Residents reported being told that showers could not be provided due to lack of staff or bath aides, and some expressed dissatisfaction with sponge baths as a substitute for showers. Another resident stated that a family member had to provide a shower due to missed scheduled baths, and voiced concerns about future missed hygiene care due to ongoing staffing shortages. Staff interviews confirmed that scheduled baths and showers were not consistently provided, often due to insufficient staffing. There was also confusion among staff regarding the difference between sponge baths and bed baths, with some staff indicating that sponge baths involved minimal assistance and did not constitute full body hygiene care. The facility was unable to provide a policy regarding bathing and personal hygiene, and documentation often conflicted with resident statements about care received.
Failure to Provide Sufficient Nursing Staff and Services
Penalty
Summary
The facility failed to provide sufficient nursing staff and related services to meet the needs of residents, as evidenced by multiple complaints and observations documented in resident council meeting minutes, confidential resident interviews, and staff interviews. Residents reported that call lights were frequently turned off by CNAs without their needs being met, and that response times to call lights were lengthy, sometimes taking up to an hour. Several residents stated they missed scheduled showers due to staffing shortages, with some relying on family members for personal care. One resident described waiting approximately 40 minutes for assistance and experiencing incontinence as a result, while another reported lying on the floor for about 20 minutes after a fall before help arrived. Staff interviews corroborated these concerns, indicating that bath aides were often reassigned to other duties, resulting in residents not receiving scheduled baths. The activity department and dining services were also reported to be understaffed, leading to delays and cold food being served. These findings affected at least seven residents who required staff assistance, and the issues persisted over several months, as reflected in repeated complaints during resident council meetings.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to serve food at palatable and appetizing temperatures across all four units, as evidenced by observations, policy review, resident council meeting minutes, and multiple resident and staff interviews. Residents consistently reported receiving cold food, with some stating that trays were set down before they could eat, resulting in the food cooling further. Several residents expressed reluctance to request reheating due to staff shortages or infection control restrictions. Resident council meeting minutes over several months documented ongoing complaints about cold food, with residents requesting solutions such as hot plates and staff education. Observations revealed that dietary staff did not consistently monitor or record food temperatures before serving, and there was a lack of education regarding when and how to take food temperatures. Dietary aides transported food on open carts and failed to use proper temperature monitoring practices, while dietary managers acknowledged that test tray quality assurance checks regarding food temperature and palatability had not been completed. These actions and inactions led to the deficiency of not providing food at safe and appetizing temperatures for residents.
Failure to Follow Infection Control and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to established infection prevention and control standards for 9 of 10 sampled residents during care activities. Observations revealed that staff did not consistently follow Enhanced Barrier Precautions (EBP), including the use of gowns and gloves during high-contact care for residents with indwelling devices, wounds, or a history of multidrug-resistant organisms. In multiple instances, staff performed hand hygiene and donned gloves but neglected to wear gowns as required by EBP policy. For example, during catheter care and wound dressing changes, staff either omitted the gown or applied it incorrectly, and in some cases, failed to change gloves or perform hand hygiene between tasks or after glove removal. Staff also failed to properly disinfect shared equipment such as mechanical lifts after use, as observed when lifts were moved from resident rooms to hallways without cleaning. Additionally, there were lapses in hand hygiene practices, with staff not performing hand hygiene after glove removal, after handling soiled items, or before handling clean items. In several cases, staff changed gloves between tasks without washing or sanitizing their hands, and sometimes handled clean supplies or resident personal items with contaminated gloves. The report further documents failures in following specific infection control procedures during catheter care, such as not cleaning catheter connection sites with alcohol before connecting new tubing. Supplies used for wound care and insulin administration were not always sanitized before being returned to common storage areas. These deficiencies were confirmed through observation, record review, and staff interviews, with administrative staff acknowledging the expectation for proper hand hygiene, PPE use, and equipment disinfection.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
Facility staff failed to ensure that a resident's call light was consistently placed within reach, as required by facility policy. Observations on two separate occasions found the call light on a chair at the foot of the bed, out of the resident's reach, while the resident was in bed. The resident, who is legally blind and non-ambulatory, reported that staff routinely moved the call light to the chair and forgot to return it to her after providing care. The resident's care plan specifically noted the need to describe the location of items at bedside due to her visual impairment.
Failure to Provide Written Notice of Room Change
Penalty
Summary
The facility failed to provide written notice of a room change to a resident and the resident's guardian, as required by facility policy. Record review showed that the resident, who has a guardian to assist with care decisions, experienced a room change, but there was no evidence in the medical record that written notification or an explanation for the move was given to the resident or the guardian. Staff interviews confirmed that the required written notice was not present in the resident's record. The facility policy states that residents and/or their representatives must receive written notice, including the reason for the change, prior to any room relocation, and be given an opportunity to discuss and ask questions about the move.
Failure to Assess and Obtain Order for Self-Administration of Medications
Penalty
Summary
The facility failed to complete an assessment and obtain a physician's order for a resident to self-administer medications, as required by facility policy. Observation revealed that the resident had two paper medication cups containing several pills and a tube of nystatin cream at the bedside. Review of the resident's medical record showed no documentation of a self-administration assessment or a physician's order authorizing self-administration of medications. An administrative nurse confirmed that the necessary assessment and order were not completed for this resident.
Failure to Maintain Resident Dignity During Personal Hygiene and Toileting
Penalty
Summary
The facility failed to maintain or enhance the dignity of two residents who required assistance with personal hygiene. For one resident, repeated observations over several days showed the individual seated in a wheelchair with a chest vest positioning device that was soiled with debris, and on one occasion, a white substance was noted on the left side of the resident's mouth and chin. The resident's care plan indicated a need for assistance with dressing, repositioning, and personal hygiene. For another resident, an observation revealed that both the room and bathroom doors were left open while the resident was seated on the toilet and visible from the hallway, with no staff present, despite the care plan indicating the need for assistance with toileting. An administrative nurse confirmed that staff are expected to keep doors closed during resident care.
Failure to Honor Resident Choice for Personal Food Items
Penalty
Summary
The facility failed to honor resident choices regarding access to personal food items stored in the resident fridge for two sampled residents. One resident reported that food brought in by her son was lost or discarded by the facility. Upon inspection, several of her meals were found in the resident food fridge, properly labeled and dated. However, when the resident requested a specific meal, staff initially told her it was missing. The meal was later found and offered to her, but she refused it at that time. This sequence of events demonstrates a failure to ensure timely and reliable access to personal food items as requested by the resident. Another resident experienced difficulty accessing personally purchased flavored coffee creamer stored in the resident food fridge. The resident expressed that nursing staff were too busy to retrieve the creamer from the kitchen and requested that it be stored in a more accessible location. Staff suggested purchasing individual creamers to keep in his room, but the resident stated these were too expensive. Staff confirmed that the creamer should be stored in the resident food fridge and delivered upon request, but the resident's concerns about access were not resolved. These incidents show the facility did not consistently support or facilitate resident self-determination and choice regarding personal food items.
Failure to Prevent Resident-to-Resident Sexual Abuse Due to Inadequate Supervision
Penalty
Summary
The facility failed to protect two residents with impaired cognition from potential sexual abuse by not ensuring adequate supervision and adherence to care plan interventions. One incident involved a resident with dementia and behavioral disturbances being found with another cognitively impaired resident in her room late at night, where the male resident admitted to kissing and holding hands with her. The female resident, who was not to be left alone with male residents due to her cognitive status and lack of safety awareness, was found awake with her knees elevated, and could not recall the incident when later questioned. The male resident had a documented history of wandering into female residents' rooms and displaying physical affection, with a behavior contract and specific monitoring interventions in place, including door alarms and staff supervision requirements. Despite these interventions, staff failed to consistently monitor the whereabouts of both residents and did not prevent unsupervised contact. Another incident occurred in the dining room, where the male resident was observed sitting next to the female resident and placing his hand on her knee, despite care plan instructions that he should not be within five feet of female residents without supervision. New dietary staff were unaware of these restrictions, further contributing to the failure to protect residents from potential abuse. The facility's lack of effective supervision and failure to implement care plan interventions resulted in residents not being free from potential sexual abuse.
Failure to Report Potential Sexual Abuse to State Survey Agency
Penalty
Summary
The facility failed to report incidents of potential abuse involving two residents who displayed sexual behaviors towards each other to the State Survey Agency (SSA), as required by facility policy. According to the policy, all incidents and results of investigations must be reported to the SSA within five working days. Record review showed that one resident could not recall the incident when questioned, while the other admitted to entering a female resident's room, holding her hand, and kissing her. Despite these documented events, the facility did not report the incident as potential abuse to the SSA.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalization
Penalty
Summary
The facility failed to provide a written notice of transfer and a bed-hold notice to a resident and their representative, as well as to the State Long Term Care Ombudsman, when the resident was hospitalized from January 30, 2025 through February 2, 2025. Record review showed that the facility's policies required written notification to the resident, their representative, and the Ombudsman prior to transfer, and that information about the bed-hold policy must be given at the time of transfer. However, documentation confirming that these notifications were completed was not found in the resident's medical record for the hospitalization event.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to ensure timely electronic submission of required Minimum Data Set (MDS) assessments for one resident, as mandated by federal regulations and outlined in the Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual. Specifically, the facility did not transmit several MDS assessments to the Centers for Medicare and Medicaid Services (CMS) Internet Quality Improvement and Evaluation System (iQIES) within the required 14-day timeframe. The late submissions included a discharge return anticipated MDS transmitted 4 days late, another discharge return anticipated MDS transmitted 3 days late, an entry tracking MDS transmitted 18 days late, and a significant change in status MDS transmitted 3 days late. These findings were confirmed through record review, staff interviews, and examination of the federal database for long-term care surveys. An administrative nurse acknowledged during an interview that the MDS assessments for the resident in question were transmitted after the required deadlines, confirming the facility's noncompliance with timely data submission requirements.
Failure to Follow Professional Standards in Medication Administration and Order Transcription
Penalty
Summary
Facility staff failed to follow professional standards of practice during insulin administration for a resident. Observation showed a nurse preparing an insulin pen for a resident without priming the pen as required by facility policy. When questioned, the nurse stated she never primes insulin pens. An administrative nurse confirmed that staff are expected to prime insulin pens before administering the prescribed dose. Additionally, the facility did not provide care in accordance with professional standards for two residents. For one resident, provider orders regarding the use of a continuous glucose monitoring system were not transcribed into the electronic health record, including the medication administration record and care plan. For another resident with an anxiety disorder, a nurse administered lorazepam without an active physician order, as the previous order had expired. An administrative nurse confirmed the medication was given without a current order.
Failure to Provide Scheduled Evening Activities to Meet Resident Preferences
Penalty
Summary
The facility failed to provide an ongoing program of meaningful activities designed to meet the interests and preferences of residents, as required by policy. Record review and interviews revealed that for at least two residents, their care plans and comprehensive assessments identified participation in favorite and group activities, including evening games and going outside, as very important. However, the activity calendars from March through May showed no scheduled evening activities, and residents reported that such activities were only available if self-initiated with other residents. Interviews with residents confirmed dissatisfaction with the lack of organized evening activities, with one resident specifically expressing a desire for more structured games like Yahtzee and cards in the evenings. An activity staff member also confirmed that no scheduled evening activities had been provided in the past three months unless initiated by residents themselves. This lack of scheduled activities did not align with the residents' documented preferences and care plan goals.
Failure to Provide Restorative Services for Resident with Contractures
Penalty
Summary
Staff failed to provide restorative nursing and therapy services as outlined in the care plan for a resident with Parkinson's disease and severe contractures. The resident's care plan specified the need for restorative interventions, including arm and leg exercises on both sides and the use of a stuffed animal in the hands to address contractures. However, observations over multiple days revealed that the resident's hands were severely contracted in a gripping position, arms were tight to the chest, and feet were pointed downward, with no adaptive devices or stuffed animals in place as required by the care plan. Interviews with multiple CNAs indicated a lack of awareness and implementation of the resident's ROM program. One CNA stated that ROM exercises should be performed by the bath aide as noted in the white binder, but confirmed she was not aware of any ROM program for the resident. Review of the white binder showed no documentation of ROM exercises for the resident. Additional CNAs reported significant difficulty in cleaning the resident's hands due to contractures and noted very limited arm mobility, with one CNA suggesting possible skin breakdown in the inner hands. These findings confirm that staff did not implement the planned interventions for contractures.
Failure to Develop and Implement Effective Pain Management Plan
Penalty
Summary
The facility failed to develop and implement an effective pain management regimen for a resident with significant pain-related diagnoses, including neuropathy, above-the-knee amputation, and chronic foot ulcers. The resident's care plan identified acute pain and set a goal for adequate pain relief, but the pain management approach relied heavily on as-needed (PRN) medications rather than scheduled dosing. The resident reported persistent, severe pain and expressed dissatisfaction with the effectiveness of acetaminophen, preferring oxycodone and wishing it was scheduled to avoid having to request it repeatedly. Observations during care activities, such as dressing changes, showed visible signs of pain, including grimacing and movement of the affected limb, with the resident rating pain as high as 8 out of 10 and frequently requesting pain medication. Review of the resident's medical record and medication administration records revealed frequent use of PRN oxycodone (67 times) and acetaminophen (8 times) over a short period, indicating ongoing, unresolved pain. Despite these frequent requests and high pain ratings documented in assessments and interviews, the facility did not adequately evaluate the effectiveness of the current pain management plan, failed to notify the provider about the frequent PRN use, and did not consider transitioning to scheduled pain medications. This lack of proactive pain management resulted in the resident experiencing ongoing pain and discomfort.
Failure to Hold Medication Prior to Surgery
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when staff did not hold aspirin as ordered by the physician prior to a scheduled surgery. The physician's order specified that aspirin should be held five days before the procedure, but review of the medication administration record showed that the medication was administered on three days when it should have been withheld. This error was due to inaccurate transcription and failure to follow the physician's order, as confirmed by a nurse manager during an interview.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 20 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Mandan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dakota Alpha | 0.5 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society Miller Pointe A Prospera Co | 3.9 mi | ★★★★★ | 5 | 0 |
| Good Samaritan Society Augusta Place A Prospera Co | 5.7 mi | ★★★★★ | 2 | 0 |
| Missouri Slope | 5.8 mi | ★★★★★ | 4 | 0 |
| St Gabriel's Community | 6.7 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.