Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Sunset Drive - A Prospera Community during CMS and state inspections, most recent first.
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.
Surveyors found that cold food items, including milk and juice, were stored above the required temperature in a unit kitchenette, and staff were not educated on proper food storage procedures. In a separate incident, a CNA's thumb came into contact with a resident's sandwich, and the CNA wiped her thumb on her pants before delivering the food without hand hygiene.
The facility failed to protect residents from sexual abuse involving two residents with dementia. One resident was found engaging in inappropriate behaviors with another resident, while the second resident displayed inappropriate sexual behaviors towards others. Despite these incidents, the facility did not recognize or address these behaviors as abuse, failing to implement necessary interventions.
The facility failed to report incidents of resident-to-resident abuse involving two residents with dementia who exhibited inappropriate sexual behaviors. One resident was found in a female resident's room with her brief pulled down, and another resident was reported to have fondled another resident's private area. These incidents were not reported to the administrative staff or the SSA, contrary to the facility's policy.
A resident with a history of gastrointestinal issues experienced increased abdominal pain, tenderness, and vomiting, but the facility failed to notify the physician of these changes. Despite interventions, the resident's condition worsened, leading to death before an ER transfer could occur. The administrative nurse confirmed the failure to notify the medical provider, violating the facility's policy.
A facility failed to follow infection control standards for a resident with a suprapubic catheter. Staff did not wear gowns during high-contact care, despite the facility's policy requiring Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. The care plan and signage indicated the need for PPE, but staff only used gloves. An administrative nurse confirmed the expectation for proper PPE use during such care activities.
The facility failed to ensure call lights were within reach for several residents, as required by policy. Observations showed that call lights were placed out of reach for residents in various positions, including in bed, in a recliner, and in a wheelchair. This failure affected the residents' ability to call for assistance.
The facility failed to maintain the dignity and quality of life for two residents. A CNA left a resident's pants pulled down after incontinence care, which the resident confirmed happened frequently. Another resident was seen with an uncovered urinary catheter bag attached to their wheelchair, visible to others. These actions do not preserve personal dignity and may affect psychosocial well-being.
A resident in a LTC facility did not receive scheduled toileting assistance as outlined in her care plan, resulting in her being left in wet clothing for several hours. Observations and record reviews showed multiple instances of staff failing to perform checks and changes every 2-3 hours, as required. Interviews with administrative nurses confirmed that staff were expected to follow care plans, but this was not adhered to, leading to a deficiency in care.
The facility failed to promptly respond to call lights for two residents, leading to prolonged wait times. One resident, at risk for falls, had to move independently due to the delay. Call light logs showed response times far exceeding the facility's 15-minute goal, with one resident waiting over 33 minutes for assistance.
The facility failed to follow infection control standards during toileting assistance for three residents. CNAs did not perform hand hygiene after glove removal and before donning new gloves, contrary to the facility's policy. This included tasks such as cleansing perineal areas, adjusting clothing, and assisting with transfers, without adhering to proper hand hygiene protocols.
A resident with dementia was improperly restrained in a wheelchair with a sheet by an RN to prevent a fall, without proper documentation or assessment as required by the facility's policy. The incident was reported by a CNA, but no immediate action was taken until another CNA removed the restraint. The resident's care plan did not address the use of restraints, contributing to the deficiency.
The facility failed to ensure food was prepared and stored in a clean and sanitary manner in both the main kitchen and a kitchenette on Unit 2. Observations revealed soiled floors, moldy food items, and improperly labeled or expired food. The administrative dietary staff confirmed these issues, which have the potential to result in foodborne illness.
The facility failed to follow infection control standards for seven residents, including improper use of PPE, inadequate toileting care, and poor colostomy care. Staff did not adhere to the facility's policies, leading to potential infection risks.
The facility failed to notify the physician of a resident's low blood sugar readings, despite specific orders to do so. The resident, with type 2 diabetes, had two instances of low blood sugar (54 mg/dL and 53 mg/dL) where the physician was not informed, contrary to the facility's policy and the resident's care plan.
The facility failed to assess the use of a wheelchair lap belt as a possible restraint for a resident with a history of CVA, hemiplegia, aphasia, and apraxia. The medical record lacked evidence of ongoing assessment and evaluation of the lap belt since the initial order, and the care plan indicated the resident was unable to remove the belt. An administrative nurse confirmed the lack of a current evaluation, placing the resident at risk for unnecessary restraint and potential injury.
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.
Improper Food Storage and Unsanitary Food Handling Observed
Penalty
Summary
Surveyors observed that food items in the Grandview Unit Kitchenette were not stored at proper temperatures after meal service. Specifically, a half gallon of milk and cranberry juice in the cold well measured 46.8 degrees Fahrenheit, exceeding the facility's policy requirement for cold food to be held at less than 41 degrees Fahrenheit. The cold well itself had a temperature of 52 degrees Fahrenheit and showed significant frost buildup. Staff interviews revealed that dietary aides were not educated on returning items to the refrigerator after meal service, and the items were left in the cold well instead. Additionally, during meal service on the Sunset Unit, a CNA's thumb accidentally touched a resident's jelly sandwich. The CNA wiped the food debris from her thumb onto her pants and then proceeded to deliver the sandwich to the resident without changing gloves or washing hands. This incident was observed and brought to the CNA's attention by a survey team member.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically sexual abuse, involving two residents with dementia. Resident #1, who had mild cognitive impairment, was documented to have inappropriate sexual behaviors, including entering a vulnerable female resident's room and engaging in inappropriate physical behaviors. On multiple occasions, Resident #1 was found in Resident #2's room, with incidents involving inappropriate touching and undressing. Despite these occurrences, the facility did not recognize these behaviors as sexual abuse and failed to implement interventions to prevent them. Resident #2, who had severe cognitive impairment, also displayed inappropriate sexual behaviors towards other residents and staff. Incidents included fondling another resident and touching a CNA inappropriately. Staff interviews revealed that Resident #2 was known to be 'touchy/feely' and attempted to engage male residents inappropriately. Despite these behaviors being known, the facility did not take adequate steps to address or report these incidents, leading to a failure in protecting residents from abuse.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the administrator and State Survey Agency (SSA) for two residents who exhibited sexual behaviors. The facility's policy, revised in July 2024, mandates that all identified incidents of alleged or suspected abuse or neglect are promptly reported and investigated. However, the facility did not adhere to this policy, as evidenced by the incidents involving two residents with dementia who displayed inappropriate sexual behaviors towards other residents. Resident #1, diagnosed with dementia and identified with mild cognitive impairment, was noted in the care plan to have behavior symptoms related to inappropriate sexual advances. An incident on November 6, 2024, involved Resident #1 being found in a female resident's room with her brief pulled down. Similarly, Resident #2, also diagnosed with dementia and severe cognitive impairment, was reported to have fondled another resident's private area on October 26, 2024. On November 5, 2024, a CNA reported seeing Resident #1 lifting Resident #2's shirt. These incidents were not reported to the administrative staff, and consequently, were not reported to the SSA, as confirmed by an administrative nurse during an interview.
Failure to Notify Physician of Resident's Condition Change
Penalty
Summary
The facility failed to notify a resident's physician of a significant change in the resident's condition, which is a violation of the facility's policy on Notification of Change. The policy requires immediate consultation with the resident's physician and notification of the resident's representative when there is a significant change in the resident's physical status or a need to alter treatment. In this case, the resident, who had a history of gastrointestinal issues, experienced increased abdominal pain, tenderness, rigidity, and vomiting, but the physician was not informed of these changes. The resident's medical record indicated a history of gastroesophageal reflux disease, gastrointestinal hemorrhage, and peptic ulcer. The care plan included monitoring for complications related to constipation, such as a swollen abdomen and vomiting. Despite these instructions, the resident's condition worsened over a period of two days, with documented complaints of abdominal pain and constipation, and the administration of medications like Milk of Magnesia and Tramadol. However, these interventions were noted to be ineffective, and the resident's condition continued to deteriorate. On the morning of the resident's death, the resident reported increased abdominal pain and dry heaving, and expressed a desire to go to the emergency room. The facility obtained consent from the resident's power of attorney to send the resident to the ER, but before the transfer could occur, the resident's condition rapidly declined, resulting in death. The administrative nurse confirmed that the staff failed to notify the resident's medical provider of the change in condition, which may have impacted the care provided to the resident.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control standards for a resident with an indwelling suprapubic catheter. The facility's policy on Enhanced Barrier Precautions (EBP) requires staff to wear personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities to prevent the transfer of multidrug-resistant organisms. This policy applies to residents with indwelling medical devices, such as urinary catheters. Despite these guidelines, staff did not wear gowns while providing high-contact care to the resident, which included transferring the resident using a mechanical lift and providing incontinent care. During the survey, it was observed that two nurses and two CNAs entered the resident's room to provide care without wearing the required gowns, although gloves were used. The resident's care plan and a sign on the door indicated the need for EBP, including the use of gowns and gloves. An administrative nurse confirmed the expectation for staff to wear appropriate PPE during high-contact care activities for residents on EBP. The failure to comply with these precautions has the potential to spread infection throughout the facility.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs regarding call lights for five of ten sampled residents. Observations revealed that call lights were not placed within reach of the residents, contrary to the facility's policy. Specifically, one resident was found resting in bed with the call light on the overbed table, out of reach. Another resident was asleep in bed with the call light hanging from the bottom rung of the bed rail, also out of reach. A third resident was asleep with the call light on the bedside table, inaccessible. Additionally, a resident seated in a recliner had the call light across the room, wrapped around the bed rail and covered with bedding. Lastly, a resident in a wheelchair was unable to locate her call light, which was wrapped around the bed rail behind her, and remained without access to it during subsequent observations.
Failure to Maintain Resident Dignity and Quality of Life
Penalty
Summary
The facility failed to provide care that promotes, maintains, or enhances the quality of life for two residents. For one resident, a certified nurse aide (CNA) was observed providing incontinence care and leaving the resident's pants pulled down below the brief, which the resident confirmed happened frequently. The resident expressed a desire to be dressed properly, indicating a lack of dignified care. Another resident was observed independently moving through the hallways in a powered wheelchair with an uncovered urinary catheter bag attached to the back, visible to other residents and visitors. This lack of coverage for the catheter bag does not preserve the resident's personal dignity and has the potential to affect their psychosocial well-being.
Failure to Provide Scheduled Toileting Assistance
Penalty
Summary
The facility failed to provide appropriate toileting assistance for a resident, leading to a deficiency in care. The resident, who was unaware of when she was wet or soiled, required regular checks and changes every 2-3 hours as per her care plan. However, observations on the day of the survey revealed that the resident was left in a wheelchair for several hours without being toileted, resulting in her pants being visibly wet with urine. The resident reported not being toileted since breakfast, and staff failed to assist her before taking her to the dining room for lunch. Further review of the resident's toileting record showed multiple instances where staff did not perform the required checks and changes every three hours, with gaps ranging from 3.5 to 7 hours. The care sheets, which were supposed to guide the CNAs in providing care, indicated the need for regular toileting assistance, but these instructions were not followed. Interviews with administrative nurses confirmed the expectation for staff to adhere to the care plans, highlighting a lapse in the facility's adherence to its own care protocols.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to promptly respond to residents' call lights, as observed in the cases of two residents. Resident #8, who has a self-care performance deficit related to deconditioning and is at risk for falls, was observed seated in her room after using her front wheeled walker to return from the bathroom without assistance. She confirmed that her call light had been on, but no staff responded, prompting her to move independently. Resident #8 reported that it often takes a while for staff to answer her call light, and she expressed a willingness to go to the bathroom by herself if staff are not available. On another occasion, both Resident #1 and Resident #8's call lights were observed flashing in the hallway, and it took approximately 35 minutes for an unidentified CNA to respond. During an interview, an administrative nurse stated that the expectation is for all staff to answer call lights within 15 minutes. However, the review of call light logs showed that Resident #1's call light was answered nearly 30 minutes after activation, and Resident #8's call light was answered over 33 minutes later. This delay in response time indicates a failure to meet the facility's policy and expectations for prompt assistance.
Inadequate Hand Hygiene Practices During Toileting Assistance
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically regarding hand hygiene practices, during toileting assistance for three residents. Observations revealed that two CNAs did not perform hand hygiene after glove removal and before donning new gloves while assisting Resident #2. The CNAs completed various tasks, including cleansing the perineal area, adjusting clothing, and transferring the resident without performing hand hygiene, which is against the facility's policy. Similarly, another CNA failed to perform hand hygiene after assisting Residents #9 and #10 with toileting cares. The CNA did not change gloves between tasks and did not offer or provide hand hygiene to the residents after toileting. This CNA also engaged in additional activities, such as combing hair and providing water, without performing hand hygiene. These actions were contrary to the facility's hand hygiene policy, which requires hand hygiene after glove removal and before engaging in new tasks.
Failure to Ensure Resident's Right to be Free from Physical Restraints
Penalty
Summary
The facility failed to ensure a resident's right to be free from physical restraints imposed for convenience, affecting one of the two sampled residents reviewed for restraints. The incident involved a resident with dementia, who was found secured in a wheelchair with a sheet tied around her waist by a registered nurse. This action was taken to prevent a fall, as the resident was COVID positive and considered a high fall risk. However, the use of the sheet as a restraint was not documented or assessed as required by the facility's policy. The facility's policy on restraints clearly states that residents should be free from any physical restraints unless required to treat medical symptoms. The policy also requires documentation and assessment before applying any non-emergency physical restraint. In this case, the resident's medical record lacked documentation of observations suggesting the need for a restraint, an assessment of the restraint, and an order for its use. Additionally, the current care plan did not address the use of a restraint, indicating a failure to follow the established procedures. The incident was initially reported by a certified nurse aide who witnessed the restraint and confronted the nurse, but no immediate changes were made. Another CNA later removed the sheet and put the resident to bed. The facility's failure to document and assess the use of the restraint, as well as the lack of a care plan addressing the restraint, contributed to the deficiency. This oversight placed the resident at risk for unnecessary restraint and potential injury.
Failure to Maintain Sanitary Food Preparation and Storage Areas
Penalty
Summary
The facility failed to ensure food was prepared and stored in a clean and sanitary manner in both the main kitchen and a kitchenette on Unit 2. Observations revealed multiple issues including soiled floors and baseboards, moldy food items, and improperly labeled or expired food. Specifically, the main kitchen had moldy biscuits, a soiled food prep sink, and spiderwebs in the dry food storage area. The walk-in cooler contained expired tuna and dusty food storage racks, while the walk-in freezer had expired and undated food items with ice crystal build-up. Additionally, the residents' food refrigerator contained moldy raspberries, shriveled blueberries, and undated containers of unknown food items. The kitchenette on Unit 2 had lime scale on the ice and water machine and coffee machine. During an interview, the administrative dietary staff member confirmed that staff failed to discard expired foods from the resident refrigerator, clean surfaces and floors in the main kitchen, and clean the machines in the kitchenette on Unit 2. These failures have the potential to result in foodborne illness to residents, visitors, and staff. The facility's policies on food supply storage, date marking, food handling, and safe handling of personal food were not adhered to, contributing to the unsanitary conditions observed by the surveyors.
Infection Control and Care Deficiencies
Penalty
Summary
The facility failed to follow standards of infection control for seven residents during various care activities. Observations revealed that staff did not properly use personal protective equipment (PPE) in rooms where residents were placed in droplet isolation. For instance, two CNAs entered a resident's room without face shields and N95 masks, another CNA donned a gown without fastening the belt and wore an N95 mask over a surgical mask, and a third CNA collected a lunch tray without wearing an N95 mask and face shield. These actions were contrary to the facility's policy on PPE usage, which was revised in December 2023. Additionally, the facility failed to perform proper toileting and colostomy care. CNAs did not cleanse the frontal perineal area of two male residents after toileting, and one CNA used a non-cleanable pillow to protect a resident's skin during a transfer, which was then placed back on the bed. Another CNA performed colostomy care without changing gloves after handling a colostomy bag filled with stool, thereby failing to maintain hand hygiene. These deficiencies were confirmed by administrative nurses during interviews.
Failure to Notify Physician of Low Blood Sugar Readings
Penalty
Summary
The facility failed to notify the physician of a change in condition for a resident who experienced low blood sugars. The resident, diagnosed with type 2 diabetes, had specific orders to notify the provider if blood sugar levels fell below 60 mg/dL. Despite this, the medical record showed two instances of low blood sugar readings (54 mg/dL and 53 mg/dL) where the physician was not notified. The facility's policy required immediate consultation with the resident's physician in the event of a significant change in the resident's physical status, which was not followed in this case. A progress note indicated that the resident had an episode of hypoglycemia and was treated with orange juice and glutose, resulting in a blood sugar level of 113 mg/dL. However, there was no documentation showing that the physician was informed of these low readings. An administrative nurse confirmed during an interview that the facility staff failed to notify the physician of the two low blood sugar readings, which was a deviation from the facility's policy and the resident's care plan.
Failure to Assess Wheelchair Lap Belt as Possible Restraint
Penalty
Summary
The facility failed to assess the use of a wheelchair lap belt as a possible restraint for a resident with a history of CVA, hemiplegia, aphasia, and apraxia. The resident was observed seated in a wheelchair with a lap belt in place, but the medical record lacked evidence of ongoing assessment and evaluation of the lap belt as a possible restraint since the initial order dated 12/13/21. The care plan indicated that the resident was unable to remove the belt and was aware of its presence but could not physically click or unclick it. The facility's policy required a licensed nurse to determine whether a device could be a restraint and to document the resident's response and ongoing re-evaluation of the need for the restraint. However, the medical record did not contain a current or recent evaluation of the lap belt, and an administrative nurse confirmed this during an interview. This failure placed the resident at risk for an unnecessary restraint and potential injury related to its use.
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 12 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 |
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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.