Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Arbor Care Centers-countryside Llc during CMS and state inspections, most recent first.
A resident with a seizure disorder and multiple comorbidities was prescribed several anticonvulsants, including Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, with specific dosing schedules. Over several days, multiple doses of these controlled anticonvulsant medications were either not administered or not signed out on the narcotic record, despite some being documented in the MAR as given, resulting in seven confirmed omitted doses. During this period, the resident experienced a fall with post-seizure activity and multiple subsequent seizures, and was ultimately transferred and admitted to the hospital for increased seizure activity.
Surveyors found that the facility did not consistently follow its controlled substance policy requiring two nurses to verify and sign narcotic counts at each shift change. Review of Controlled Drug-Count Records for multiple halls over several weeks showed frequent missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that narcotic counts were not properly documented. The DON confirmed that the expectation was for oncoming and outgoing nurses to count all narcotic medications together and sign the record once the count was verified, and acknowledged that these forms were not completed as required.
Surveyors found that a resident with a seizure disorder and multiple psychiatric and neurological diagnoses had several anticonvulsant medications documented as given on the MAR, while the corresponding narcotic records showed multiple doses of controlled anticonvulsants and another anti-seizure drug were not signed out as administered. Facility policy required adherence to the six rights of medication administration and accurate documentation, but interviews with the DNS and Administrator confirmed that staff charted doses as given when they were not actually administered, resulting in an inaccurate medical record.
Staff failed to consistently use Enhanced Barrier Precautions, including gowns and gloves, during high-contact care for residents with wounds, indwelling devices, or MDROs, and did not follow proper hand hygiene or equipment cleaning protocols. Observations included improper cleaning and storage of a CPAP machine, omission of gowns during catheter and toileting care, and failure to perform hand hygiene at required intervals.
The facility failed to complete discharge summaries for two residents and failed to notify the State Ombudsman of resident transfers and discharges. One resident was admitted with pneumonia and pancreatic cancer and later transferred to the ER, while another resident was admitted with fractures, infected surgical wounds, respiratory failure, and self-care deficits and later discharged before PCP orders were received. Both discharge summaries lacked key details such as discharge date, reason, final status, and medication disposition.
Missing Required Initial Staff Training: The facility failed to ensure 4 of 5 newly hired staff had evidence of required initial training within 2 weeks of employment, including resident rights, emergency preparedness, abuse and neglect, and dementia care. Record review showed no documentation that NA-Q, NA-R, an LPN, and the Administrative Assistant completed the required orientation topics, and the Administrator confirmed the missing training records.
A resident with dementia, bladder incontinence, and self-care deficits following a hip fracture did not receive bathing assistance at least weekly as required. Bathing records showed intervals of up to 13 days between baths, despite the resident's dependence on staff for ADLs and the facility's policy to provide bathing services based on individual needs.
The facility did not complete required post-fall assessments and documentation after a resident experienced an unwitnessed fall with injury, and also failed to consistently follow physician's orders for wound care treatments for another resident, with multiple missed or undocumented treatments confirmed by the DON.
Two residents with multiple chronic conditions and cognitive impairment were neither offered nor given the pneumococcal vaccine, and there was no documentation in their medical records to show the vaccine was offered, administered, or declined, as confirmed by facility staff.
Uncovered Urinary Drainage Bag: A resident with an indwelling catheter had a urinary drainage bag repeatedly observed uncovered and hanging on a walker. The resident stated that others could see the bag and that this affected meals in the dining room. Facility policy required catheter drainage bags to always be covered, and an RN confirmed they should be covered.
Incomplete informed consent for psychotropic medications. Two residents had psychotropic drug orders documented on the MAR and MDS, including an antidepressant, antipsychotic, mood stabilizer, and antianxiety medication, but the consent forms did not include required side effects, and one resident’s consent also listed incorrect meds and dosages. The DON confirmed the consent forms were incomplete and that a new consent should have been completed when psychotropic orders were added or increased.
A resident received PRN ABH cream containing an antipsychotic for anxiety and/or agitation over multiple months, but the record showed no face-to-face physician re-evaluation when the order was renewed. The DON acknowledged being unaware that PRN antipsychotics were limited to 14 days and required in-person re-evaluation by the ordering provider.
The facility did not meet the requirement of having an RN on duty for 8 hours daily, as there was no RN coverage on three consecutive days in November 2024. This was confirmed by the DON during an interview.
The facility did not follow its policy to address pharmacist recommendations for two residents' medication regimens. A resident's recommendations for dose reductions and medication clarifications were not forwarded to the provider timely, and another resident's medication stop date requests were not addressed. The facility lacked evidence of timely communication and resolution of these issues.
The facility failed to implement Enhanced Barrier Precautions (EBP) for two residents with MRDOs, as a nurse aide did not wear a gown during high-contact care activities. Additionally, the facility lacked ongoing evidence of antibiotic surveillance, with only one month of data available from the past 13 months, as confirmed by the Infection Preventionist.
A resident with a history of falls and medical conditions requiring supervision was frequently left unattended in a wheelchair, contrary to their care plan. Despite being dependent on staff for transfers and mobility, the resident was observed alone multiple times, attempting to get up and calling for help. Staff interviews confirmed the resident's needs, and the DON acknowledged the failure to follow the fall prevention plan, leading to the deficiency.
A facility failed to ensure a resident's long-term antibiotic use had a clinical rationale or ordered duration, violating its Antibiotic Stewardship Program. The resident, dependent on assistance and frequently incontinent, was on Nitrofurantoin Macrocrystal since 2020 for chronic cystitis prevention. The Infection Preventionist confirmed no ongoing infection surveillance or antibiotic use review, leading to the deficiency.
A facility failed to follow its Antibiotic Stewardship Policy by not providing stop dates or documented clinical rationale for a resident's ongoing antibiotic use. The resident, who required substantial assistance and was frequently incontinent, was on a scheduled antibiotic for chronic cystitis prevention. The Medication Administration record showed the resident was taking Nitrofurantoin Macrocrystal daily since 2020 without a defined duration. The IP-RN confirmed the lack of ongoing infection surveillance or antibiotic use review per the facility's ASP.
The facility failed to evaluate adverse findings in criminal background checks for three staff members, compromising resident protection. Despite policies requiring screening for abuse, neglect, and exploitation histories, the facility did not investigate criminal findings for certain staff, including charges of possession, driving offenses, and shoplifting. The Administrator confirmed the lack of adherence to hiring policies and absence of documented investigations into these findings.
The facility did not comply with its policy to post daily nurse staffing information, which includes the facility's name, date, census, and total hours worked by nursing staff. Observations and record reviews showed no postings were made from December 2 to December 3, 2024, and none were completed over the past 30 days. An RN consultant confirmed the postings were not done.
A facility failed to investigate and report a potential exploitation case involving a resident who was cognitively intact but had delusions and multiple medical conditions. The resident was involved with potential scammers and requested to cash a Social Security check. Despite the Social Service Director contacting APS and the police, no investigation was completed or submitted to the State Agency as required.
Repeated Omission of Anticonvulsant Doses Leading to Seizure Exacerbation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors, specifically repeated omissions of prescribed anticonvulsant medications. Facility policy defined a medication error as any preparation, provision, or administration of medications not in accordance with physician orders, manufacturer specifications, accepted professional standards, or the five/six rights of medication administration. Despite this, documentation and narcotic records showed discrepancies between what was charted as given and what was actually removed from the narcotic box and signed out, indicating that some doses documented as administered were not provided. The affected resident had a seizure disorder with a history of seizures and multiple related diagnoses, including genetic intellectual disability, anxiety disorder, autistic disorder, major depressive disorder, and urinary tract infection. The resident required assistance with activities of daily living and was prescribed several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the Medication Administration Record (MAR) for a defined period showed that not all ordered doses of Brivaracetam and Lamictal were documented as given, with one Brivaracetam dose marked as “medication not available.” Further review of the resident’s narcotic records revealed that multiple scheduled doses of Brivaracetam and Clobazam, as well as Brivaracetam and Perampanel on several evenings, were not signed out as given, despite some being charted in the electronic MAR as administered. In total, the Director of Nursing Services confirmed that seven anticonvulsant doses were omitted over several days. Progress notes documented that the resident experienced seizure activity, including a fall with post-seizure signs and multiple subsequent seizures, leading to the physician ordering hospital transfer for increased seizure activity and the resident’s eventual admission to the hospital.
Failure to Consistently Complete and Verify Narcotic Counts
Penalty
Summary
The deficiency involves the facility’s failure to accurately account for narcotic medications in accordance with its own Controlled Substance Administration and Accountability Policy dated April 2025. The policy required that in areas without automated dispensing systems, two licensed nurses (the nurse coming on and the nurse going off shift) would complete inventory verification for all controlled substances and exchange keys at the end of each shift, with both nurses signing the Controlled Drug-Count Record to confirm that all narcotic medications were accounted for. The facility census was 36, with a sample size of 4, and the issue had the potential to affect all residents receiving narcotic medications. Record review of the Controlled Drug-Count Record forms for multiple halls and months showed repeated missing signatures from nurses coming on and going off the 6A–6P and 6P–6A shifts, indicating that the required dual verification and documentation of narcotic counts was not consistently completed. On Hall 200 in February 2026, nurses failed to sign the narcotic count form on numerous days for both shifts; similar omissions were found on Hall 100 in March 2026, Hall 200 in March 2026, and Hall 300 in March 2026. In an interview, the DON confirmed that the expectation was for the oncoming and outgoing nurses to count all narcotic medications together and sign the Controlled Drug-Count Record once the count was verified as correct, and further confirmed that these forms were not completed or signed as required to confirm the narcotic counts.
Inaccurate Documentation of Anticonvulsant Medication Administration
Penalty
Summary
Surveyors identified a failure to maintain accurate medication administration documentation for one resident. Facility policy on medication administration required staff to follow the six rights of medication administration, review the Medication Administration Record (MAR), compare medications with the MAR, administer medications as ordered, observe consumption, and sign the MAR after administration, including signing the narcotic record for controlled substances. For a resident with moderate cognitive impairment and multiple diagnoses including seizure disorder, anxiety, depression, genetic intellectual disability, autistic disorder, and urinary tract infection, the active orders included several anticonvulsant medications: Brivaracetam, Clobazam, Lamictal, Perampanel, and Zonisamide, each with specific dosing times. Review of the resident’s MAR for a defined period in February showed that nearly all ordered anticonvulsant doses were documented as administered, with only two missed doses noted (one Brivaracetam dose marked as medication not available and one Lamictal dose not given). However, review of the Resident Narcotic Record for the same period revealed that multiple scheduled doses of controlled anticonvulsants (Brivaracetam and Clobazam) and Perampanel were not signed out as given on several mornings and evenings. In interviews, the DNS and Administrator confirmed that the medications had been signed as given on the MAR even though they were not actually administered, and further confirmed that the resident’s medical record documentation was not accurate to reflect that the resident did not receive these medications.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement its infection prevention and control program as required, specifically regarding Enhanced Barrier Precautions (EBP) and proper cleaning protocols. Observations revealed that staff did not consistently use gowns and gloves during high-contact care activities for residents who were either colonized or infected with multidrug resistant organisms (MDROs), had wounds, or had indwelling medical devices. For example, during toileting assistance for one resident and catheter care for another, staff either omitted the use of gowns or failed to perform hand hygiene at appropriate intervals. In several instances, staff were unaware of residents' EBP status or did not follow the policy for donning personal protective equipment during high-contact care. Additionally, the facility did not ensure proper cleaning and storage of resident care equipment, such as CPAP machines. Multiple observations showed a resident's CPAP mask and tubing left on the floor or improperly stored, and staff confirmed that cleaning was not performed according to facility policy or CDC guidelines. This failure to clean and store equipment as required increased the risk of cross-contamination and infection. Hand hygiene practices were also not consistently followed. Staff were observed failing to perform hand hygiene before and after glove use, after removing gloves, and between clean and soiled tasks. These lapses occurred during wound care, catheter care, and incontinent care for multiple residents. Interviews with staff and the infection preventionist confirmed that these practices were not in line with facility policy, which requires hand hygiene at specific intervals during resident care.
Incomplete discharge summaries and missing Ombudsman notifications
Penalty
Summary
The facility failed to complete required discharge documentation for two residents and failed to complete required notifications to the State Ombudsman when residents were transferred or discharged. For Resident 37, the record showed admission to the facility with pneumonia and pancreatic cancer, then transfer to the Emergency Room after a brief stay; the resident’s family later reported the resident would most likely not return to the facility and would return home with hospice services. The interdisciplinary discharge summary for this resident did not include a discharge date, reason for discharge, final summary of status, or medication disposition. For Resident 39, the record showed admission with recent rib and spine fractures, infected surgical wounds requiring IV antibiotic treatment, respiratory failure, and self-care deficits. Progress notes documented that the resident hoped to eventually discharge from therapy and return home, and later noted the resident discharged from the facility before receiving discharge orders from the PCP. The interdisciplinary discharge summary for this resident also lacked a discharge date, reason for discharge, final nursing summary of status, and medication disposition. During interviews, the DON confirmed discharge summaries had not been completed for Residents 37 and 39, and the Regional Director of Corporate Services confirmed the facility had no evidence it was notifying the State Ombudsman of facility transfers and/or discharges.
Missing Required Initial Staff Training
Penalty
Summary
The facility failed to ensure that 4 of 5 staff members had the required initial training within 2 weeks of employment, including resident rights, emergency preparedness, abuse and neglect, and dementia care. Record review showed that NA-Q, hired on 11/3/25, NA-R, hired on 10/28/25, LPN-T, hired on 10/21/25, and the Administrative Assistant, hired on 10/20/25, had no evidence in their files that the initial training had been completed. Review of the facility's Abuse, Neglect, and Exploitation Policy dated September 2024 showed that new employees were to receive education during initial orientation on abuse, exploitation, misappropriation of resident property, signs of abuse, the reporting process, and behavioral symptoms that may increase the risk of abuse. The Administrator confirmed on 12/18/25 at 10:00 AM that the facility did not have evidence that these staff members received the required initial training.
Failure to Provide Timely Bathing Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide bathing assistance to a resident with dementia, bladder incontinence, and self-care deficits following a recent hip fracture. The resident was dependent on staff for activities of daily living, including bathing, and was unable to bear weight on the left leg. According to the resident's care plan, staff were required to assist with bathing. However, a review of bathing records showed that the resident was not bathed at least weekly, with intervals of up to 13 days between baths. The Director of Nursing confirmed that there was no evidence the resident received bathing assistance at the required frequency, despite the facility's policy to provide bathing services according to individual needs and preferences.
Failure to Complete Post-Fall Assessments and Follow Wound Care Orders
Penalty
Summary
The facility failed to provide appropriate follow-up evaluations and condition assessments after a resident experienced a fall. Specifically, after a resident slipped and fell in their room, initial documentation indicated the resident was alert, denied hitting their head, and had no visible injuries. However, the following morning, red drainage was observed on the resident's right cheek and shirt, which the resident confirmed was related to the fall. Interviews with facility staff, including the DON and Administrator, confirmed that required neurological assessments, vital signs, and post-fall evaluations were not completed or documented as per facility policy, despite the fall being unwitnessed and resulting in an injury. Additionally, the facility did not follow physician's orders for the treatment of a foot ulcer for another resident. Review of the Treatment Administration Record (TAR) over several months revealed multiple instances where wound care treatments were not signed off as completed, and in some cases, treatments were marked as not done due to the resident sleeping, which was confirmed by the DON as not appropriate. The lack of documentation and completion of ordered treatments indicated that staff were not consistently following physician's orders for wound care.
Failure to Offer or Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to provide evidence that two residents were up to date with, or had been offered, pneumococcal vaccinations as required by facility policy. According to the policy, all residents should be offered onsite pneumococcal vaccinations annually by October 1. Record review showed that one resident with heart failure, high blood pressure, kidney disease, and moderate cognitive impairment, and another resident with anemia, high blood pressure, diabetes, Alzheimer's disease, dementia, depression, chronic lung disease, and severe cognitive impairment, had not received or been offered the pneumococcal vaccine. There was no documentation in either resident's medical record indicating the vaccine was offered, administered, or declined. Interviews with facility staff confirmed that these residents were not offered the vaccination as required.
Uncovered Urinary Drainage Bag
Penalty
Summary
The facility failed to ensure Resident 10’s dignity by not covering the resident’s urinary drainage bag. Facility policy titled Catheter Care stated that residents with indwelling catheters were to receive appropriate care and that privacy bags would be available and catheter drainage bags would always be covered while in use. Resident 10’s MDS dated 12/13/25 showed the resident had an indwelling catheter, and the care plan dated 11/29/25 directed that the urinary catheter bag and tubing be placed away from the entrance of the room door. During multiple observations, Resident 10’s urinary drainage bag was seen hanging uncovered on the lower side or lower bar of the walker. On 12/15/25 at 7:45 AM, the resident stated they rarely went to the dining room for meals because everyone could see the bag. The bag was again observed uncovered at 12:45 PM on 12/15/25, at 7:20 AM and 2:05 PM on 12/17/25, and at 8:10 AM on 12/18/25. At the last observation, the resident stated that everyone could see the bag and know that there was a problem. RN-O, the Infection Control Nurse, confirmed on 12/17/25 that urinary drainage bags should always be covered.
Incomplete informed consent for psychotropic medications
Penalty
Summary
Residents 8 and 9 did not have the required informed consent documentation for psychotropic medications. Facility policy stated that residents and their representatives should be educated on the risks and benefits of drug use, as well as alternative treatments and non-pharmacological interventions. Resident 8’s MAR showed Sertraline 100 mg daily for depressive disorder, and the MDS documented use of an antidepressant and a diagnosis of depression. However, the informed consent for psychopharmacological medications listed Sertraline 100 mg daily without documenting the reason for the medication or its side effects. Resident 9’s MAR showed multiple psychotropic medications, including Seroquel, Sertraline, Lamictal, and Lorazepam, with diagnoses of Non-Alzheimer’s Dementia and Depression documented on the MDS. The informed consent form listed Seroquel, Sertraline, Lamictal, and Lorazepam, but the doses and indications did not match the MAR, and no side effects were documented. The responsible party signed the same consent form on two separate dates, and the DON confirmed that the consent form did not include the side effects for Residents 8 and 9 and that Resident 9’s consent did not reflect the correct medications or dosages; the DON also confirmed that a new informed consent should be completed each time a new psychotropic order was received or a psychotropic medication was increased, and this was not done for Resident 9.
Failure to Re-evaluate PRN Antipsychotic Use
Penalty
Summary
The facility failed to ensure Resident 25 received the required face-to-face physician evaluations to continue PRN antipsychotic medication use. The facility policy stated PRN psychotropic drugs were to be used only for a diagnosed specific condition, PRN psychotropic orders were limited to 14 days, and PRN antipsychotic medications were limited to 14 days with no exceptions, with the attending physician or prescribing practitioner required to evaluate the resident before writing a new order. Resident 25’s MAR showed an order for ABH cream containing Ativan, Benadryl, and Haldol, applied every 4 hours PRN for anxiety and/or agitation, and the medication was administered repeatedly across multiple months in 2025. Review of Resident 25’s hospice physician orders showed renewals of the ABH cream on multiple dates, but there was no evidence the resident was seen or re-evaluated by the physician when the orders were renewed. The DON stated during interview that she was unaware PRN antipsychotic medications were limited to 14 days and required a face-to-face re-evaluation by the ordering provider, and confirmed the physician had not completed in-person evaluations of Resident 25 each time the PRN antipsychotic medication was continued beyond 14 days.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage daily, as mandated by licensure reference number 175 NAC 12-006.04(F). A review of the nurse's schedule for November 2024 revealed that there was no RN coverage on November 1st, 2nd, and 3rd. This deficiency was confirmed during an interview with the Director of Nursing (DON) on December 5th, 2024, at 10:00 AM, where the DON acknowledged the absence of RN coverage on the specified dates.
Failure to Address Pharmacist Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to adhere to its policy of addressing pharmacist recommendations for medication regimen reviews for two residents. For Resident 1, the pharmacist recommended a sleep assessment and dose reductions for Risperdal and Zoloft, as well as a clarification for the use of Nitrofurantoin. Despite these recommendations, there was no evidence that the facility forwarded these to the provider in a timely manner or that the recommendations were addressed according to the facility's policy. The provider did not indicate agreement with the recommendations, and there was no documented response for the Nitrofurantoin clarification. Similarly, for Resident 27, the pharmacist noted the need for a stop date for Ativan and requested a review of two insomnia medications. The provider documented the rationale for the antianxiety medications but did not respond to the insomnia medication review or the stop date request. The facility did not ensure these recommendations were sent to the provider again in a timely manner, and there was no evidence that the identified irregularities were addressed as per the facility's policy.
Failure to Implement Enhanced Barrier Precautions and Maintain Antibiotic Surveillance
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for the prevention of transmission of Multi-Drug-Resistant Organisms (MRDOs) during the care of two residents. Resident 20 required substantial assistance with dressing, transfers, and hygiene, and had skin ulcers and a pressure ulcer. Despite being on EBP for wounds, a nurse aide assisted the resident with toileting and hygiene without wearing a gown, only using gloves. Similarly, Resident 25, who had an active MRDO wound and required moderate assistance, was also assisted by the same nurse aide without the use of a gown, contrary to the care plan that required gown and glove use for high-contact activities. The facility also failed to maintain ongoing evidence of antibiotic surveillance. The Infection Preventionist confirmed that the facility lacked evidence of conducting ongoing and real-time surveillance of infections or reviewing antibiotic use as per their Antibiotic Surveillance plan. The facility was only able to provide one month of infection surveillance data from the past 13 months, indicating a significant lapse in their infection control and prevention program.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement necessary interventions to prevent potential falls for a resident, identified as Resident 27, who was at risk due to their medical conditions, including Non-Traumatic Brain Dysfunction, Dementia, Anxiety, and Depression. The resident was dependent on staff for assistance with transfers and wheelchair mobility. Despite having a care plan that required the resident not to be left alone in their room while in a wheelchair, observations over several days revealed that the resident was frequently left unattended. This lack of supervision occurred even though the resident had a history of falls, including two falls with no injury and two with minor injuries since the last assessment. Observations documented multiple instances where the resident was left alone in their room while seated in a reclining wheelchair, attempting to get up independently, and calling out for assistance. Interviews with nursing assistants confirmed that the resident required a mechanical lift for transfers and was dependent on staff for mobility. The Director of Nursing acknowledged that staff failed to adhere to the fall intervention plan, which increased the risk of further falls. The facility's failure to provide adequate supervision and follow the established fall prevention procedures led to the deficiency identified in the report.
Failure to Ensure Appropriate Antibiotic Use
Penalty
Summary
The facility failed to ensure that a resident's long-term use of an antibiotic had a clinical rationale for continued use or an ordered duration of use. The facility's Antibiotic Stewardship Program (ASP) policy, revised in March 2023, mandates that all antibiotic prescriptions include a specific dose, duration, and indication for use. However, a review of the resident's care plan and medication administration record revealed that the resident was on a scheduled antibiotic, Nitrofurantoin Macrocrystal, since December 2020, without a defined duration for its use. The resident, who required substantial assistance with daily activities and was frequently incontinent, was receiving the antibiotic for the prevention of chronic cystitis, a condition characterized by chronic bladder inflammation without active infection. During an interview, the facility's Infection Preventionist Registered Nurse (IP-RN) confirmed that there was no evidence of ongoing and real-time surveillance of infections or a review of antibiotic use in accordance with the facility's Antibiotic Surveillance plan. This lack of oversight and adherence to the ASP policy led to the deficiency, as the resident's antibiotic regimen did not comply with the facility's requirements for monitoring and documenting the use of antibiotics, including specifying the duration of use.
Failure to Follow Antibiotic Stewardship Policy
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Policy, as evidenced by the lack of stop dates or documented clinical rationale for ongoing antibiotic use for a resident. The facility's Antibiotic Stewardship Program (ASP), revised in March 2023, is part of the infection prevention and control program aimed at optimizing infection treatment and reducing adverse events from antibiotic use. The Infection Preventionist (IP), under the Director of Nursing's (DON) oversight, leads the ASP, with support from the Medical Director, Consultant Pharmacist, and attending Physicians. The policy mandates that all antibiotic prescriptions include a specific dose, duration, and indication for use. A review of a resident's records revealed that the resident, who required substantial assistance with daily activities and was frequently incontinent, was on a scheduled antibiotic for chronic cystitis prevention. The resident's Medication Administration record showed they were taking Nitrofurantoin Macrocrystal daily since December 2020, but there was no defined duration for this antibiotic order. During an interview, the IP-RN confirmed the facility lacked evidence of ongoing and real-time infection surveillance or antibiotic use review per their ASP, and the resident's antibiotic order lacked a defined duration.
Failure to Evaluate Criminal Backgrounds of Staff
Penalty
Summary
The facility failed to evaluate adverse findings regarding criminal background checks for three out of five sampled staff members, which compromised the protection of residents from potential abuse. The facility's policy on Abuse, Neglect, and Exploitation outlined the need for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation, including conducting background, reference, and credential checks. However, the facility did not adhere to these policies, as evidenced by the lack of investigation into the criminal background findings of certain staff members. Specifically, the criminal background checks for a Nurse Aid (NA)-M revealed findings of careless driving, possession of marijuana, and driving under suspension; NA-N had findings of possession of controlled substances, transporting a child while intoxicated, driving under suspension, shoplifting, and attempt of a felony; and a Medication Aid (MA)-O had findings of driving under the influence of alcohol. The facility's failure to investigate these findings and determine the suitability of these individuals for employment was confirmed during interviews with the facility Administrator. The Administrator admitted that hiring decisions were finalized through Human Resources after reviewing background checks, but there was uncertainty about how the facility recorded the review of these checks or the conclusions of the hiring decisions. Furthermore, the Administrator confirmed that the facility had not followed its hiring and HR policy related to criminal background checks and had no documented evidence that the findings on the criminal history checks were further investigated to determine if the employees were appropriate or suitable for positions on the nursing staff.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post daily nurse staffing information, which is essential for transparency and accountability in resident care. The facility's policy, dated January 2024, mandates that a Nurse Staffing Sheet be posted daily, including details such as the facility's name, date, census, and total actual hours worked by licensed and unlicensed nursing staff. This information should be displayed prominently for residents and visitors. However, observations on December 2 and December 3, 2024, revealed no staff postings throughout the facility. Record reviews further indicated a lack of evidence for staff postings from December 2 to December 3, 2024, and no postings were completed over the past 30 days. An interview with an RN consultant confirmed that the Nurse Staff Posting had not been completed or posted.
Failure to Investigate and Report Potential Exploitation
Penalty
Summary
The facility failed to investigate an allegation of potential abuse, misappropriation, or exploitation concerning a resident and did not submit the results of the investigation to the State Agency as required. The facility's policy mandates that all suspected acts of abuse, neglect, exploitation, or misappropriation of resident property be promptly reported and thoroughly investigated, with a written report submitted to the State Agency within five working days. However, despite the Social Service Director (SSD) and the Director of Nursing (DON) being aware of the resident's interactions with potential scammers and the resident's request to cash a Social Security check, no investigation was conducted or reported to the State Agency. The resident involved was cognitively intact but had delusions and was diagnosed with osteomyelitis, gas gangrene, major depressive disorder, anxiety, and diabetes. The resident was also identified as having a diabetic foot ulcer and a surgical wound. The SSD and DON were aware of the resident's potential exploitation by scammers, as the resident had been buying Apple cards to send to them. Despite the SSD contacting Adult Protective Services (APS) and the local police on the recommendation of the State Ombudsman, the facility did not complete or submit a written investigation to the State Agency within the required timeframe.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Community Pride Care Center | 13 mi | ★★★★★ | 7 | 0 |
| Stanton Health Center | 13.5 mi | ★★★★★ | 2 | 0 |
| St. Joseph's Rehabilitation And Care Center | 13.8 mi | ★★★★★ | 17 | 0 |
| Heritage Of Bel Air | 14.4 mi | ★★★★★ | 0 | 0 |
| Mid-nebraska Lutheran Home | 18 mi | ★★★★★ | 14 | 0 |
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