Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pleasant View Center during CMS and state inspections, most recent first.
Failure to Include Residents in Quarterly Care Plan Meetings: The facility did not facilitate resident and/or representative participation in quarterly care plan conferences for 5 reviewed residents. Interviews showed the residents did not remember attending recent care plan meetings, and record review found no documentation of regular care plan meetings for several residents after admission, readmission, or prior meetings. The SW confirmed there were no quarterly care plan meetings for these residents, despite the facility policy requiring regularly scheduled care plan conferences and resident/rep participation.
Failure to document that a resident and/or representative was informed of the risks and benefits of a psychotropic medication before initiation. The resident’s antidepressant was changed from sertraline to duloxetine for depression, but the NP stated the discussion was not provided, the MAR showed duloxetine was given daily, and the record contained no documentation of informed discussion; the DON confirmed the finding.
Failure to honor resident meal-time choice. Two residents reported that meal trays were served when they were not ready to eat or after returning from dialysis, and staff would not reheat the food, stating it could not be done due to germs or cross contamination. Both residents said they had to eat cold meals, and staff interviews showed inconsistent reheating practices.
Admission Medications Not Given: A newly admitted resident did not receive multiple ordered meds and supplements, including melatonin, MiraLAX, olanzapine, phenytoin, Tamiflu, sennosides-docusate sodium, CoQ10, and tuberculin. Notes said some meds were waiting on stock or pharmacy delivery, but there was no documentation that the provider was notified. Inventory showed several items were already available in house stock or the automated med dispenser, and an LPN confirmed the meds were not administered because he/she did not have access to the dispenser.
The facility failed to include care plan interventions for two residents who smoked and for one resident with documented activity preferences. One resident was a tobacco user who required supervision while smoking, another was an unsupervised smoker, and both had no smoking interventions in their care plans. A third resident had multiple very important activity preferences documented on the MDS, but the care plan had no activity interventions.
Medication administration standards were not followed for three residents. One resident missed documented blood sugars and insulin doses despite an order for sliding-scale insulin. Another resident with a nicotine patch was also smoking, and staff removed the patch before smoking even though the NP was unaware of the ongoing smoking. A third resident with a J-tube received crushed lamotrigine despite a do-not-crush label, and the LPN did not verify tube placement before administering meds.
Failure to provide ordered skin and itch care: A resident with severe cognitive impairment and a dx of seborrheic dermatitis was observed with a bright red, raised, bumpy chest and was scratching while stating, "I'm always itchy." The MAR showed orders for CeraVe itch relief and PRN HydrOXYzine, but the skin review documented ongoing redness, scratches, and itching, and the MAR showed no HydrOXYzine given during the month reviewed.
A housekeeper failed to follow TBP PPE requirements for a resident on Droplet Precautions for suspected influenza. While wearing a mask, gown, and gloves in the resident’s room, the housekeeper left the room, went into the hallway, spoke with staff, and entered another resident’s room without removing PPE or performing hand hygiene; the IP confirmed PPE should be removed and hand hygiene performed before leaving the room.
A resident’s smoking care plan did not match the smoking assessment. The assessment identified the resident as a supervised smoker, but the care plan stated the resident may smoke without supervision. The resident and the Nurse Supervisor both confirmed the resident smokes independently, and the facility policy required smoking supervision needs and safe smoking measures to be documented on the care plan.
The facility did not follow its antibiotic stewardship program, as antibiotic use protocols such as the Loeb Minimum Criteria were not documented or utilized for a resident receiving antibiotics for UTI prophylaxis. The Infection Preventionist could not provide evidence of protocol use, and antibiotic use data was not discussed in QAPI meetings, as required by facility policy.
Two residents had conflicting documentation regarding their advance directives and code status, with discrepancies between physician orders, care plans, and other medical record sections. Staff confirmed the inconsistencies, and the facility did not ensure that the residents' current code status was accurately reflected and communicated as required by policy.
A resident was placed in a pedal broda chair with two wheels locked, restricting movement and causing agitation. Staff confirmed the wheels were locked to limit the resident's mobility, but there were no physician orders or care plan interventions authorizing this restraint.
Two newly admitted residents did not receive multiple prescribed medications for serious conditions such as COPD, heart failure, depression, hypertension, hypokalemia, atrial fibrillation, diabetes, and infection because the medications were not available in the facility. Staff did not notify a provider or document alternative orders as required by facility policy.
Multiple residents did not have care plans addressing their assessed needs, including activity preferences, supervised smoking, mobility and transfer assistance, skin integrity interventions, smoking status changes, complex medical regimens, and communication barriers. Staff interviews and observations confirmed that these omissions led to unaddressed resident needs and lack of staff awareness regarding required interventions.
A resident with repeated falls, including incidents from bed and wheelchair resulting in a fractured clavicle, did not have post-fall reviews or root cause analyses completed as required by facility policy. The DON confirmed that no assessments or care plan updates were made to prevent further falls.
A resident with PTSD did not have a completed trauma assessment or a care plan addressing trauma triggers and interventions. Staff, including an LNA, LPN, and Social Worker, were unaware of the PTSD diagnosis, and the Social Worker had not completed the required assessment or consulted the resident's guardian. The DON confirmed the care plan lacked trauma-informed interventions, despite facility policy requiring such measures.
The facility did not follow its pneumococcal vaccine policy for two residents, including missing documentation of vaccine history, lack of eligibility assessment, and failure to provide required education before or after vaccine refusal. Staff confirmed these documentation and process gaps.
Three residents did not receive COVID-19 vaccination and education as required by facility policy. Two residents over 65 received only one dose of the 2024-2025 vaccine with no record of a second dose or education, despite signed consent. Another resident under 65 had consent for vaccination but no documentation of vaccine administration, history, or eligibility assessment. The Infection Preventionist confirmed these lapses, and there was no vaccine shortage.
A resident with a high risk of infection recurrence did not receive a required CT scan after leaving the initial appointment and refusing a rescheduled one, with no further attempts made to complete the imaging or provide results to the ordering practitioner.
The facility did not provide required transfer/discharge and bed-hold notices to two residents who were hospitalized, as confirmed by record review and staff interviews. Facility policy mandates these notifications and documentation, but they were not present in the residents' files.
Three residents experienced significant changes in hospice care status, but the facility did not complete the required Significant Change in Status MDS assessments within the mandated timeframe. In one case, the assessment was completed late after hospice admission; in another, no assessment was done after hospice discharge; and for a third, no assessment was completed within 14 days of hospice admission. These deficiencies were confirmed through staff interviews and record reviews.
A resident in a LTC facility was hospitalized after receiving incorrect medications intended for another resident. The error involved multiple medications, including Ativan and Zyprexa, instead of the resident's prescribed Atenolol and others. The resident, with a history of hypertension and chronic kidney disease, became lethargic and hypotensive, requiring Narcan and emergency transfer to the hospital for further management.
A resident received incorrect medications due to a nurse's error, leading to lethargy and hospital admission. The facility delayed reporting the incident to the SSA, violating its policy requiring immediate notification for alleged abuse or serious injury.
The facility failed to administer medications timely for two residents, leading to deficiencies in care. A resident's insulin was administered late, affecting their blood sugar management, while another resident experienced multiple delays in receiving their prescribed intravenous antibiotic for Staph aureus septicemia. These delays were confirmed by staff interviews.
A facility failed to ensure that a Registered Nurse, who was assigned through an agency, had the necessary competencies to care for residents. The nurse did not receive orientation or skills assessment and was unfamiliar with the facility's electronic medical record system and medication administration procedures. The Night Supervisor had to provide basic guidance after their shift. The Administrator confirmed the absence of orientation for agency staff working a single shift.
A facility failed to maintain accurate records for a resident's controlled drugs, specifically Dilaudid 2 mg tablets. Discrepancies were found between the narcotic count and the documented count, with no investigation conducted. The narcotic book and medication administration record showed multiple discrepancies, and facility policies requiring accurate accountability and immediate reporting of discrepancies were not followed.
A facility failed to improve performance in reporting alleged violations, as evidenced by a medication error where a nurse administered incorrect medications to a resident. The error was recognized during verification, and the resident was assessed with no allergic reaction noted. The facility's QAPI agenda lacked documentation for improvement projects, and the deficiency had been cited in four consecutive surveys.
Two residents experienced significant delays in medication administration, with medications given more than two hours past their scheduled times. The Director of Nursing confirmed the expectation for timely administration but could not provide a facility policy on timing.
A facility failed to report an alleged abuse incident and investigation results within the required timeframe. A resident was found with a bruise of unknown origin, and during an interview, implicated a Licensed Nursing Assistant (LNA) as the alleged perpetrator. The initial report was delayed, and the interview findings were not reported to the State Survey Agency (SSA) as required by the facility's policy.
A facility failed to notify a resident's DPOA-H of significant changes in the resident's condition and treatment, including the introduction of new medications like Azithromycin and Oxycodone. Despite the resident's refusal of a chest x-ray and medications, and the DPOA-H's later concerns about Oxycodone, the facility did not document any notification to the DPOA-H, violating their policy on required notifications.
A resident with dementia and psychotic disturbance eloped from the facility without staff knowledge and was found consuming alcohol at a nearby hotel. Despite the incident, the facility failed to report the elopement to the State Survey Agency, violating its policy on abuse, neglect, and exploitation.
The facility failed to follow infection control guidelines for water management and Enhanced Barrier Precautions (EBP). It lacked documentation and control measures to prevent Legionella spread. Additionally, a nurse did not wear a gown while administering medication to a resident with a PICC line, contrary to CDC guidelines for preventing MDRO spread.
The facility failed to maintain accurate records for controlled drugs, with missing staff signatures and discrepancies in narcotic counts. A resident's methadone count was miscalculated, and corrections were undocumented, as confirmed by staff interviews.
The facility failed to properly label and store medications, with expired insulin pens found on a medication cart and a cart left unlocked and unattended. A resident had inhalers at their bedside without proper storage or documentation, contrary to facility policy.
A resident was found to be self-administering two inhalers without staff supervision, despite facility policy requiring an assessment for self-administration. The resident had physician orders for unsupervised use of one inhaler, but the other was to be clinician-administered. No assessment or care plan was documented, and staff were unaware of the resident's self-administration.
The facility failed to report alleged abuse and neglect incidents involving two residents to the State Survey Agency within the required timeframe. One resident felt bullied by a nurse, while another reported neglect by an LNA. The incidents were not reported as per facility policy.
A resident experienced significant pain due to missed doses of Hydrocodone-Acetaminophen 7.5-300 mg after the facility ran out of the medication. The resident's scheduled doses were missed over two days, and no emergency dose was available. This deficiency was confirmed through interviews and record reviews, highlighting a failure in pain management.
A resident with wounds on the abdomen and groin did not receive daily wound care as per physician orders. The Treatment Administration Record showed that the wounds were not cleaned on multiple days in June and July. Interviews with staff confirmed the expectation for daily cleaning, and the facility's policy required adherence to physician orders for wound care.
The facility did not provide the required SNF Advance Beneficiary Notice (ABN) to two residents who were discharged from Medicare Services but remained in the facility. The Business Officer confirmed that the SNF ABN forms were not completed for these residents, indicating a lapse in the notification process.
The facility failed to notify residents of the bed hold policy before hospital transfers. A resident discharged on a specific date had no evidence of receiving the policy, confirmed by the Director of Social Services. Another resident's record also lacked this information, confirmed by a Business Office staff member. The facility's policy requires providing this information before transfers, but it was not followed.
The facility failed to create comprehensive care plans for two residents, one requiring supervised smoking and another on anticoagulant medication. Despite assessments and physician orders, the care plans lacked necessary documentation and monitoring measures, as confirmed by the DON and ADON.
The facility failed to report alleged misappropriation/diversion of medications. An anonymous individual noticed a pattern of narcotics being signed out of the narcotic book but not recorded in the eMAR for several residents, indicating potential drug diversion. The issue was reportedly being handled by the unit manager and administration, but the allegation was not reported to the Administrator. The Administrator and DON were unaware of any allegations of misappropriation/diversion of residents' medications.
The facility failed to ensure accurate accounting for controlled medications for four residents. Discrepancies were found between the eMAR and the narcotic book, with medications being signed out more times than documented as administered. Interviews with residents and staff confirmed these findings.
Failure to Include Residents in Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to facilitate the inclusion of residents and/or their representatives in quarterly care plan meetings for 5 of 5 residents reviewed for care plan meetings in a final sample of 30 residents. Interviews with residents #6, #13, #16, #37, and #68 showed that they did not remember attending recent care plan meetings, and several stated they had not attended one in over a year or had never attended one. Record review showed no documentation of quarterly care plan meetings for resident #13 after 10/29/24, for resident #37 after 2/15/24, for resident #6 after 5/27/25, and for resident #16 since admission in 2024. For resident #68, the record showed no documentation of a care plan meeting since readmission in June 2025. The social worker confirmed on interview that there were no quarterly care plan meetings for residents #6, #13, #16, #37, and #68. The facility policy titled Care Planning-Resident Participation, revised 6/25, stated that the facility will discuss the plan of care with the resident and/or representative at regularly scheduled care plan conferences, allow them to see the care plan at initial and routine intervals and after significant changes, make an effort to schedule the conference at the best time for the resident or representative, and obtain a signature after discussion of viewing the care plan.
Failure to Document Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to document that Resident #66 and/or the resident’s representative was fully informed of the risks and benefits of a psychotropic medication before duloxetine was started. The resident had depression that had been treated with sertraline 25 mg daily, and the provider progress note dated 12/5/25 documented a decision to discontinue sertraline and prescribe duloxetine 30 mg daily. During interview, the Nurse Practitioner stated that he/she did not explain the risks and benefits of the medication with the resident and/or the resident’s representatives before starting duloxetine. The resident’s December MAR showed duloxetine 30 mg daily had been administered since 12/5/25, and review of the medical record found no documentation that the resident and/or representative had been informed of the risks and benefits of the medication. The DON confirmed these findings, and the facility policy required that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative be informed in advance of the benefits, risks, and alternatives.
Failure to Honor Resident Meal-Time Choice
Penalty
Summary
The facility failed to provide resident choice regarding meal times for 2 of 3 residents reviewed for choices in a final sample of 30 residents, identified in the report as Residents #48 and #64. Resident #64 reported that he/she receives dialysis three times a week and usually returns to the facility during lunchtime, where the meal tray is already waiting and the food is cold; when the resident requested that the meal be reheated, staff stated they could not, and the resident had to eat the meal cold. Resident #48 reported that he/she was not always ready to eat when the meal tray was served and, when requesting that the meal be reheated, staff stated they could not due to germs, resulting in the resident having to eat the meal cold. Staff interviews confirmed inconsistent reheating practices, with one LNA stating food used to be heated but is no longer allowed due to cross contamination, and an RN stating food is reheated unless the resident has already eaten because of germs on the plate or food.
Admission Medications Not Administered
Penalty
Summary
The facility failed to ensure that admission medications and supplements were administered for a newly admitted resident. The resident stated that he/she was admitted to the facility and was not given all medications that evening. Review of the January 2026 MAR showed multiple physician-ordered medications and supplements were not documented as administered, including melatonin, MiraLAX, olanzapine, phenytoin sodium extended, sennosides-docusate sodium, Tamiflu, and tuberculin on the day of admission, as well as phenytoin sodium extended, Coenzyme Q10, and Tamiflu the following day. Progress notes documented that medication was on order and waiting for arrival, that phenytoin sodium extended was not administered due to waiting to receive stock, and that Coenzyme Q10 and Tamiflu were not administered due to waiting to receive from pharmacy. There was no documentation that the provider was notified of the missed doses. The NP stated he/she was not notified of the missed doses. Review of the facility’s inventory showed that melatonin, MiraLAX, Tamiflu, sennosides-docusate sodium, Coenzyme Q10, and tuberculin were available in house stock, and that olanzapine 2.5 mg and phenytoin sodium extended 100 mg were available in the automated medication dispenser. An LPN confirmed he/she worked the evening shift and did not administer the medications, stating he/she did not have a code to access the automated medication dispenser that day.
Missing Care Plan Interventions for Smoking and Activities
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents with identified smoking needs and activity preferences. Resident #38 was documented as a tobacco user on the admission MDS, and a smoking/vaping screening assessment showed the resident required supervision while smoking, but the care plan contained no smoking interventions. Resident #113 stated he/she was a smoker and could go outside to the designated smoking area anytime he/she wanted; the smoking/vaping screening assessment identified the resident as an unsupervised smoker, yet the care plan also had no smoking interventions. Staff J, RN Supervisor, confirmed there was no smoking care plan in place for either resident. The facility also failed to develop activity-related care plan interventions for Resident #66. The annual MDS showed that while in the facility, the resident rated several activities as very important, including reading books, newspapers, and magazines; listening to music; being around animals; keeping up with the news; doing things with groups of people; doing favorite activities; and participating in religious services or practices. Review of the care plan showed no interventions for activities, and the Director of Social Services confirmed this finding.
Medication, Smoking, and Enteral Tube Administration Failures
Penalty
Summary
The facility failed to follow professional standards for medication administration for a resident receiving sliding-scale insulin. The resident stated that he or she sometimes did not get insulin. Review of the physician’s order showed insulin lispro was to be given subcutaneously before meals and at bedtime based on blood sugar results. Review of the December 2025 and January 2026 MARs showed no documentation of blood sugars or insulin administration on multiple dates, including several early morning doses in December and one evening dose in January. The NP confirmed the missed blood sugars and insulin, and the facility policy required the six rights of medication administration, including right documentation. The facility also failed to follow standards related to smoking and nicotine replacement therapy for another resident. The resident had an order for a 24-hour nicotine patch for smoking cessation and had a long history of smoking before admission. The resident stated that he or she was a smoker, went out to smoke with staff, and that a staff member removed the nicotine patch before smoking. The NP stated that he or she was not aware the resident was occasionally smoking. The facility’s smoking/vaping policy required the interdisciplinary team, with physician guidance, to support informed smoking decisions and develop a safe smoking/vaping plan or individualized plan to quit. The facility further failed to follow standards during medication administration through an enteral tube for a resident with a J-tube. During observation, an LPN crushed lamotrigine 100 mg even though the pharmacy label stated do not crush, flushed the J-tube, administered the crushed medication through the tube, and flushed again. The LPN did not verify J-tube placement before giving the medications and confirmed this during interview. The manufacturer’s instructions stated the tablet should be swallowed whole and not crushed, and the facility’s medication administration and feeding tube policies required medications to be given according to manufacturer specifications and tube placement to be verified before administration.
Failure to Provide Ordered Skin and Itch Care
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice to meet the physical, mental, and psychosocial needs of Resident #125, who was reviewed for skin conditions. During observation, the resident was seen sitting in the hallway with the top of the button shirt open and was scratching the chest area, which was bright red, raised, and had bumps. When interviewed, the resident stated, "I'm always itchy." The resident's MDS showed a BIMS score of 03, indicating severe cognitive impairment, and the medical record listed a diagnosis of seborrheic dermatitis. The resident had orders for CeraVe itch relief to be applied to the arms and back twice daily for dry skin and for HydrOXYzine 25 mg every six hours as needed for itching, starting 11/24/25. The weekly skin review documented right breast redness, pink groins, and scratches all over the upper body related to complaints of itching, with lotion applied and the condition noted as ongoing, and the nurse practitioner was aware. The nurse practitioner confirmed awareness of the ongoing condition and stated no new orders were given. Review of the January 2026 MAR showed the resident had not received any HydrOXYzine during that month.
Failure to Follow Droplet Precautions PPE Requirements
Penalty
Summary
The facility failed to implement established infection prevention policies for transmission-based precautions for one resident who was on Droplet Precautions for suspected influenza. During observation of the resident’s room, signage for Droplet Precautions was present, and two housekeepers were seen wearing PPE including a mask, gown, and gloves while performing cleaning tasks in the room. After completing some cleaning tasks, one housekeeper left the room wearing the same PPE, went to the housekeeping cart, spoke with other staff, walked down the hall, and entered another resident’s room while still wearing the PPE from the first room and without performing hand hygiene. The housekeeper confirmed leaving PPE on after exiting the room and entering the hallway and another resident’s room. The Infection Preventionist confirmed that, for Droplet Precautions, PPE should be removed and hand hygiene performed before leaving the room.
Smoking Care Plan Did Not Match Assessment
Penalty
Summary
The facility failed to care plan according to its smoking assessment for Resident #68, who was identified in the smoking assessment dated 11/6/25 as a supervised smoker. Review of the resident’s smoking care plan, revised 1/6/26, stated that the resident may smoke without supervision per smoking assessment, which did not match the assessment. During interview, Resident #68 stated that he/she smokes independently, and Staff J, the Nurse Supervisor, confirmed that Resident #68 smokes independently. Review of the facility’s Resident Smoking policy stated that residents who smoke are to be further assessed to determine whether supervision is required and that all safe smoking measures are to be documented on each resident’s care plan and communicated to staff, visitors, and volunteers responsible for supervising residents while smoking.
Failure to Implement Antibiotic Stewardship Program and Protocols
Penalty
Summary
The facility failed to implement its antibiotic stewardship program and antibiotic use protocols as outlined in its policy. Review of the June 2025 antibiotic line list showed that while the list included resident names, infections, antibiotics, and start/end dates, it did not indicate whether antibiotics were appropriate for use or if the Loeb Minimum Criteria was utilized. Specifically, a resident was prescribed Bactrim DS and Nitrofurantoin for urinary tract infection prophylaxis, but there was no documentation in the medical record of the Loeb's minimum criteria evaluation prior to the initiation of antibiotics. Interviews with the Infection Preventionist revealed an inability to explain or provide documentation that the Loeb's criteria were used for antibiotic initiation during the month in question. The Infection Preventionist also confirmed that data regarding resident infections and antibiotic use had not been discussed in QAPI meetings since their employment began. The Administrator corroborated that there had been no discussion of these topics in recent QAPI meetings, confirming the facility's failure to monitor and discuss antibiotic use as required by its own protocols.
Failure to Accurately Document and Communicate Advance Directives
Penalty
Summary
The facility failed to ensure that residents' advance directives and code status were accurately documented and consistently communicated across all relevant sections of the medical record for two residents. For one resident, the medical record contained conflicting information, with the resident header and physician's order indicating Do Not Resuscitate (DNR), Do Not Intubate (DNI), and Do Not Hospitalize (DNH) status, while the care plan and special instructions listed Full Code status. The code status binder also contained both a Full Code face sheet and a portable DNR form for this resident. Staff interviews confirmed the presence of these discrepancies and clarified that the resident's current code status was DNR, not Full Code. For the second resident, the physician's order indicated DNR status, but the care plan listed Full Code status. Documentation from the resident's guardian authorized a DNR/DNI order, but the care plan was not updated to reflect this change. Staff interviews confirmed that the care plan did not match the physician's order. These inconsistencies demonstrate a failure to adhere to facility policy regarding the accurate and timely documentation and communication of residents' advance directives and code status.
Use of Physical Restraint Without Medical Authorization
Penalty
Summary
A deficiency was identified when a resident was observed in a pedal broda chair with the leg rest elevated and two of the four wheels locked, which restricted the resident's ability to move freely. The resident was seen struggling to propel the chair and appeared agitated. Staff interviews confirmed that the wheels were intentionally locked to prevent the resident from moving around due to restlessness. Review of the resident's medical records, including physician's orders, assessments, and care plan, revealed no documentation or interventions authorizing the use of the locked wheels as a restraint. The Director of Rehab confirmed that the chair was provided for mobility, not restraint.
Failure to Provide and Administer Medications to Newly Admitted Residents
Penalty
Summary
The facility failed to ensure that prescribed medications were available and administered to two newly admitted residents. For one resident, multiple medications for conditions including COPD, heart failure, depression, hypertension, hypokalemia, and atrial fibrillation were not given on the first and second days after admission due to the medications not being received from the pharmacy. The resident reported not receiving all prescribed medications, and medical record review confirmed the missed doses. The facility's emergency medication supply did not contain all required medications, and there was no documented communication with a provider regarding the missed doses. For the second resident, essential medications for cardiac conditions, diabetes, hypertension, and infection were not administered on the day of admission because they were unavailable. Progress notes indicated the medications were not on hand, and there was no evidence that a provider was notified about the missed doses. The facility's emergency supply only included a lower dose of one of the required medications. Facility policy required staff to notify a physician and obtain alternative orders when medications were unavailable, but this was not documented in either case.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for seven residents, as identified through record review, observation, and staff interviews. For one resident, the care plan did not address individual or group activity preferences, despite the resident expressing strong interests in reading, music, animals, news, favorite activities, and religious services. Staff confirmed the absence of a care plan for these preferences, and the Activities Director acknowledged this omission. Another resident, who required supervised smoking per assessment and facility policy, did not have a care plan addressing supervised smoking, and the Unit Manager confirmed this gap. A resident dependent on a wheelchair for mobility and requiring assistance with eating, hygiene, and transfers did not have a care plan addressing these needs, as confirmed by staff. Another resident with physician orders to offload heels to prevent skin breakdown was repeatedly observed in bed with heels directly on the mattress, and staff were unaware of the care plan intervention or physician order. Additionally, a resident who had smoking privileges revoked did not have a care plan addressing smoking status or the removal of privileges, as confirmed by the Director of Nursing. Further deficiencies included a resident on hemodialysis and multiple medications who required assistance with activities of daily living but only had care plans for code status and nutritional risk, with no interventions for other identified needs. Lastly, a resident whose primary language was Cambodian and who only understood simple English commands did not have a care plan addressing communication barriers, and staff were unaware of the resident's language needs. These findings demonstrate multiple failures to develop and implement care plans that address the comprehensive needs of residents as identified in their assessments.
Failure to Investigate and Address Causes of Resident Falls
Penalty
Summary
The facility failed to determine the causes or contributing factors for multiple falls experienced by a resident, and did not revise the resident's plan of care or facility practices to reduce the likelihood of further falls. The resident, who had a history of repeated falls from both bed and wheelchair, sustained a fractured clavicle as a result of one of these incidents. Progress notes documented several falls over a period of time, including incidents where the resident slid out of bed, was found on the floor next to the bed, was found on the floor in the dining room (resulting in an emergency room visit for shoulder pain), and was found sitting on the floor in the hallway. Review of post-fall documentation revealed that for each of these falls, there was either no post-fall review completed or no description of what occurred and no root cause identified. The facility's policy required completion of a post-fall assessment, incident report, care plan review, and documentation of all assessments and actions following a fall. However, interviews and record reviews confirmed that these steps were not followed for the resident's falls, and no interventions were identified or implemented to prevent further incidents.
Failure to Identify and Address PTSD Triggers in Resident Care Plan
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) had identified triggers and interventions in place to eliminate or mitigate the risk of re-traumatization. Review of the resident's medical record showed an incomplete Social History and Trauma Assessment, which had been initiated but not completed. The resident's care plan did not address PTSD, nor did it include any identified triggers or interventions related to trauma. Interviews with facility staff, including a Licensed Nursing Assistant, an LPN, and the Social Worker, revealed that they were unaware of the resident's PTSD diagnosis and that the Social Worker had not completed the necessary assessment or interviewed the resident's guardian regarding trauma history and triggers. The Director of Nursing confirmed the absence of a care plan addressing PTSD triggers and interventions for this resident. Facility policy requires a multi-pronged approach to identifying trauma history, including direct inquiry about triggers and the development of individualized care plan interventions to minimize or eliminate re-traumatization. Despite these policy requirements, the facility did not complete the trauma assessment or incorporate trauma-informed care planning for the resident with PTSD. This resulted in a lack of staff awareness and absence of documented strategies to address the resident's trauma-related needs.
Failure to Implement Pneumococcal Vaccine Policy for Two Residents
Penalty
Summary
The facility failed to implement its pneumococcal vaccine policy for two residents. For one resident, there was no documentation of pneumococcal vaccine history or assessment of eligibility upon admission, despite a signed consent from the resident's guardian for vaccine administration. There was also no record that the vaccine was administered, and staff were unable to provide documentation of any assessment for vaccine eligibility. For the second resident, the immunization record showed no history of receiving a pneumococcal vaccine, and although the vaccine was refused, there was no documentation that education about the vaccine was provided to the resident or their representative before or after the refusal. Staff confirmed the absence of required documentation and education for both residents, indicating noncompliance with the facility's policy and CDC guidelines regarding pneumococcal immunizations.
Failure to Implement COVID-19 Vaccination Policy and Documentation
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy for three of five residents reviewed for immunizations. According to the facility's policy, residents and staff are to be educated about the COVID-19 vaccine, offered the vaccine, and have their vaccination status properly documented. For residents aged 65 and older, the policy requires two doses of the 2024-2025 COVID-19 vaccine, while those aged 12-64 require one dose. Review of records revealed that two residents in their 70s and 80s received only one dose of the 2024-2025 vaccine, with no documentation of a second dose being administered or offered, despite signed consent forms. Additionally, there was no documentation of education provided to one of these residents or their representative. Another resident, in their 60s and under 65, had a signed consent form for the COVID-19 vaccine but no documentation of vaccine administration, history, or assessment of eligibility. Interviews with the Infection Preventionist confirmed these findings and clarified that there was no shortage of vaccine supply, as doses could be ordered from the pharmacy as needed. The lack of documentation and follow-through on vaccine administration and education for these residents constitutes a failure to follow the facility's established COVID-19 vaccination policy.
Failure to Obtain Ordered Radiology Services
Penalty
Summary
A deficiency occurred when the facility failed to obtain radiology services as ordered for a resident who was at high risk for recurrence of infection and required a CT scan of the abdomen and pelvis with contrast. The resident initially went to an appointment for the CT scan but left before it could be completed and did not recall the reason. The scan was rescheduled at another location, but the resident refused to attend the second appointment, and no further appointment was made. Review of the medical record showed no results or follow-up for the required imaging, despite ongoing orders and the resident's continued need for assessment related to infection risk. Staff interviews confirmed that the imaging was not completed and that the ordering practitioner had not received results.
Failure to Provide Required Transfer and Bed-Hold Notices During Hospitalizations
Penalty
Summary
The facility failed to provide required notifications and documentation regarding transfer, discharge, and bed-hold policies for two residents who were hospitalized. For one resident, medical record review showed two separate hospital transfers, but there was no documentation that a bed hold notice was provided for either event. Staff interviews confirmed the absence of this documentation. For the second resident, the medical record indicated a hospital transfer, but there was no evidence that a transfer/discharge notice or bed hold notice was given. Staff interviews further confirmed that these notifications were not provided. Facility policy requires that a signed and dated copy of the bed-hold notice be kept in the resident's file and that transfer/discharge notices be provided in an understandable manner to the resident and their representative, with evidence that the notice was sent to the Ombudsman. Review of the records and staff interviews confirmed that these requirements were not met for the two residents involved.
Failure to Complete Timely Significant Change MDS Assessments for Residents with Hospice Status Changes
Penalty
Summary
The facility failed to ensure timely completion of Significant Change in Status Minimum Data Set (MDS) assessments for three residents who experienced significant changes in their hospice care status. For one resident, the MDS assessment was completed late after the resident was admitted to hospice care, as confirmed by the MDS Coordinator. Another resident was discharged from hospice services, but no Significant Change in Status MDS was completed following the end of hospice care, as verified by the Director of Nursing. Additionally, a third resident was admitted to hospice care, but no Significant Change in Status MDS was completed within the required 14-day period following the change. These findings were confirmed through interviews with facility staff and review of resident records, which documented the changes in hospice status and the lack of timely or completed MDS assessments as required.
Significant Medication Error Leads to Hospitalization
Penalty
Summary
The facility failed to ensure that a resident remained free from significant medication errors, resulting in the resident requiring hospitalization. During a morning medication round, a registered nurse inadvertently administered the incorrect medications to a resident, giving them another resident's medications instead of their prescribed ones. The medications administered in error included Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, while the resident was supposed to receive Atenolol, Lactobacillus, and Omeprazole. The nurse recognized the error upon verifying the medication administration record and immediately assessed the resident, notified the attending physician, and informed the family. The resident, who had a medical history of hypertension, hyperlipidemia, bladder cancer, chronic hypoxemic respiratory failure, and chronic kidney disease, became lethargic and was later found to have hypotension. The physician ordered frequent monitoring of vital signs and PRN Naloxone spray. Despite these interventions, the resident's condition worsened, leading to the administration of Narcan and subsequent transfer to the hospital via emergency medical services. At the hospital, the resident required brief bag mask ventilation and was admitted for observation and medical management due to hypotension caused by the medication error.
Failure to Timely Report Medication Error and Alleged Abuse
Penalty
Summary
The facility failed to report an alleged violation of abuse immediately to the State Survey Agency (SSA) as required. A registered nurse (RN) inadvertently administered incorrect medications to a resident, including Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, instead of the prescribed Atenolol, Lactobacillus, and Omeprazole. The error was recognized during the medication administration round, and the attending physician was notified. The resident was assessed, and the family was informed. Despite no initial allergic reaction, the resident became lethargic, and Narcan was administered following a telehealth provider's order. The resident was eventually sent to the hospital via emergency services. The Director of Nursing confirmed the resident's hospital admission, and the facility administrator began investigating the incident the day after it occurred. However, the incident was not reported to the SSA until two days later, which was not in compliance with the facility's policy. The policy mandates that alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after the allegation is made. In this case, the delay in reporting the incident to the SSA constituted a deficiency in the facility's adherence to its reporting policy.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to administer medications timely for two residents, leading to deficiencies in care. For Resident #4, a delay in administering scheduled insulin was observed. The resident's blood sugar was recorded at 177, and the insulin, which was supposed to be administered before breakfast at 7:00 a.m., was not given until 8:51 a.m. This delay was confirmed during an interview with Staff H, a Registered Nurse, who acknowledged the late administration. Resident #1 experienced multiple delays in receiving their prescribed intravenous antibiotic, Cefazolin, which was ordered to be administered every 8 hours for Staph aureus septicemia. The medication was consistently administered late on several occasions, with delays ranging from over an hour to several hours past the scheduled time. These delays were confirmed by the Director of Nursing, Staff A, during an interview. The repeated late administration of this critical medication highlights a significant lapse in adhering to prescribed medication schedules.
Lack of Competency Assessment for Agency Nurse
Penalty
Summary
The facility failed to ensure that licensed nurses had the necessary competencies and skill sets to meet residents' needs, as evidenced by the experience of a Registered Nurse (Staff E) who was assigned to a shift through an agency. Upon arrival, Staff E did not receive any orientation or skills assessment, despite being unfamiliar with the facility's electronic medical record system and the location of the medication room. During the shift, Staff E encountered difficulties administering antibiotics to a resident due to a lack of knowledge about the intravenous pump required for the medication. The Night Supervisor (Staff G) confirmed that Staff E expressed concerns about their unfamiliarity with the electronic medical record system, and Staff G had to stay after their shift to provide basic guidance. The facility's Administrator (Staff B) acknowledged that there was no orientation or skills assessment for agency staff working a single shift.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, specifically for a resident's Dilaudid 2 mg tablets. On February 23, 2025, a discrepancy was discovered during a narcotic count reconciliation by a registered nurse and the night shift nurse. The count of narcotics did not match the documented count in the narcotic book. The night supervisor adjusted the narcotic book to match the physical count without conducting an investigation into the discrepancy. Further interviews confirmed that there was no investigation into the missing narcotics, and the director of nursing was not informed of the discrepancy as required by the facility's policy. A review of the narcotic book and the resident's medication administration record revealed multiple discrepancies in the number of tablets documented as administered on various dates in February 2025. Additionally, there were illegible entries in the narcotic book for medication administration and the amount received from the pharmacy on February 21, 2025. The facility's policies require accurate accountability of controlled substances and immediate reporting and investigation of any discrepancies, which were not followed in this case.
Medication Error and Reporting Deficiency
Penalty
Summary
The facility failed to take actions aimed at performance improvement and measure its success in reporting alleged violations of abuse and neglect. A specific incident involved a registered nurse inadvertently administering incorrect medications to a resident during a morning medication round. The medications given included Ativan, Zyprexa, Tramadol, Amantadine, Amlodipine, Cymbalta, Gabapentin, and Protonix, instead of the prescribed Atenolol, Lactobacillus, and Omeprazole. The nurse recognized the error while verifying the medication administration record and immediately assessed the patient, notified the attending physician, and informed the family. No allergic reaction was noted, and the physician ordered PRN Naloxone spray. The facility's Quality Assurance and Performance Improvement (QAPI) agenda lacked documentation for performance improvement projects related to reporting alleged violations. The administrator confirmed the findings and began investigating the incident two days after it occurred, reporting it to the SSA on the same day as the survey review. The facility's survey history revealed that the deficiency related to the reporting of alleged violations had been cited in the last four consecutive surveys, indicating a pattern of non-compliance in this area.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure timely administration of medications for two residents, leading to a deficiency in meeting professional standards of quality. For Resident #5, there was a delay in administering Sevelamer, a phosphate binder, which was scheduled for 7:30 a.m. but given at 11:59 a.m., and Fluticasone-Salmetrol, an inhalation medication for wheezing, scheduled for 4:00 p.m. but administered at 9:16 p.m. These medications were administered more than two hours past their scheduled times, which is outside the acceptable window for non-time-critical medications. Similarly, Resident #6 experienced delays in medication administration. Humalog, an insulin sliding scale to be given with meals, was scheduled for 8:00 a.m. but administered at 11:08 a.m. Additionally, Depakote, an anticonvulsant, and Midodrine, for hypotension, both scheduled for 9:00 a.m., were administered at 11:09 a.m. The Director of Nursing confirmed these findings and stated the expectation was to administer medications within one hour before or after the scheduled time, but was unable to provide a facility policy on medication administration timing.
Failure to Timely Report Alleged Abuse and Investigation Results
Penalty
Summary
The facility failed to report an alleged violation of abuse within the required 24-hour timeframe and did not report the results of the investigation to the State Survey Agency (SSA) for one resident. A nurse initially reported a bruise of unknown origin on a resident's right forearm, which was first noted on a provider's note. The Social Service Director interviewed the resident, who mentioned a tall black man, and the facility identified the alleged perpetrator as a Licensed Nursing Assistant (LNA). The initial report about the bruise was sent to the SSA two weeks after it was first noted, and the interview findings implicating the LNA were not reported to the SSA. The facility's policy requires reporting all alleged violations to the Administrator, state agency, adult protective services, and other required agencies within specified timeframes, which was not adhered to in this case. The Assistant Director of Nursing confirmed the findings and stated that the LNA's contract was terminated.
Failure to Notify DPOA-H of Resident's Condition and Treatment Changes
Penalty
Summary
The facility failed to notify the activated Durable Power of Attorney for Healthcare (DPOA-H) of a resident's change in condition and medication alterations. The resident, who was being monitored for hypoxia and nasal congestion, refused a chest x-ray and was subsequently prescribed Azithromycin and Oxycodone, while Morphine was discontinued. Despite these significant changes in treatment, the DPOA-H was not informed, as confirmed by the Assistant Director of Nursing during an interview. The resident continued to exhibit symptoms, including difficulty breathing and increased congestion, and refused medications and meals. The DPOA-H later contacted the facility, expressing concern over the administration of Oxycodone, which they were unaware had been started. The facility's policy mandates notification of significant changes in a resident's condition or treatment, which was not adhered to in this case, as there was no documentation of the DPOA-H being informed.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an incident of elopement involving a resident with dementia and psychotic disturbance to the State Survey Agency. On the evening of July 28, 2024, a nurse discovered that the resident was missing from the facility, having not signed out at the check-out book or reception desk. The administration was notified, and a statement was given to the police. The resident was eventually found at a nearby Holiday Inn, where they had consumed alcohol at the bar, and was returned to the facility later that night. The resident involved in the incident was diagnosed with unspecified dementia with psychotic disturbance and was on several medications, including Clorazepate Dipotassium, Gabapentin, Depakote sprinkles, and Venlafaxine. Despite the seriousness of the situation, the facility's administrator confirmed that no report was made to the State Survey Agency regarding the elopement. This failure to report was in violation of the facility's policy on abuse, neglect, and exploitation, which mandates reporting such incidents to the appropriate authorities within specified timeframes.
Infection Control Deficiencies in Water Management and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to established infection control guidelines concerning water management and Enhanced Barrier Precautions (EBP). During a review of the facility's Water Management Program, it was found that the facility lacked essential documentation, such as a plumbing map or schematic, to monitor and control measures against Legionella. Interviews with the Infection Preventionist and Maintenance Director confirmed the absence of a system to prevent the introduction and spread of Legionella, as well as a lack of control measures in place. Additionally, the facility did not follow the CDC guidelines for Enhanced Barrier Precautions for a resident with a peripherally inserted central catheter (PICC). During medication administration, a registered nurse was observed wearing gloves but not a gown, which is required for high-contact resident care activities involving indwelling medical devices. The facility's policy and CDC guidelines specify the use of gowns and gloves to prevent the spread of multidrug-resistant organisms (MDROs) during such activities, but these precautions were not followed in this instance.
Controlled Drug Recordkeeping Deficiency
Penalty
Summary
The facility failed to maintain an accurate system of records for the receipt and disposition of controlled drugs, which led to discrepancies in narcotic counts. Specifically, the facility's policy on Controlled Substance Administration & Accountability was not adhered to, as evidenced by missing staff signatures in the Controlled Substances Book for various dates on both the 4th and 3rd Floor South Side Medication Carts. Interviews with staff confirmed these findings, indicating a lack of compliance with the policy requiring two licensed nurses to account for all controlled substances and access keys at the end of each shift. Additionally, the facility failed to properly document and reconcile the narcotic count for a resident receiving methadone for chronic pain. The resident's narcotic count showed discrepancies, including a miscalculation of the remaining methadone available and a lack of documentation for corrections made to the narcotic count. Interviews with nursing staff confirmed these discrepancies and the failure to document the transfer of medication appropriately, resulting in an inaccurate account of the controlled drug.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to professional standards. During an observation of a medication cart on the third floor, it was found that a resident's Insulin Aspart Flex pens had expired, and another resident's Humulin Regular U-500 insulin pen was open without an open expiration date on the label. A registered nurse confirmed these findings. The manufacturer's instructions for both medications specify that they should be disposed of after 28 days of being opened, which was not adhered to in this case. Additionally, a medication cart on the fourth floor was observed to be unlocked and unattended in the hallway for approximately 15 minutes, with residents present in the area. This was confirmed by a registered nurse. Furthermore, a resident was found to have two inhalers at their bedside without a lock box or locked storage compartment, contrary to the facility's policy. The resident had no orders for the inhalers to be kept at bedside, and there was no documentation of instructions provided to the resident regarding proper storage. The Director of Nursing confirmed these findings.
Failure to Assess Resident's Ability to Self-Administer Medication
Penalty
Summary
The facility failed to determine the clinical appropriateness of self-administration of medication for a resident. During an observation, it was noted that the resident had two inhalers on their bedside table: an Albuterol Sulfate Aerosol Solution inhaler and a Combivent Respimat Inhalation Aerosol Solution inhaler. The resident confirmed that they self-administered these inhalers without staff supervision. A review of the resident's active physician orders showed an order for unsupervised self-administration of the Combivent inhaler, but the Albuterol Sulfate inhaler was to be administered by a clinician. Further investigation revealed that there was no assessment conducted to determine the resident's ability to self-administer the inhalers, nor was there a care plan in place for the self-administration of these medications. Interviews with staff, including a Registered Nurse and the Director of Nursing, confirmed the lack of awareness and documentation regarding the resident's self-administration of inhalers. The facility's policy requires an interdisciplinary team assessment for residents who wish to self-administer medications, but this was not conducted for the resident in question.
Failure to Timely Report Alleged Abuse and Neglect
Penalty
Summary
The facility failed to report alleged violations of abuse or neglect to the State Survey Agency (SSA) within the required timeframe for two residents. Resident #49 reported feeling scared, bullied, and harassed by a registered nurse, Staff N, to the Assistant Director of Nursing, Staff D. Despite being informed that Staff N would no longer provide care to Resident #49, the incident was not reported to the SSA. The Administrator, Staff P, was unaware of the incident until several days later and had not reported it to the state. Similarly, Resident #22 filed grievances regarding neglect by a Licensed Nursing Assistant, Staff O, who allegedly refused to assist with personal care tasks and failed to clean a urine collection device. These grievances were not reported to the SSA, and Staff O was no longer employed at the facility. The facility's policy requires immediate investigation and reporting of all alleged violations, which was not adhered to in these cases.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #19, who was part of a sample of 31 residents reviewed for pain management. The deficiency was identified through an interview and record review. The resident reported being awake and in pain all night in early July 2024 because the facility ran out of their prescribed pain medication, Hydrocodone-Acetaminophen 7.5-300 mg. A progress note from a registered nurse on July 7, 2024, confirmed that the resident's morning dose was missed, and no emergency dose was available from the E-Kit. The resident's Medication Administration Record showed missed doses on July 7 and July 8, 2024. A nurse practitioner documented on July 8, 2024, that the resident reported significant pain due to the missed doses.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to adhere to physician orders for wound care for a resident with skin conditions. The resident, identified as having wounds on the abdomen and groin, reported that the wounds were supposed to be cleaned daily but had not been cleaned since the previous week. A review of the resident's physician orders indicated a specific regimen for wound care, including cleansing with wound cleaner, applying skin prep, Medi honey, and silicone bordered foam dressing, to be performed every shift and as needed. However, the Treatment Administration Record (TAR) showed that the resident's wounds were not cleaned on 13 out of 30 days in June and 17 out of 23 days in July. Interviews with facility staff, including a Nurse Practitioner and a Wound Care Nurse, confirmed the expectation that the resident's wounds should be cleaned daily according to the physician's orders. The facility's policy on Wound Treatment Management, revised in January 2024, also stipulated that wound treatments should be provided in accordance with physician orders, including the method of cleansing, type of dressing, and frequency of dressing changes. The failure to follow these orders resulted in a deficiency in the care provided to the resident.
Failure to Provide SNF ABN to Residents
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were informed of the Skilled Nursing Facility (SNF) Advance Beneficiary Notice (ABN) for two residents. Resident #49 was discharged from Medicare Services on July 5, 2024, but remained in the facility without receiving the required SNF ABN form. Similarly, Resident #139 was discharged from Medicare Services on May 25, 2024, and also remained in the facility without the SNF ABN form being provided. During an interview on July 25, 2024, Staff C, the Business Officer, confirmed that the SNF ABN forms for both residents had not been completed, acknowledging the oversight in the notification process.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to notify residents of the bed hold policy before transfers to the hospital for three residents in a sample of 31. Resident #77 was discharged to the hospital on 7/17/2024, and there was no evidence in their medical record that the bed hold policy was provided at the time of transfer. Similarly, Resident #146 was discharged to the hospital on 6/18/2024, and their medical record also lacked evidence of the bed hold policy being provided. An interview with the Director of Social Services confirmed that the bed hold policy was not being provided at the time of transfer. Resident #5 was discharged to the hospital on 4/14/2024, and their medical record showed no evidence of the bed hold policy being provided upon transfer. An interview with a staff member from the Business Office confirmed that the bed hold policy was not provided to residents transferred to the hospital. The facility's policy, dated 7/2021, requires that residents or their representatives be given written information about the bed hold policy before a transfer to the hospital or therapeutic leave, but this was not adhered to in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, leading to deficiencies in their care. Resident #48, who required supervised smoking, did not have a care plan addressing this need. Despite an assessment indicating the necessity for supervision, the care plan lacked documentation of safe smoking measures, which should have been communicated to all responsible parties. This oversight was confirmed by the Director of Nursing during an interview. Similarly, Resident #5, who was prescribed Eliquis for nonrheumatic aortic valve stenosis, did not have a care plan for monitoring the side effects of the anticoagulant medication. The absence of a care plan for this critical aspect of the resident's treatment was confirmed by the Assistant Director of Nursing. The facility's policy on comprehensive care plans mandates that care plans describe the services necessary to maintain the resident's highest practicable well-being, which was not adhered to in these cases.
Failure to Report Alleged Drug Diversion
Penalty
Summary
The facility failed to report alleged misappropriation/diversion of medications. An interview with an anonymous individual revealed a pattern of narcotics being signed out of the narcotic book but not recorded in the resident's electronic Medication Administration Record (eMAR) for several residents. This practice could indicate drug diversion. The anonymous individual was informed by a staff member that the issue was being handled by the unit manager and administration, but the allegation was not reported to the Administrator. Interviews with the Administrator and the Director of Nursing confirmed that they were unaware of any allegations of misappropriation/diversion of residents' medications.
Failure to Accurately Account for Controlled Medications
Penalty
Summary
The facility failed to ensure accurate accounting for all controlled medications for four residents. The policy review revealed that after administering medication, it should be documented in the Medication Administration Record (MAR), Treatment Administration Record (TAR), and controlled substance sign-out record. However, discrepancies were found in the documentation and administration of Oxycodone HCL for Residents #1, #2, #3, and #7. For instance, Resident #1's eMAR showed no documentation of Oxycodone administration, yet the narcotic book indicated it was signed out six times. Resident #1, who is moderately impaired, reported not using extra pain medication and preferred Tylenol instead. Similarly, Resident #2's eMAR showed only one instance of Oxycodone administration, but the narcotic book indicated it was signed out 23 times. Resident #2, who is cognitively intact, reported rarely using Oxycodone and did not recall recent usage. Resident #3's eMAR documented multiple administrations of Oxycodone, but the narcotic book showed an extra 19 instances of signing out the medication. Resident #3, who is also cognitively intact, confirmed receiving Oxycodone as needed, mostly during nighttime hours. Lastly, Resident #7's eMAR showed two instances of Oxycodone administration in February and one in March, but the narcotic book indicated 12 sign-outs in February and 37 in March. Interviews with the Administrator and Director of Nursing confirmed these findings.
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Illustrative
What surveyors actually found near you
We read the 150 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Concord
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Presidential Oaks | 0.4 mi | ★★★★★ | 9 | 0 |
| Harris Hill Center, Genesis Healthcare | 1.5 mi | ★★★★★ | 11 | 0 |
| Havenwood-heritage Heights | 2.9 mi | ★★★★★ | 6 | 0 |
| Epsom Healthcare Center | 10.4 mi | ★★★★★ | 11 | 0 |
| Hackett Hill Healthcare Center | 11.6 mi | ★★★★★ | 5 | 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.