Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Alaris Health At St Marys during CMS and state inspections, most recent first.
Surveyors identified that two residents did not have consistent documentation of required nursing treatments on the TAR, including wound care, skin care, and regular turning and repositioning. Multiple treatments were left blank across various shifts and dates, despite staff statements that documentation should be complete and accurate after each intervention.
Two residents with significant care needs had multiple instances where ADL care tasks such as personal hygiene, turning and repositioning, and continence care were not documented as completed across several months. Staff interviews confirmed that both CNAs and nurses were responsible for ADL documentation, and facility policy required complete and accurate records.
A resident who was cognitively intact and required assistance for mobility was discharged to a boarding home without the ordered VNS/PT/OT services being initiated. The Director of Social Services did not coordinate the required community services or follow the facility's discharge policy, and the resident's physician was not informed of the discharge location or the lack of services.
The facility failed to ensure smoking safety for a resident in a piped-in oxygen room, leading to an Immediate Jeopardy situation. Additionally, a ventilator-dependent resident was injured during an unsafe transfer due to inadequate staff presence. The facility also failed to effectively supervise a resident with a history of substance abuse, who was found with drug paraphernalia and tested positive for illicit substances.
A resident in a persistent vegetative state sustained a traumatic hematoma of the right eye, and the facility failed to conduct a thorough investigation into the injury. Discrepancies in staff statements and a lack of adherence to transfer protocols were identified. The Director of Nursing acknowledged miscommunication, and hospital records indicated a suspicion of elder abuse.
The facility failed to manage residents' Personal Needs Accounts (PNA) effectively, resulting in 21 residents having balances exceeding the $2,000.00 Medicaid eligibility threshold. Interviews revealed a lack of clear responsibility and communication between the Certified Social Worker, Business Office Manager, and Per Diem Social Worker, leading to inadequate oversight and management of PNA funds.
The facility did not have a Surety Bond to protect resident funds, affecting all residents with Personal Needs Accounts. The LNHA provided a Certificate of Liability Insurance instead, as instructed by corporate oversight. A review showed eighty-five resident accounts with a total balance of $84,036.27, and the LNHA could not confirm if funds were in interest-bearing accounts.
The facility failed to maintain an effective QAPI program, leading to deficiencies in resident safety. A resident was found smoking in their room despite a no-smoking policy, another resident with substance abuse issues was not adequately managed, and a third resident sustained an injury of unknown origin. The facility's QAPI program did not effectively review or address these incidents, and the Medical Director was not informed of critical safety concerns.
A resident with paralysis was unable to reach their call bell due to it being placed on the wrong side, despite requests for it to be moved. Observations confirmed the call bell was consistently placed out of reach, contrary to the resident's care plan and facility policy.
Two residents in an LTC facility did not receive appropriate incontinence and personal hygiene care. One resident was found with saturated briefs and a lack of specific care instructions, while another had untrimmed, dirty nails despite receiving morning care. The facility's management confirmed that staff were responsible for these care tasks.
A resident with Diabetes Mellitus experienced a delay in podiatry care, with a consult ordered in early December but not completed until mid-January. The resident was observed with dry, cracked skin and blackened areas on the feet, and was not wearing the prescribed pressure-relieving boots. The facility's policy for routine and emergency podiatry services was not followed, as the podiatrist was available weekly but the consultation was delayed by six weeks.
Two residents experienced a lack of dignified care in the facility. One resident was left without bed linens, pillows, or blankets, despite having severe cognitive impairment and needing assistance for mobility. Another resident reported that staff failed to empty urinals and did not respond promptly to call lights, with urinals found full during meal times. The facility's policies on dignity and respect were not adhered to, as observed by surveyors.
A resident with severe cognitive impairment was found with a hematoma and facial bruising, which was not reported by the CNA who observed it. The RN was informed five hours later by the resident's representative. The facility failed to notify the family or responsible party as required by policy, leading to a deficiency.
The facility failed to maintain safe handrails on the 3rd floor Dementia Unit, with multiple unsecured and cracked handrails observed. Despite being identified, the issues were not addressed promptly, and maintenance logs were incomplete. Maintenance staff acknowledged the problem but lacked a process to address it, and the facility had no specific policy for handrail maintenance.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in care management. One resident was incorrectly coded as not being a smoker, despite evidence to the contrary. Another resident's discharge MDS was not completed in a timely manner, only being addressed after surveyor inquiry. These issues highlight lapses in the facility's process for updating resident records.
A resident was observed with medications left at their bedside, contrary to facility protocol, which requires nurse supervision during administration. The LPN admitted to leaving the medications unattended and failing to ensure they were taken. The resident was not assessed for self-administration capability, and the Comprehensive Care Plan lacked focus on this aspect. The facility's policy mandates safe and timely medication administration, with self-administration only allowed after proper assessment.
A facility failed to administer oxygen therapy according to a physician's order and did not ensure proper storage of oxygen equipment for a resident with multiple health conditions, including COPD and diabetes. The resident received oxygen at incorrect flow rates, and the nasal cannula was improperly stored, contrary to facility policy and physician orders. Staff interviews confirmed the discrepancies in oxygen administration and equipment storage.
A facility failed to ensure a resident had the cognitive ability to sign an arbitration agreement. The resident, who was legally blind and had severe cognitive impairment, was unable to understand or sign documents. Despite this, the arbitration agreement was signed without the involvement of a legally authorized representative. The facility's policy required that agreements be explained in a manner understandable to the resident or their representative, which was not followed.
The facility failed to prevent the spread of infection by not adhering to PPE protocols for residents on contact precautions. A RN/UM and a RD entered the rooms of two residents with C. Auris colonization without donning the required gowns and gloves, despite clear signage and prior training. Both residents had severe medical conditions necessitating contact precautions.
Failure to Consistently Document and Provide Nursing Treatments on TAR
Penalty
Summary
The facility failed to ensure that nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficiency was identified for two residents who required multiple treatments and interventions, including topical ointments for wound prevention and care, skin care, use of gel cushions and heel lifts, and regular turning and repositioning. Review of the TARs for these residents over several months revealed multiple instances where required treatments were not documented as completed, with blank entries noted for various shifts and dates. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, the TAR showed missing documentation for several treatments such as application of Boudreaux's butt paste ointment, Lac-Hydrin lotion, turn and reposition every two hours, gel cushion placement, heel lifts, vitamins A and D ointment, zinc oxide cream, and pressure-relieving mattress checks. These omissions occurred across multiple dates and shifts, indicating a pattern of incomplete documentation for essential nursing interventions. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had missing documentation for required turning and repositioning on several occasions. Interviews with the Unit Manager and Director of Nursing confirmed that nurses were expected to document treatments on the TAR after completion, and that documentation should be objective, complete, and accurate as per facility policy. However, the review of records demonstrated that this standard was not consistently met.
Failure to Consistently Document ADL Care Provided to Residents
Penalty
Summary
The facility failed to consistently document the provision of Activities of Daily Living (ADL) care for two residents who required assistance. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, multiple blank entries were found in the ADL documentation forms over several months. These blank entries indicated that tasks such as personal hygiene, turning and positioning every two hours, bladder and bowel continence care, rolling left and right, and use of a preventative mattress were not documented as completed on numerous shifts across June, July, and August. The resident was assessed as cognitively intact, and the documentation gaps were identified through a review of the resident's medical records and documentation survey reports. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had multiple blank spaces in their ADL documentation forms. These omissions included personal hygiene, turning and repositioning, bladder and bowel continence care, rolling left and right, and use of a preventative mattress, with missing documentation noted on various day, evening, and night shifts. The review of documentation for this resident covered the months of June and July, with similar patterns of incomplete records for required care tasks. Interviews with staff revealed that CNAs were responsible for turning and positioning residents who were incontinent and in bed, and that nurses provided reports to CNAs identifying which residents required this care. The Director of Nursing (DON) confirmed that if care was not documented, it was considered not done, and stated that both nurses and CNAs were responsible for completing ADL documentation. The DON also indicated that the Assistant Director of Nursing (ADON) and nurse manager were tasked with auditing ADL documentation for completion. Facility policy required that documentation in the medical record be objective, complete, and accurate.
Failure to Coordinate Discharge Services and Follow Discharge Policy
Penalty
Summary
The facility's Director of Social Services (DSS) failed to assist a resident in obtaining needed community services and did not follow the facility's Discharge Policy. The resident, who was cognitively intact and required supervision or assistance for mobility, had a care plan indicating a wish to be discharged home with arrangements for community resources such as home care, PT/OT, and nursing services. Physician orders were in place for discharge to home with VNS/PT/OT services. However, the resident was instead discharged to a boarding home, and there was no documentation of discussions with the resident or family about this change prior to discharge. The DSS admitted that the ordered VNS/PT/OT services were not initiated and expressed uncertainty about which facilities could accommodate these services, citing unfamiliarity with the area. The resident's physician was not informed of the discharge to a boarding home and confirmed that the ordered services were not provided. The facility's policies and the DSS job description require coordination of discharge planning and provision of medically related social services, which were not followed in this case.
Deficiencies in Smoking Safety, Resident Transfer, and Substance Abuse Supervision
Penalty
Summary
The facility failed to ensure effective interventions for a resident who was identified as a smoker and resided in a piped-in oxygen room. Despite the facility's smoking safety policy, the resident was observed smoking inside their room, creating an Immediate Jeopardy situation. The resident's room contained smoking materials within reach, and the facility's staff, including the security guard and social worker, were not adequately informed or updated about the resident's smoking status. The resident's smoking assessment was incomplete, and the smoking agreement contract was unsigned, indicating a lack of proper documentation and monitoring. Another deficiency involved the unsafe transfer of a ventilator-dependent resident who sustained a traumatic hematoma to the right eye and required hospitalization. The facility failed to ensure that two staff members were present during the transfer, as required for residents dependent on mechanical lifts. The investigation into the incident was not thorough, with discrepancies in staff statements and a lack of clarity on the cause of the injury. The facility's policy for transferring residents with ventilators was not provided, and the incident was not adequately investigated as a potential abuse incident. Additionally, the facility failed to provide effective interventions and supervision for a resident with a history of substance abuse. The resident was found with drug paraphernalia and tested positive for illicit substances on multiple occasions. Despite being placed on one-to-one supervision and having room searches initiated, the resident continued to access and use illicit drugs. The facility's documentation of monitoring was incomplete, and the interventions were insufficient to prevent the resident from obtaining illegal substances.
Removal Plan
- The resident's room was searched and smoking material was removed from the room.
- Resident's representative party was re-educated about the smoking policy and that any smoking material needed to be handled directly to the security guard or staff.
- A new smoking contract was completed with Resident #143 and responsible party.
- IDT team met to discuss resident's smoking plan of care.
- Physician's orders were added to Medication Administration Record for room search for any smoking material.
- All department heads and Unit Managers were in-serviced on smoking procedures by the Director of Nursing.
- Smoking policy was revised.
- Smoking list was updated to reflect all current smokers in the building.
- Smoking contract was revised.
- All current smokers had a new smoking assessment completed.
Inadequate Investigation of Resident Injury
Penalty
Summary
The facility failed to conduct a thorough and complete investigation into an injury of unknown origin sustained by a resident in a persistent vegetative state, who was dependent on staff for all care and required a mechanical ventilator for breathing. The resident was found with a hematoma and ecchymosis on the right side of the face, and was subsequently diagnosed with a traumatic hematoma of the right eye. The investigation into the incident was inadequate, as it did not identify a causal factor for the injury, and there were discrepancies in the statements provided by the staff involved. The investigation revealed inconsistencies in the accounts of the staff members who were responsible for the resident's care on the day of the incident. CNA #1 provided two conflicting statements regarding the timing and circumstances of the injury, and CNA #2, who was claimed to have assisted with the transfer, denied being involved. The RN on duty did not notice any changes during her rounds and was only informed of the injury by the resident's family member. The Respiratory Therapist confirmed that proper protocol for transferring a ventilator-dependent resident was not followed, as there was no documented evidence of assistance from a nurse or RT during the transfer. The Director of Nursing acknowledged the discrepancies in the investigation and admitted to a misunderstanding and miscommunication regarding the incident. The facility's Abuse Prevention Program requires that all injuries of unknown origin be investigated as potential abuse incidents, but the investigation failed to meet this standard. The Medical Director was informed that the injury was caused by the mechanical lift, but no additional information was provided. The hospital records indicated a suspicion of elder abuse, highlighting the severity of the oversight in the facility's investigation.
Failure to Manage Resident Personal Needs Accounts
Penalty
Summary
The facility failed to ensure that residents with Personal Needs Accounts (PNA) were notified when their account balances approached the limit that could jeopardize their eligibility for Medicaid or Supplemental Security Income (SSI). This deficiency was identified for all residents maintaining PNAs at the facility. A review of the Funds Balance Report revealed that 21 residents had PNA funds ranging from $1,852.93 to $3,997.38, exceeding the $2,000.00 threshold for Medicaid eligibility. Interviews with the Certified Social Worker (CSW) and the Business Office Manager (BOM) indicated a lack of clear responsibility and communication regarding the management of these accounts. The CSW stated that the business office handled the PNA, and the BOM confirmed that the list of residents with PNA was reviewed monthly, but there was no effective system in place to ensure funds were spent down appropriately. Further interviews with the Per Diem Social Worker (PDSW) revealed that she was not regularly involved in managing the PNA accounts and only received the list of accounts with balances over $2,000.00 on the day of the surveyor's inquiry. The PDSW acknowledged that the list had not been addressed and that funds should be spent down when approaching $1,800.00. The facility administration was unable to provide additional information regarding the PNA balances, indicating a systemic issue in managing resident funds and ensuring compliance with Medicaid eligibility requirements.
Failure to Secure Resident Funds with Surety Bond
Penalty
Summary
The facility failed to ensure the security of all personal funds of residents deposited with the facility by not having a Surety Bond in place. This deficiency affected all residents who maintained a Personal Needs Account with the facility. During the survey, the Licensed Nursing Home Administrator (LNHA) provided a Certificate of Liability Insurance, which included coverage for crime and burglary, instead of a Surety Bond. The LNHA stated that this was the document provided by corporate oversight. A review of the Funds Balance Report revealed that there were eighty-five active resident accounts with a total balance of $84,036.27. When questioned about whether the residents' funds were kept in interest-bearing accounts, the LNHA was unable to provide this information and confirmed that the facility used the Certificate of Liability as their documentation, as instructed by corporate management.
Deficiencies in QAPI Program and Resident Safety
Penalty
Summary
The facility failed to maintain an effective comprehensive data-driven Quality Assurance and Performance Improvement (QAPI) program by not reviewing all services provided, including significant events, to determine root causes and prevent further occurrences. This deficiency was evident in several incidents involving residents with a history of smoking in their rooms, possession of drug paraphernalia, and an injury of unknown origin. Specifically, a resident with a history of smoking in their room was found with cigars and a lighter despite the facility's smoking policy prohibiting smoking in rooms, especially with piped-in oxygen present. Another resident with a history of substance abuse was found with drug-related equipment and tested positive for multiple substances, including cocaine and opiates. The facility failed to adequately address the resident's substance abuse issues, and the Medical Director was not informed of the resident's condition or the presence of smoking materials, which could pose a significant fire risk. The facility's QAPI program did not effectively manage or review these incidents, as evidenced by the lack of documentation and follow-up on the substance abuse and smoking issues. Additionally, a resident who was dependent on staff for all care sustained an injury of unknown origin that required hospitalization. The investigation into the injury was not thorough, with discrepancies in staff statements and a lack of clarity on the cause of the injury. The facility's QAPI program did not adequately review or address this significant event, and the Licensed Nursing Home Administrator acknowledged the investigation was not concise or thorough. The failure to maintain an effective QAPI program had the potential to affect all residents in the facility.
Removal Plan
- Assess and care plan for all current smokers
- Ensure awareness of the facility smoking policy among residents and staff
- Ensure residents who smoke do so safely
- Address resident non-compliance
- Identify residents needing frequent monitoring
- Educate resident responsible parties on the facility smoking policy
- Implement a program to identify and manage substance abuse
- Reduce incidents of substance abuse
Failure to Ensure Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was readily accessible and within reach, as evidenced by multiple observations on different dates. Resident #43, who was paralyzed from a stroke and unable to move their right arm, repeatedly had their call bell placed on their right side, which they could not reach. Despite the resident's requests to have the call bell placed on their left side, where they had some mobility, staff continued to place it on the right side. This was observed by the surveyor on three separate occasions, and the resident confirmed their inability to use the call bell when it was placed on the right side. The resident's medical records indicated a diagnosis of paraplegia and muscle weakness, with a care plan that required the call bell to be within reach. Interviews with facility staff, including a CNA and an RN, revealed a misunderstanding of the resident's abilities, as the CNA believed the resident could use their right side, while the RN confirmed the resident's inability to use the call bell when placed on the right side. The facility's policy required call bells to be accessible for communication, yet this was not adhered to, leading to the deficiency.
Deficient Incontinence and Personal Hygiene Care
Penalty
Summary
The facility failed to provide appropriate incontinence care and personal hygiene for two residents. Resident #33 was observed in bed with a strong urine odor in the room, indicating that they had not been changed since the previous night. The resident was found wearing two saturated incontinent briefs, and the care plan did not specify the frequency of care or repositioning. The CNA responsible for the resident had not provided care since starting her shift, and the resident's care plan lacked specific instructions for incontinence management. Resident #8 was observed with long, jagged nails and a yellow substance underneath, despite having received morning care. The resident, who was on hospice and required extensive assistance for ADLs, did not have a care plan addressing ADL self-care performance deficits. The hospice aide stated that she was not allowed to trim the resident's nails, and the responsibility fell to the CNAs. The facility's management acknowledged that staff were responsible for providing nail care.
Delayed Podiatry Care and Non-Compliance with Physician Orders
Penalty
Summary
The facility failed to provide timely podiatry care for a resident who had a podiatry consult ordered on December 4, 2024, but the consultation was not completed until January 20, 2025. During this period, the resident, who had a diagnosis of Diabetes Mellitus and was at risk for endocrine complications, was observed with dry, cracked skin on both feet and blackened areas on the right heel and the ball of the left foot. The resident was also not wearing the prescribed pressure-relieving boots, which were ordered to be worn every shift starting December 11, 2024. The surveyor's observations and interviews with the LPN Unit Manager revealed that the podiatrist was available weekly, yet the consultation was delayed by six weeks. The LPN confirmed the resident was supposed to wear heel protectors, but they were not in use during the surveyor's visits. The facility's Podiatry Services Policy, which mandates routine and emergency podiatry services, was not adhered to, as evidenced by the delay in consultation and the lack of adherence to the physician's orders for pressure relief boots.
Failure to Maintain Dignity and Hygiene for Residents
Penalty
Summary
The facility failed to provide a dignified environment for two residents, as observed by surveyors. Resident #113 was found in their room without bed linens, pillows, or blankets on multiple occasions. The resident, who had severe cognitive impairment and required assistance for mobility, was left in a bed stripped of linens after it was soiled, and the Certified Nurse Aide (CNA) did not return promptly to address the situation. The Registered Nurse Unit Manager acknowledged the issue as a dignity concern but did not provide a satisfactory explanation for the delay in addressing the resident's needs. Resident #91 expressed concerns about the staff's failure to empty urinals, which were observed to be almost full and hung on the footboard of the bed. The resident, who was alert and oriented, reported that the night shift staff did not empty the urinals and did not respond promptly to call lights. The Quality Assurance CNA confirmed that the norm was to check residents and provide care before breakfast, but the urinals were still found full during meal times. The Unit Manager acknowledged that staff should have emptied the urinals before serving meals. The facility's policies emphasize the importance of treating residents with dignity and respect, ensuring their comfort and quality of life. However, the observations and interviews revealed a failure to adhere to these policies, resulting in a lack of dignified care for the residents involved. The issues were presented to the facility administration, but no further information was provided regarding corrective actions.
Failure to Notify Family of Resident's Condition Change
Penalty
Summary
The facility failed to notify the family or responsible party when a resident experienced a change in condition that required transport to the emergency room. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found by a resident representative with a hematoma to the right eye and ecchymosis to the facial area. The incident was not reported by the Certified Nursing Assistant (CNA) who observed the bruise after transferring the resident to bed, and it was only brought to the attention of the Registered Nurse (RN) five hours later by the resident representative. The resident's medical records did not document the presence of the bruise or hematoma prior to the resident representative's report, and there was no record of how the injuries were acquired. The facility's policy required immediate notification of the resident's family or legal representative in such cases, but this was not adhered to. The Director of Nursing (DON) classified the incident as significant and reported it to the Department of Health, but discrepancies in staff statements were noted, and the DON chose not to ask staff to amend their statements. The resident was transferred to the hospital and diagnosed with a traumatic hematoma of the right orbit. The failure to notify the family or responsible party of the resident's condition change and the delay in reporting the incident by the CNA contributed to the deficiency. The resident representative expressed concerns about not being informed of the incident before discovering the bruise, and the resident was subsequently transferred to another facility.
Failure to Maintain Safe Handrails on Dementia Unit
Penalty
Summary
The facility failed to maintain safe handrails on one of its resident units, specifically the 3rd floor, which is a Dementia Unit. During a surveyor's tour, multiple instances of unsecured and cracked handrails were observed outside various rooms and areas, including the soiled linen room and a telephone out cove. The maintenance worker confirmed that the handrails were not safe or secure and acknowledged that maintenance staff was responsible for checking them. Despite the issues being identified, the handrails remained in the same condition the following day, indicating a lack of timely repair. The maintenance log for the 3rd floor showed only two entries from before the surveyor's observations, with no entries on the day the handrails were identified as needing repair. The RN/UM stated that she had entered the handrails into the maintenance log, but pages related to the handrails appeared to have been removed. Maintenance staff admitted that residents frequently tear out the handrails and acknowledged the absence of a process to address this issue. The facility lacked a specific policy or procedure for handrail maintenance, although a general maintenance policy was provided. The concerns were presented to the facility administration.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the management of their care. For one resident, the MDS was incorrectly coded as not being a current tobacco user, despite evidence from the resident's care plan and direct observation that the resident was a smoker. The MDS Coordinator acknowledged the oversight, stating that the resident should have been coded as a smoker in the MDS. This discrepancy was identified during a surveyor's review of the resident's medical records and confirmed through an interview with the MDS Coordinator. For another resident, the facility failed to complete a discharge MDS in a timely manner. The resident was discharged home, but the most recent MDS on record was an admission assessment dated prior to the discharge. The discharge MDS was only completed after the surveyor's inquiry, indicating a lapse in the facility's process for updating resident records. The facility's policy requires MDS assessments to be completed at specific intervals, including upon discharge, but this was not adhered to in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to administer medication in accordance with the physician's order and professional standards of nursing practice. During an initial tour, a surveyor observed a resident sitting in a wheelchair with a medication cup containing five tablets on the bedside table. Additionally, five vials of albuterol sulfate were also present. The nurse responsible for administering the medication was observed at the other end of the hallway, and the medications were identified as colace, Steglator, lasix, potassium chloride, and metoprolol. The resident informed the surveyor that nurses would leave the medication at the bedside for them to take with meals, although the breakfast meal had been delivered earlier. The Unit Manager Registered Nurse confirmed that the resident was not assessed as capable of self-administering medication, and the nurse should have ensured the medication was taken before leaving the room. The Licensed Practical Nurse admitted to leaving the medications at the bedside and forgetting to return to ensure they were taken, acknowledging that this was against facility protocol. A review of the resident's records showed no assessment for self-administration of medication, and the Comprehensive Care Plan did not reflect a focus on this. The Physician Order Sheet included orders for various medications, but the electronic medication administration record indicated that the LPN documented the medications as administered, despite them being left on the bedside table. The facility's policy stated that medications should be administered safely and timely, and residents could only self-administer if assessed and approved by the Interdisciplinary Care Team and the attending physician.
Failure to Administer Oxygen Therapy as Ordered and Improper Equipment Storage
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order and did not ensure proper storage of oxygen equipment for a resident. During an initial tour, a surveyor observed a resident receiving oxygen at 5 liters per minute (LPM) via nasal cannula, contrary to the physician's order of 4 LPM. The nasal cannula was improperly stored, being wrapped around the wheelchair handle and exposed to the environment. On a subsequent observation, the resident was on 4 LPM, but the nasal cannula was again improperly stored, in contact with the resident's socks and not in a protective covering. The resident in question was admitted with multiple health conditions, including pneumonia, anemia, chronic obstructive pulmonary disease (COPD) with exacerbation, and type 2 diabetes mellitus. The resident's medical records indicated a physician's order for oxygen therapy at 4 LPM, which was not consistently followed. Additionally, the resident's care plan included instructions for oxygen therapy related to shortness of breath and congestive heart failure, with interventions to administer oxygen as ordered. Interviews with facility staff revealed a lack of adherence to physician orders and proper storage protocols for oxygen equipment. A registered nurse acknowledged the discrepancy in oxygen administration and improper storage of the nasal cannula. The Assistant Director of Nursing confirmed that oxygen equipment should be stored in a special plastic bag when not in use, which was not done in this case. The facility's revised oxygen therapy policy also emphasized the importance of following physician orders and proper storage of equipment, which was not adhered to in this instance.
Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign arbitration agreements, as evidenced by the case of a resident who was legally blind and had severe cognitive impairment. The resident, identified as Resident #61, was observed by a surveyor to be unresponsive and unable to see. The resident's representative confirmed that the resident was legally blind and unaware of any arbitration agreement, stating that the resident was not capable of signing any documents. A review of the resident's records showed a diagnosis of legal blindness, brief psychotic disorder, and cerebral infarction, with a Brief Interview for Mental Status (BIMS) score of 02 out of 15, indicating severe cognitive impairment. The facility's Admissions Director stated that it was her responsibility to provide the Voluntary Binding Arbitration Agreement (VBAA) to residents and/or their families, ensuring they understood the agreement. She mentioned that a BIMS score of 13 or higher was required for a resident to sign such agreements, acknowledging that a score of 02 was insufficient for understanding. Despite this, the VBAA was signed by the resident without the involvement of a legally authorized representative. The facility's policy required that the arbitration agreement be explained in a manner understandable to the resident or their representative, which was not adhered to in this case.
Failure to Adhere to PPE Protocols for Contact Precautions
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols by not donning Personal Protective Equipment (PPE) before entering the rooms of residents on contact precautions. This deficiency was observed in two instances. In the first instance, a Registered Nurse Unit Manager (RN/UM) entered the room of a resident with a diagnosis of C. Auris colonization without wearing a gown or gloves, despite signage indicating the need for contact precautions. The RN/UM acknowledged the oversight when questioned by the surveyor. The resident had severe cognitive impairment and was on contact precautions due to C. Auris colonization. In the second instance, a Registered Dietitian (RD) was observed inside the room of another resident on contact precautions, handling a tube feeding bottle without wearing the required PPE. The RD admitted to not following the contact precaution signage. This resident also had a diagnosis of C. Auris and CPO colonization. Both staff members had previously received training on the proper use of PPE, yet failed to comply with the facility's infection control policy, which mandates the use of gowns and gloves for all entries into rooms of residents on contact precautions.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Orange
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookhaven Health Care Center | 0.8 mi | ★★★★★ | 9 | 0 |
| White House Healthcare And Rehabilitation Center | 0.8 mi | ★★★★★ | 11 | 0 |
| Park Crescent Healthcare & Rehabilitation Center | 1.4 mi | ★★★★★ | 12 | 0 |
| Grove Park Healthcare And Rehabilitation Center | 1.5 mi | ★★★★★ | 11 | 1 |
| Complete Care At Orange Park | 1.7 mi | ★★★★★ | 13 | 0 |
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