Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Subacute At Autumn Lake Healthcare during CMS and state inspections, most recent first.
An LPN could not locate a resident’s ordered Sevelamer in the med cart, and staff later used another resident’s home supply of the same medication after finding a bottle with the name blacked out. The resident had ESRD and was on HD, but MAR entries were inconsistent, with some nurses documenting administration, some refusal, and some that the med was unavailable. Interviews showed staff confusion about medication procurement and no clear documentation when the med was missing.
A resident on hemodialysis did not consistently receive Sevelamer as ordered because the medication was not available in the med cart, was not stocked in the backup machine, and documentation on the MAR was inconsistent. Staff, the DON, pharmacy consultant, dialysis center staff, and physicians gave conflicting accounts about who was responsible for obtaining the medication, and there were no progress notes documenting what staff did when the medication was unavailable or refused.
Missing physician order for hinged knee brace: A resident with a left tibia fracture was observed wearing a hinged brace on the left leg, and the resident described how the brace had been changed from a knee immobilizer to a hinged brace and later adjusted to allow bending. The LPN, LPN/UM, and RN/ADON reviewed the EMR with the surveyor and could not locate a PO for the brace. The chart included provider instructions for WBAT with the brace unlocked and only needed for walking, but no PO for the device placement or use.
A resident with ESRD receiving hemodialysis had repeated gaps in the dialysis communication binder, including missing pre- and post-dialysis documentation and several instances where the dialysis center did not return completed information. Interviews with the LPN/UM and DON showed inconsistent understanding of who completed each section of the communication form, while the facility policy required routine communication sheets to be sent to and received from the dialysis unit.
Failure to act on CP medication review recommendations. A resident with DM2, severe sepsis, and intact cognition had orders for Lispro insulin, ropinirole, Flomax, and Protonix. The CP identified administration concerns for each medication, including timing and crushing/opening restrictions, but the EMR showed no evidence the facility followed up on the recommendations or documented that they were addressed.
Improper Bedside Storage of Medications: Two residents had medications left on bedside tables without authorization for self-administration. One resident with COPD and acute respiratory failure had a Trelegy inhaler at the bedside after it had been administered, and another resident with COPD and chronic respiratory failure had multiple meds, including inhalers and OTC products, at the bedside even though no self-administration order was in place. Staff stated meds should be kept on the med cart unless self-administration is ordered.
A resident with dysphagia, malnutrition, DM2, and severe cognitive impairment had a documented Halal/no-meat food preference in the care plan and dietary records. Despite this, the resident received the wrong dinner tray with meat that did not respect the dietary restriction, and staff interviews confirmed the tray was not checked against the meal ticket before delivery.
Surveyors observed multiple food safety and sanitation failures, including staff with hair not fully covered while preparing food, ice machines in the kitchen and two bistros with residue, corrosion, and slime-like buildup, and ice tools stored in a way that prevented proper drainage. The dishwasher temperature log was also missing an entry despite wash cycles being completed, and staff stated that temperatures and chemical levels were not checked or documented as required.
Two residents with significant care needs had incomplete documentation in their medical records regarding toileting, bowel, and bladder care, with missing entries for multiple shifts. Additionally, after a fall incident, a resident's transfer out of the facility was not fully documented, lacking the time of transfer and details of departure. Staff interviews confirmed that CNAs were responsible for this documentation, and facility policy required complete and accurate records.
A resident with multiple medical conditions experienced ongoing nausea, decreased appetite, and diarrhea, but the facility failed to notify the physician after the resident refused STAT lab tests and did not obtain a urine specimen as ordered. The resident's critically high WBC count was not acted upon, and there was no evidence of adequate monitoring or follow-up despite worsening symptoms. Family requests for hospital transfer were denied, and communication lapses contributed to the resident's unmonitored decline and death.
A resident with advanced cancer and severe pain was admitted with physician orders for Dilaudid and acetaminophen, but staff failed to consistently administer the prescribed pain medications. Delays in obtaining prescriptions, lack of medication availability, and inadequate documentation led to the resident experiencing high pain levels without effective relief. Staff interviews revealed confusion about medication access and insufficient communication with the pharmacy and physician, resulting in significant harm to the resident.
A resident with advanced cancer and severe pain did not receive physician-ordered Dilaudid for an extended period due to failures in medication procurement, documentation, and staff communication. Despite repeated reports of high pain levels, the resident experienced delays in receiving effective pain relief, with alternative medications either not administered or proving ineffective. Staff interviews revealed confusion about procedures for accessing backup medications and escalating unresolved medication issues.
The facility failed to maintain an effective QAPI program, resulting in two residents experiencing serious harm. One resident with multiple medical conditions did not receive timely physician notification, appropriate monitoring, or follow-up after a significant change in condition and abnormal lab results. Another resident with pancreatic cancer did not receive ordered Dilaudid for pain management due to delays in pharmacy communication and lack of staff follow-up, leading to unmanaged severe pain.
An LPN was observed touching the inside of medication cups with bare fingers while administering medications to two residents, without wearing gloves. Both the LPN and facility leadership acknowledged that this practice did not meet infection control standards.
A cognitively impaired resident with dysphagia received a regular texture meal instead of a prescribed ground diet, leading to a choking incident. The CNA was unaware of the resident's dietary needs and did not verify the meal tray against the ticket information. Facility policies on therapeutic diets and care plans were not followed, resulting in the resident receiving the incorrect meal.
A resident with severe cognitive impairment and dysphagia had a family request to exclude pudding from meals, which was not honored by the facility. Despite clear signage, the resident received pudding on their meal tray. Staff interviews revealed a communication breakdown in notifying dietary staff of the family's preferences, contrary to the facility's policy on resident self-determination.
The facility failed to create comprehensive care plans for four residents, each with multiple health issues. A resident with diabetes and embolism had a care plan focusing only on pain without interventions. Another resident with cardiac arrest and diabetes had a plan addressing only nutritional status. A third resident with dementia had a plan focusing on behavior and nutrition, ignoring other needs. The fourth resident with brain hemorrhage and embolism had a plan covering only nutrition and recreation. Staff interviews revealed inconsistencies in care plan development timelines.
A facility failed to complete a comprehensive MDS assessment within the required 14 days of admission for a resident. The surveyor found the assessment overdue by five days, and the MDS coordinator confirmed it was incomplete. The Regional Director of Nursing noted the delay was due to the recent resignation of the MDS coordinator.
The facility failed to complete baseline care plans within 48 hours for two residents, one with serious health conditions and another with multiple diagnoses, including a pressure ulcer. The required sections of the care plans were incomplete, and necessary signatures were missing. Staff interviews revealed confusion about responsibilities for completing the care plans, contrary to the facility's policy.
The facility failed to ensure the Infection Preventionist attended the QAPI quarterly meeting, as required by policy. The RDON noted that no QAPI activities had been conducted since the previous year, and although training was initiated, the team was not prepared for a quarterly meeting in July. The facility's policy requires the QAA committee to meet quarterly with specific members, including the Infection Preventionist.
A resident with a history of falls was not monitored according to their care plan, resulting in them being found on the floor mat next to their bed. An LPN from an outside agency closed the resident's door instead of checking on them, despite the facility's policy for regular checks. The family, using a video monitoring device, reported the resident had been yelling prior to the fall. The facility's purposeful rounding policy was not followed, leading to the LPN's suspension.
Improper Use of Another Resident’s Sevelamer Supply
Penalty
Summary
The facility failed to ensure that a resident received the prescribed medication Sevelamer HCl as ordered and instead administered another resident’s home supply of the same medication. During a medication pass observation, an LPN could not locate the resident’s Sevelamer in the medication cart and stated it was not available in the backup dispensing machine. The medication was later found in a bottle with the name blacked out, and the DON confirmed that staff had been using another resident’s home medication for this resident. The resident was admitted with diagnoses including polyneuropathy and end stage renal failure and was on hemodialysis. The most recent MDS showed the resident was cognitively intact with a BIMS score of 14 out of 15 and required supervision with activities of daily living. The MAR reflected inconsistent documentation for the Sevelamer doses, with some entries showing administration, some showing refusal, and some showing the medication was not available. The resident stated that the medication was sometimes brought in as one pill and sometimes as three pills, and that the resident refused doses when the amount did not match what was ordered. The record and interviews showed that the medication had been ordered on admission, but staff did not have a consistent supply available in the cart. The LPN/UM stated that nurses who found the medication unavailable should have documented what they did or notified a supervisor, but there were no progress notes documenting those actions. Multiple nurses later stated they administered Sevelamer from a home supply in the cart, while others stated they gave it from a bottle with the name blacked out or documented refusal. The pharmacy consultant confirmed finding the unlabeled bottle in the cart, and the facility pharmacy and dialysis-related interviews showed confusion about who was responsible for ensuring the resident had the medication.
Dialysis Medication Not Available and Inconsistently Documented
Penalty
Summary
The facility failed to establish a system to ensure that a resident on dialysis received medications according to physician orders. During a medication pass observation, an LPN was unable to locate Sevelamer HCl 800 mg for a resident with end stage renal failure who was receiving hemodialysis. The LPN stated the medication should have been in the medication cart, but it was not available in the backup dispensing machine and was not stocked there. The issue was referred to the LPN/UM. The resident’s record showed diagnoses including polyneuropathy and end stage renal failure, and the MDS indicated the resident was cognitively intact and required supervision with ADLs while on hemodialysis. The MAR reflected inconsistent documentation: some nurses documented administration, some documented refusal, and some documented that the medication was not available. Physician orders for Sevelamer changed several times, including orders for dosing on dialysis and non-dialysis days, but the surveyor found no progress notes documenting what staff did when the medication was unavailable or when the resident refused it. The resident stated that he/she had only taken Sevelamer about three times since admission and refused it the rest of the time because the nephrologist had told him/her it was not needed when phosphorus levels were normal. The resident also reported that nurses sometimes brought one pill and sometimes three pills, and that he/she refused when the dosage did not match what was expected. The DON confirmed that the medication had not been delivered when first ordered and that it was later delivered after surveyor inquiry. Interviews with the pharmacy consultant, facility staff, dialysis center staff, and physicians showed confusion about whether the dialysis center or the facility was responsible for obtaining the medication, and the facility policy stated that prescribed medications must be available and administered in a timely, safe, and accurate manner.
Missing physician order for hinged knee brace
Penalty
Summary
The facility failed to obtain a physician's order for a left leg immobilization device for one resident who was reviewed for supportive devices. During the initial tour, the surveyor observed the resident sitting in a wheelchair with a hinged brace on the left leg, visible over the resident's pants. The resident stated they had previously worn a black knee immobilizer after a fracture below the knee, and that in mid-January the immobilizer was replaced with a hinged brace locked straight for almost 60 days. The resident further stated that in early March the hinges were opened at a follow-up appointment, allowing gradual bending of the knee, and that the brace was worn when standing or walking and removed at bedtime. The resident also stated the brace sometimes slid down and needed adjustment so the hinges aligned with the knee. When the surveyor observed the resident, the resident was adjusting the brace strap for comfort and alignment. The assigned LPN, the LPN/UM, and the RN/ADON each reviewed the electronic medical record with the surveyor and acknowledged that they could not locate a physician's order for the knee immobilization device. The record showed diagnoses including an unspecified fracture of the upper end of the left tibia, a BIMS score of 15, and care plan focus areas related to falls, non-weight bearing left lower extremity, and limited mobility. The record also included a physician office letter stating the resident was weight bearing as tolerated with a hinged brace unlocked and only needed the brace for walking, along with a nursing note reflecting those instructions, but the order summary did not contain an order for the placement or use of the knee immobilization device.
Missing Dialysis Communication Documentation
Penalty
Summary
The facility failed to consistently ensure communication with a contracted dialysis facility for one resident receiving hemodialysis. The resident had diagnoses including morbid obesity, end stage renal disease, and cancer of the liver and intrahepatic bile duct. The resident’s MDS indicated dialysis services, and the care plan included hemodialysis with interventions to monitor for infection at the access site and for bleeding or hemorrhage. The resident stated they had been attending dialysis three times weekly for approximately two and a half years. The resident’s dialysis communication binder showed multiple instances where required information was missing. On several dialysis dates, the facility failed to document post-dialysis information, and on some dates it also failed to document pre-dialysis information such as vital signs, physician name, medications given before dialysis, meal or snack sent, additional information, and nurse signature. On some dates, the facility also failed to receive documentation from the dialysis center. The record specifically showed missing documentation on 2/25/2026, 3/3/2026, 3/4/2026, 3/6/2026, 3/9/2026, 3/11/2026, 3/13/2026, 3/16/2026, and 3/18/2026. Interviews with the LPN/UM and facility administration showed inconsistent understanding of who was responsible for completing the dialysis communication form. The LPN/UM stated the receiving nurse should call the dialysis facility if information was left blank and acknowledged that the nurse should have called on one date when dialysis center information was missing. The DON gave differing explanations during interviews, at one point stating dialysis staff completed the middle section and the receiving nurse completed post-dialysis information, and later stating all three sections of the communication sheet were required to be completed. The facility policy stated that communication sheets were to be sent and received from the dialysis unit and maintained on the unit.
Failure to Act on Consultant Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to follow through in a timely manner on recommendations made by the Consultant Pharmacist during the monthly medication regimen review for one resident reviewed for unnecessary medications. The resident had diagnoses including type II diabetes mellitus and severe sepsis, and the comprehensive MDS dated 2/23/26 showed a BIMS score of 15 out of 15, indicating intact cognition. The resident's physician orders included Lispro insulin sliding scale coverage, ropinirole 5 mg twice daily for restless leg syndrome, Flomax 0.4 mg daily for urinary incontinence, and Protonix 40 mg daily for GERD. The consultant pharmacist's report dated 2/14/26 identified several medication administration concerns, including that Lispro should be given within 15 minutes before a meal or immediately after a meal, ropinirole should be given 2 to 3 hours before bedtime when used for restless leg syndrome, Flomax should be administered 30 minutes after a meal and not crushed, chewed, or opened, and Protonix should not be crushed and should be changed if the resident could not swallow it whole. The medical record contained no evidence that the facility followed up on these recommendations. The DON stated that desk nurses and unit managers had access to the CP reports daily, that nurses were expected to address pharmacist concerns with the provider, and that unit managers were responsible for ensuring recommendations were addressed and documented, but the record did not show that this occurred for the resident.
Improper Bedside Storage of Medications
Penalty
Summary
The facility failed to properly store and secure medications left at the bedside for two residents. Resident #15, who had COPD and acute respiratory failure with hypoxia and a BIMS score of 9, was observed with a Trelegy Ellipta inhaler sitting on top of the bedside table after the inhaler had been administered earlier that day. The resident’s care plan addressed altered respiratory status related to COPD exacerbation and RSV, and the medical record showed an order for the inhaler to be given once daily for COPD. Resident #43, who had COPD, chronic respiratory failure with hypoxia, a displaced right femur fracture, and a BIMS score of 12, was observed with multiple medications on the bedside table, including Breztri Aerosphere inhaler, Mylanta, TUMS, and Asper Creme. The resident stated the medications were brought in from home. The record showed an order for Breztri Aerosphere twice daily for COPD, and the care plan addressed altered respiratory status and difficulty breathing related to COPD and chronic respiratory failure. Staff interviews confirmed that medications should be stored on the medication cart unless a resident has an order to self-administer. The LPN/UM stated that medication should not be at the bedside unless self-administration had been assessed and ordered, and the DON and LNHA stated medications should be stored on the medication cart unless self-administration was authorized. The facility policy stated that medications must be stored in a safe, secure, and orderly manner, and that medications found at the bedside without authorization should be given to the charge nurse for return to the family or responsible party.
Failure to Honor Resident Food Preference
Penalty
Summary
The facility failed to honor a resident’s food preference by serving meat that did not match the resident’s documented halal/no-meat preference. The resident had diagnoses including dysphagia, mild protein-calorie malnutrition, hyperlipidemia, and type II diabetes, and the quarterly MDS showed a BIMS score of 0, indicating severe cognitive impairment. The care plan documented that the resident followed a Halal diet and included interventions to honor the resident’s food preferences, including lacto-ovo vegetarian preferences with seafood allowed and no other meat unless Halal. The record showed that the resident’s nutrition evaluation noted the resident ate Halal at home and that food preferences should be honored as able with no meat. The dietary slip also listed no chicken, beef, pork, or turkey. Despite this, a nurse’s note documented that the resident received the wrong dinner meal from the kitchen and that the meal did not respect the resident’s dietary restrictions of no meat. The note stated that the resident was ultimately given a salad and ate dinner without complications. Interviews confirmed that meal trays were expected to match the resident’s ticket and that dietary staff were supposed to verify the diet before trays were sent to the unit. The RD stated the resident required a kosher/halal diet and that the facility was not a kosher facility and did not have Halal meat, so the resident had been accommodated with a vegan diet. The RD also stated that the meal tray error occurred because the person assembling trays did not look at the ticket. The LNHA stated that resident meals should be accurate and that the facility could not accommodate a resident with a Halal diet and different textured meats, so a vegan diet was offered.
Food Safety and Sanitation Deficiencies in Kitchen and Bistro Areas
Penalty
Summary
Food was not prepared and handled in accordance with professional standards when surveyors observed kitchen staff and leadership with hair not fully contained by hair restraints while working in food service areas. The Food Service Director had hair extending near her shoulder blades that was uncovered and not within the hairnet she was wearing. The Regional Director of Operations was also observed making peanut butter and jelly sandwiches while wearing a baseball cap with hair exposed along the sides and back of his head, and after removing the hat, the hairnet on his head was flat and did not cover the hair on the sides and nape of his neck. The Food Service Director stated that hairnets must be worn in the kitchen and that exposed hair should never be present for food safety. The kitchen and bistro ice equipment were observed in an unsanitary condition. When the surveyor opened the kitchen ice machine door, the white hard plastic interior area had black and brown residue and buildup in several areas, and the Food Service Director stated she did not know when it was last cleaned. In the third-floor bistro, the ice machine had slime-like residue in the drip tray, white corrosion on the interior and exterior parts of the spout, and the ice scooper was resting in a metal container and could not drain freely. In the second-floor bistro, the ice machine also had residue and corrosion around the spout, and an ice scooper and tong were resting on a yellow-tinged paper towel inside a metal pan; the LPN/UM stated that should not be like that. The dishwasher process was also not documented as required. On follow-up, the surveyor requested the dishwasher temperature log and found no entry for that morning, even though the FSD stated two wash cycles had been completed. The FSD stated that dishwasher temperature and chemical levels should have been checked and documented before running a cycle to ensure dishes were properly cleaned. The dietary aide stated he did not check the temperatures and chemical levels because he had to scrape four big racks of plates from the prior night's dinner. The LNHA stated that dishwasher temperatures should be checked every morning and documented, and the IP stated that ice machines should be maintained in a clean and sanitary manner at all times and that ice scoopers should be washed daily and drain freely.
Incomplete Documentation of Resident Care and Transfers
Penalty
Summary
The facility failed to consistently document and maintain complete medical records regarding toileting, bowel and bladder continence, and incontinent care for two residents. For one resident with diagnoses including type II diabetes, osteoarthritis, and hypertension, documentation was missing in the daily shift records and progress notes for multiple dates in February. The resident required substantial assistance with toileting, as indicated by the Minimum Data Set (MDS) and care plan, but there were gaps in the records for bladder and bowel continence and bowel movements across several shifts. Another resident, admitted with conditions such as cerebral infarction, heart failure, and mobility issues, also had incomplete documentation in October. This resident required partial assistance with toileting transfer and was fully dependent in toileting hygiene. The records lacked documentation for bladder and bowel continence and bowel movements for a specific evening shift. Additionally, after an incident where this resident was sent out of the facility for further evaluation following an allegation of a fall, the medical record did not include the time of transfer, and there was no documentation indicating when the resident left the facility, despite a note confirming the resident's return. Interviews with staff, including an LPN, Unit Manager, DON, and a CNA, confirmed that CNAs were responsible for documenting incontinent care in the electronic medical record and that documentation was important for tracking care and preventing skin issues. The DON and other staff acknowledged the presence of blanks in the documentation and emphasized that all services provided should be documented completely and accurately, as required by facility policy.
Failure to Notify Physician and Monitor Resident After Refusal of STAT Labs and Ongoing Symptoms
Penalty
Summary
The facility failed to notify the physician when a resident refused immediate (STAT) laboratory tests on two occasions, and there was no documentation in the electronic medical record (EMR) that the refusals were communicated to the provider. Additionally, the facility did not obtain a urine specimen for a urinalysis with culture and sensitivity as ordered, nor was there evidence that the physician was notified of the failure to collect the specimen. The resident, who was cognitively intact and had a history of myelodysplastic syndrome, anemia, and acute congestive heart failure, experienced ongoing symptoms including nausea without vomiting for three days, decreased appetite, and persistent diarrhea. Despite these symptoms, the facility did not adequately monitor the resident for changes in condition. Nursing notes indicated that the resident had decreased appetite and diarrhea for several days, and while Imodium was ordered for the diarrhea, there was no evidence of further assessment or monitoring after a late entry note documented the resident's ongoing symptoms. A critically high white blood cell (WBC) count of 26.4 K/CU.MM was reported, but there was no documentation that this result was acted upon or that follow-up laboratory tests were ordered as recommended by a nurse practitioner. The resident was later found unresponsive and was pronounced deceased, with the death certificate listing suspected sepsis due to diarrhea and hypokalemia as causes of death. Interviews with staff and family members revealed communication breakdowns and a lack of timely response to the resident's declining condition. Family members reported requesting hospital transfer, which was denied by staff who stated the physician did not approve it, and they were not informed of their right to call 911 themselves. The facility's own policies required timely laboratory services and provider notification, but these were not followed, contributing to the resident's unmonitored decline and subsequent death.
Removal Plan
- Educate licensed nurses on documentation and provider notification requirements when residents refuse diagnostic testing or exhibit changes in condition
- Educate licensed nurses on acute changes in condition protocol and documentation requirements
- Educate licensed nurses on honoring resident's/family rights to transfer to hospital when requested, including the obligation to inform providers and document the decision in the electronic medical record (EMR)
Failure to Provide Consistent Pain Management for Resident with Severe Pain
Penalty
Summary
A resident with a diagnosis of pancreatic adenocarcinoma and other serious medical conditions was admitted to the facility with physician orders for pain management, including Dilaudid and acetaminophen. Despite these orders, staff failed to consistently administer the prescribed pain medications as ordered. Documentation revealed that the resident experienced severe pain, with pain levels reaching up to 10 on a 0-10 scale, and there were multiple instances where pain medications were not available or not given as ordered. The resident's medication administration record showed significant delays in receiving both Dilaudid and Tramadol, and there were periods where the resident received only acetaminophen, which was documented as ineffective for their pain level. The facility's records indicated that there were issues with obtaining the necessary prescriptions from the physician and with the timely delivery of medications from the pharmacy. The pharmacy did not receive a written prescription for Dilaudid until several days after the resident's admission, resulting in the medication not being available in the facility. Staff interviews confirmed that some nurses did not have access to the Pyxis medication dispensing system due to their employment status, and there was confusion about the process for obtaining medications when they were not immediately available. Documentation also showed that alternative pain medications were not always administered promptly, and there was a lack of consistent pain assessment and follow-up after medication administration. Throughout the resident's stay, there were repeated failures to document pain levels, reasons for holding medications, and the effectiveness of pain interventions. Nursing notes and medication administration records frequently lacked explanations for missed or delayed doses, and there was insufficient communication with the physician regarding the resident's unmanaged pain. The resident continued to experience high levels of pain until pain management was eventually adjusted, but the initial failure to provide timely and appropriate pain relief resulted in significant harm and increased the likelihood of a painful death.
Removal Plan
- Educate licensed nurses on the facility's policy for Pain Management
- Educate on actions to take when physician ordered medications are unavailable for administration
- Use Pyxis for immediate availability of narcotics on admission
- Document pain scores before and after pain medication administration and document effectiveness for PRN medications used for pain
- Educate that if any resident is experiencing unmanaged pain, the nurse will call the physician for alternate orders
- Provide resident with alternate physician ordered medications to ensure relief until the prescribed narcotic is available
Failure to Provide Timely Physician-Ordered Pain Medication
Penalty
Summary
A deficiency occurred when the facility failed to acquire and administer physician-ordered pain medication for a resident admitted with pancreatic adenocarcinoma and other serious conditions, including an upper gastrointestinal bleed and portal vein thrombosis. Upon admission, the resident had orders for Dilaudid and acetaminophen for pain management. Despite these orders, the facility did not ensure the timely procurement and administration of Dilaudid, resulting in the resident experiencing high levels of pain. Documentation showed that the resident repeatedly reported severe pain, with pain scores as high as 10, and that alternative pain medications were either not administered or were ineffective. The clinical record revealed significant delays in the administration of Dilaudid, with the first dose given approximately 35 hours after admission. During this period, the resident received acetaminophen and, at times, Tramadol, but these interventions provided minimal or no relief. There were also instances where pain medications were not available in the facility's Pyxis system, and staff did not consistently document pain assessments or reasons for withholding medication. Communication lapses were evident, as the pharmacy did not receive the required prescription for Dilaudid until several days after admission, and staff did not escalate the issue promptly to supervisors or the DON as required by policy. Interviews with staff indicated confusion regarding procedures for obtaining medications from the Pyxis system and the steps to take when medications were unavailable. Some staff members lacked access to the Pyxis due to their employment status, and there was inconsistency in following the facility's policy for medication procurement and escalation. The failure to provide the ordered pain medication resulted in the resident experiencing unmanaged pain for an extended period, as documented in nursing and progress notes.
Removal Plan
- Education to the licensed nursing staff on the Medication Procurement and Pharmacy Services Policies
- Education on pharmacy notification when medications are not delivered
- If ordered pain medications are unavailable, the nurse will notify the Supervisor
- If unresolved, the issue will be escalated to the DON
- If still unresolved, the Medical Director will be contacted
- Use of the Pyxis for availability of narcotics at admission
- For any resident experiencing unmanaged pain, the nurse will place a call to the physician for alternate orders
- The resident will be provided alternate physician ordered medication to ensure relief until the prescribed narcotic is available
Failure to Maintain Effective QAPI Program and Ensure Timely Pain Management
Penalty
Summary
The facility failed to maintain an ongoing, effective QAPI program that systematically identified, reported, investigated, analyzed, and prevented adverse events, as well as documented the development, implementation, and evaluation of corrective actions or performance improvement activities. Specifically, the facility did not recognize or appropriately respond to a decline in a resident's change in condition and did not consistently provide pain management or ensure that pain medication was ordered and available upon admission for another resident. These failures were identified through record review, interviews, and document review, and resulted in serious harm to two residents. One resident with myelodysplastic syndrome, anemia, and acute congestive heart failure was admitted with a high cognitive status. The facility did not notify the physician of the resident's refusal to have an immediate laboratory test, failed to obtain a urine culture and sensitivity test as ordered, did not monitor the resident after reports of ongoing nausea, decreased appetite, and diarrhea, and failed to act upon a critically high white blood cell count. Documentation and communication regarding the resident's change in condition were lacking, and there was insufficient follow-up and monitoring after significant symptoms and abnormal lab results were reported. Another resident admitted with pancreatic adenocarcinoma and other serious conditions had orders for Dilaudid for pain management, but the facility failed to consistently provide the medication as ordered. The pharmacy did not receive the written script for Dilaudid until several days after admission, resulting in the resident experiencing pain levels up to 10 out of 10. The DON was not aware of the medication's unavailability, and nursing staff did not follow up with the pharmacy when the medication was not delivered. This failure led to the resident not receiving adequate pain management during their stay.
Failure to Maintain Infection Control During Medication Administration
Penalty
Summary
During medication administration, a Licensed Practical Nurse (LPN) was observed handling medication cups in a manner that did not maintain infection control standards for two residents. Specifically, the LPN was seen placing her bare index and middle fingers inside the medication cup containing medication for one resident and touching the inside of the medication cup with her index finger for another resident. In both instances, the LPN was not wearing gloves. The LPN, Infection Preventionist, and Director of Nursing all acknowledged that the nurse should not have touched the inside of the medication cup with bare hands or fingers prior to administering the medication.
Failure to Provide Correct Therapeutic Diet to Resident
Penalty
Summary
The facility failed to provide the correct therapeutic diet to a cognitively impaired resident with a known diagnosis of dysphagia, pharyngeal phase. The resident had a physician's order and plan of care for a ground diet and required feeding assistance. On the specified date, a CNA delivered a meal tray containing a regular texture meal to the resident, which included corn and tortillas that were not ground texture. The CNA confirmed that the meal tray was incorrect, and the resident's family observed the resident with food in their mouth, reporting that the resident was choking. The CNA stated that she was not aware that the resident was on an altered texture diet or that the resident required feeding assistance. The facility's policies titled Therapeutic Diet Orders and Comprehensive Care Plans were not followed, as the CNA did not verify the tray and ticket information at the resident's bedside. The CNA should have notified a nurse if the tray seemed incorrect, but this did not occur, leading to the resident receiving the wrong meal. Interviews with facility staff, including LPNs and the Food Service Director, highlighted the importance of following diet orders and care plans to ensure residents receive the care they need. The Food Service Director acknowledged that the facility did not follow its policy related to resident diet, as a resident received the wrong meal. The facility's Therapeutic Diets policy and Comprehensive Care Plans policy were reviewed, revealing that all residents should have a diet order prescribed by the attending physician and that qualified staff should be notified of their roles and responsibilities for carrying out interventions specified in the care plan.
Removal Plan
- Resident #3 was assessed for aspiration precautions.
- Resident #3's physician was notified of the incident.
- The DON (Director of Nursing) was notified of the incident.
- The CNA was in-serviced regarding verification of tray and ticket information.
- Resident care staff was in-serviced regarding meal tray accuracy.
- Kitchen staff were in-serviced regarding ensuring resident meals are of the correct texture.
- The [NAME] on shift at the time of the incident was given an Employee Corrective Action related to failure to follow the meal tracker ticket as read.
- Tray accuracy audits were performed for Resident #3's breakfast, lunch, and dinner trays. 100% accuracy was documented.
- The facility initiated weekly meal tray audits for texture meals and tray accuracy for all residents.
- A system compliance plan was developed to submit texture meals and tray accuracy results to Quality Assurance and Performance Improvement (QAPI) on an ongoing basis.
Failure to Honor Resident's Dietary Preferences
Penalty
Summary
The facility failed to appropriately respond to a resident family's request regarding food preferences, specifically concerning the exclusion of pudding from the resident's meals. The resident in question, who was admitted with diagnoses including dysphagia and severe cognitive impairment, had clear signage placed by the family indicating that pudding and milk should not be provided. Despite this, during a meal observation, the resident's tray included pudding, which was confirmed by the Assistant Director of Nursing (ADON) as being against the family's preferences. Interviews with facility staff, including the ADON and a Licensed Practical Nurse (LPN), revealed that there was a breakdown in communication and adherence to the resident's preferences. The ADON acknowledged that the dietary staff should have been informed of the family's request, and the LPN stated that it was the responsibility of the notified staff to ensure that all relevant personnel were aware of the resident's dietary restrictions. The facility's policy on Resident Self Determination and Participation was reviewed, which emphasized the importance of honoring resident choices and involving family input when the resident is unable to communicate preferences.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for four residents, as identified during a survey. Resident #1, who had multiple diagnoses including Type 2 diabetes mellitus and acute embolism, was observed without a comprehensive care plan addressing all identified needs. The only focus area in the care plan was pain, which lacked specific interventions, and no other areas were addressed before the resident's discharge. Resident #99, admitted with conditions such as cardiac arrest and type 2 diabetes mellitus, had a comprehensive care plan that only addressed nutritional status, despite the Minimum Data Set (MDS) indicating the need for care planning in several areas, including ADL, falls, and pressure ulcers. Similarly, Resident #6, with advanced dementia and other health issues, had a care plan that only focused on behavior symptoms and nutritional status, neglecting other identified needs like cognitive loss and urinary incontinence. Resident #96, with complex medical conditions including traumatic subarachnoid hemorrhage and pulmonary embolism, had a care plan that only addressed nutritional problems and recreational choices, leaving out other triggered areas such as cognitive loss and ADL function. Interviews with facility staff revealed inconsistencies in understanding the timeline and requirements for developing comprehensive care plans, contributing to the deficiencies observed.
Failure to Complete Timely MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within 14 days of admission for a resident, as required by regulations. The deficiency was identified during a surveyor's review of the electronic medical record (EMR) for the resident, which showed that the admission assessment was still in progress and overdue by five days. The MDS coordinator confirmed during an interview that the assessment had not been completed on time, acknowledging that it should have been finalized by the specified date. The Regional Director of Nursing corroborated the surveyor's findings, noting that the assessment should have been completed earlier and attributing the delay to the recent resignation of the MDS coordinator. The facility's policy on MDS 3.0 Completion mandates that an admission assessment be completed within 14 days of admission, counting the day of admission as day one. This policy was not adhered to in the case of the resident, resulting in the identified deficiency.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan (BCP) within 48 hours of admission for two residents, leading to a deficiency. Resident #90 was admitted with serious health conditions, including malignant neoplasm of the mandible, type 2 diabetes, protein-calorie malnutrition, and a tracheostomy. However, sections 2 and 3 of the BCP, which cover functional abilities and health conditions, were not completed within the required timeframe. Additionally, the BCP summary was incomplete, and the necessary signatures from the resident and their representative were missing, with only the Director of Rehab and Director of Social Services having signed the document. Resident #241, who was admitted with conditions such as rhabdomyolysis, sepsis, type 2 diabetes, a urinary tract infection, and a pressure ulcer, also did not have a completed BCP within 48 hours. None of the seven sections of the BCP were completed on time, although they were eventually finished on a later date. Interviews with facility staff revealed confusion about the responsibility for completing the BCP, with discrepancies between the roles of LPNs, the Unit Manager, and the Director of Nursing. The facility's policy requires the BCP to be developed within 48 hours, including essential healthcare information, but this was not adhered to in these cases.
Infection Preventionist Absence at QAPI Meeting
Penalty
Summary
The facility failed to ensure the presence of the Infection Preventionist at the Quality Assurance Performance Improvement (QAPI) quarterly meeting, as required by their policy. This deficiency was identified for one of the last three quarters. During a review of the facility's QAPI documentation, it was noted that the sign-in sheet for the QAPI/QA Quarter 3 meeting lacked the signature or name of the Infection Preventionist. Additionally, the facility did not hold QAPI meetings on a quarterly basis as required, with deficiencies noted in two of the last three quarters. The Regional Director of Nursing (RDON) confirmed that upon their arrival in April, there had been no QAPI activities conducted since the previous year. The RDON initiated training and education for all department heads and staff on QAPI requirements and established a QAPI board for transparency with families. Despite these efforts, the RDON acknowledged that a quarterly meeting could have been held in July, but the team was not yet prepared. The facility's policy mandates that the QAA committee be interdisciplinary and meet at least quarterly, including specific members such as the Director of Nursing, Medical Director, and Infection Preventionist.
Failure to Monitor Fall-Risk Resident
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a history of falls, as evidenced by an incident where the resident was found on the floor mat next to their bed. The resident, who was cognitively impaired and required extensive assistance with mobility and personal care, was supposed to be monitored hourly according to their care plan. However, a Licensed Practical Nurse (LPN) from an outside agency, who was on duty, closed the resident's door instead of checking on them, despite the resident's history of falls and the facility's policy for regular checks. The family, who had a video monitoring device in the room, reported that the resident had been yelling prior to the fall, and the nurse's action of closing the door was contrary to the facility's purposeful rounding policy. The incident was reported as a Facility Reportable Event (FRE), and it was noted that the resident was found on the floor mat by the day shift staff. The resident was assessed for injuries, and although none were found, the family requested that the resident be sent to the hospital for further evaluation. The facility's policy on purposeful rounding was not adhered to, as the resident was not checked on as frequently as required for someone with their fall risk status. The LPN involved was suspended and not allowed to work at the facility again, highlighting a failure in ensuring that staff, especially those from outside agencies, adhere to established care protocols.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,454 citations issued within 25 miles in the last 12 months — including the 16 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Voorhees
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Echelon Care & Rehab | 0.5 mi | ★★★★★ | 0 | 0 |
| Voorhees Pediatric Facility | 0.5 mi | ★★★★★ | 2 | 0 |
| Lions Gate | 0.7 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Voorhees | 1 mi | ★★★★★ | 3 | 1 |
| Complete Care At Kresson View, Llc | 1.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.