Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Caremeridian Llc, Dba Neurorestorative during CMS and state inspections, most recent first.
The facility failed to provide written transfer notices, including the reason for transfer, to the resident, representative, and Ombudsman for multiple residents who had unplanned hospital transfers. One resident’s record also lacked documentation that the resident or representative received the facility’s bed hold policy notice when transferred. The residents had significant medical needs, including respiratory failure, ventilator dependence, tracheostomy and gastrostomy status, quadriplegia, NSTEMI, Guillain-Barre Syndrome, anoxic brain injury, and cerebral infarction.
QAPI failed to ensure the infection prevention program tracked staff COVID vaccine screening, education, consent, administration or declination, and documentation retention. The DON, Administrator, and Regional DON stated staff were offered COVID vaccines through clinics, but the facility did not document or monitor the process, and the IP worked remotely rather than on site for several months before the current IP became certified.
The facility failed to ensure a properly trained IP worked at the facility for a period of time and failed to maintain a process for offering and documenting staff COVID-19 vaccines. The Regional DON served remotely as the IP and visited monthly until the current IP became certified, while the Administrator and IP confirmed staff vaccine education, offering, screening, and tracking were not documented; staff were only required to show proof of vaccination upon hire.
The facility failed to screen staff for COVID vaccine eligibility, provide vaccine education, offer the vaccine, and document whether staff accepted or declined it. The Regional DON could not produce tracking records, the Administrator said staff were only given a flyer for a vaccine clinic, and the DON/IP confirmed staff vaccination status was collected at hire but not tracked or monitored; the facility also could not provide a COVID immunization policy.
Missing Full-Time DON Coverage: The facility failed to ensure a DON served on a full-time basis for 2 of 15 months reviewed. The previous DON resigned and the facility had no DON from September through December, despite the facility assessment requiring a full-time DON working 8 hours per day, 5 days per week and on call 24/7. The DON role included oversight of staffing, infection control, care planning, regulatory compliance, and staff supervision.
A CNA was found to have verbally abused and neglected residents by yelling personal care needs down the hallway, exposing private health information, failing to provide proper incontinence and peritoneal care, and not using gloves or hand hygiene. Residents reported being left without needed assistance, receiving upsetting comments, and experiencing poor privacy and dignity during care. The DON and Administrator were aware of repeated complaints, but the grievance log lacked documented grievances related to the CNA.
Improper bed rail use and inconsistent side rail assessment: A resident with spastic quadriplegic CP, scoliosis, spinal fusion, and cognitive impairment was observed in bed with both upper and lower half-length rails enabled, while squirming and trying to fit between the rails. The OT assessments documented the resident's representative requested bilateral upper rails, noted cognitive impairment and entrapment risk, and identified impulsivity and limb entrapment concerns, yet the resident's representative often enabled the lower rails. An LPN, OT, and DON gave differing descriptions of how side rail appropriateness was determined and acknowledged the risks associated with bed rail use.
A resident with severe neurologic and respiratory diagnoses had orders for controlled seizure medications, including lacosamide and clobazam via g-tube. The controlled drug records did not show the morning doses, the clobazam bottle lacked measurement marks, and the DON said the pharmacy was not contacted about the bottle issue. An LPN also admitted the morning lacosamide dose was documented as given on the MAR even though it had not been administered, and the DON stated there was uncertainty about when to document controlled medications and update the remaining count.
A resident with behavioral diagnoses and psychotropic medication orders had repeated gaps in required TAR documentation for behavior and side effect monitoring across multiple shifts, despite orders for monitoring every shift. Another resident with chronic pain syndrome had duplicate active pregabalin orders entered into the order set and MAR, with both orders remaining active at the same time, creating a risk of double dosing.
Unlabeled and undated resident food was found in a pediatric section satellite kitchen. Surveyors observed a take-out container with accoutrements and a quart of milk in the refrigerator with no visible placement or use-by date, and an uncovered partially consumed ice cream type product in the freezer with no resident name, placement date, or use-by date.
Administration failed to verify that the IP had the training and competency to manage COVID vaccination education and tracking, and the facility did not document staff screening, education, offering, acceptance, or declination of the COVID vaccine. The Infection Control Manual lacked COVID-related staff monitoring, immunizations, and resident care content, and the DON/IP and Administrator confirmed the facility did not monitor or track staff COVID vaccination status beyond hire.
Facility Assessment Did Not Include Nicotine Dependence: The FA failed to list nicotine abuse or addiction among the facility’s common diagnoses and conditions and did not document the number of residents with active or current substance use disorders. The DON confirmed the FA was incomplete, even though three residents were current cigarette smokers/vapers and the facility had a designated smoking area accessed through the main entrance.
QAPI committee failed to include all required members during a quarterly meeting. The sign-in sheet showed attendance by the Administrator, DON, Director of Rehabilitation, Maintenance Director, Medical Director, and direct care staff, but no IP was present. The Administrator confirmed the IP did not attend the first quarter QAPI meeting, so the committee did not have all required members involved.
Isolation Precautions were not implemented correctly for a resident with rhinovirus/enterovirus, as EBP signage was initially posted instead of Droplet Precautions signage and staff interviews showed confusion about the required PPE and timing of isolation. The DON later stated the resident should have been placed on isolation immediately, and the facility’s infection control materials were also incomplete because the IPCP did not include COVID staff immunizations, work restrictions, or resident care guidance, and staff could not locate a COVID policy.
The facility failed to ensure abuse prevention training was completed on time for 2 of 19 sampled employees. One RD completed annual training 7 days late, and one RN had no documented abuse prevention training in the personnel record. The OM confirmed staff were required to complete training upon hire and annually, and the facility policy required orientation and annual education on abuse, neglect, misappropriation, and reporting.
Behavioral health care training was not completed timely for 3 of 19 sampled employees. An RD had annual training completed 7 days late, a CNA had initial training completed 152 days late, and an RN had no documented behavioral health training in the personnel record. The OM confirmed staff were required to complete dementia care training upon hire and annually, and confirmed the RN worked with resident contact.
A resident with cerebral palsy and dysphagia had an outdated and incomplete personal property inventory, despite ongoing additions of items such as clothing, plants, books, and sentimental objects. The resident’s guardian later found the resident’s cupboard completely empty, although it had previously contained food, candy, Tupperware, ceramic mugs from vacations, a soup bowl from a great grandmother, gift cards, and greeting cards from deceased relatives. Staff, including a CNA and SW, acknowledged that many belongings in the room were never added to the inventory list, and the DON informed the SW that the resident’s items had been removed and placed in a secure cabinet in preparation for a survey, with gift cards unaccounted for. This failure to maintain an accurate inventory and the removal of belongings without notifying the guardian violated the resident’s right to retain and use personal possessions.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school and told a CNA that a teacher had pulled their hair, pinched them, yelled at them, and refused to change them, while documentation also showed a 9 cm abrasion on the resident’s back after a reported school incident. The CNA immediately brought the resident to the SW, who, according to the CNA, dismissed the allegation, stated they did not believe the teacher, and referenced the resident’s history of fabricating stories, then the CNA reported the concern to the DON. The DON acknowledged being informed that the resident returned crying and soiled and notified the Abuse Coordinator, but neither the DON nor the Abuse Coordinator reported the allegation to the SA, law enforcement, ombudsman, physician, or responsible parties, despite facility policy requiring immediate reporting of any alleged or suspected abuse or injuries of unknown source.
A resident with cerebral palsy, communication deficits, and mental health diagnoses returned from school distressed and reported to a CNA that a teacher had pulled the resident’s hair, pinched the resident, yelled, and refused requested care. The CNA brought the resident to the SW, who expressed disbelief in the allegation, characterized the resident as fabricating stories, and referenced potential school expulsion and limiting friend visits. Nursing documentation the same day noted a new 9 cm abrasion on the resident’s upper back present on return from school. The DON, who was notified by the CNA, did not interview the resident, teacher, or SW and did not review the clinical record or complete a wound assessment. The Abuse Coordinator, though aware of behavioral issues reported by the teacher, did not obtain statements, review the record, or initiate any abuse investigation, despite facility policy outlining required investigative steps for abuse and neglect allegations.
A resident with quadriplegia, ventilator dependence, complex wound care needs, and significant pain management requirements was transferred to a hospital for surgical and ID evaluation of a stage 4 pressure injury. After the hospital determined the wounds were stable, discontinued IV pain meds, and cleared the resident for return, facility emails showed that leadership expressed concerns about worsened wounds, the pain regimen, and the likelihood of rapid re-hospitalization, and ultimately declined readmission. However, the facility’s records lacked documentation of the specific needs it could not meet, any attempts to meet those needs, or communication of those needs to the hospital at the time of the readmission referral, and there was no policy governing return after hospitalization despite admission agreement language on transfer, discharge, and bed-hold rights.
A resident with acute respiratory failure, quadriplegia, and ventilator dependence was transferred to an acute care hospital for surgical evaluation and an ID consult for a hip wound infection, after the SW coordinated acceptance, secured a hospital bed, and arranged transportation. Although the facility's admission agreement contained a bed-hold policy and readmission rights, the clinical record showed no written notice of this policy was provided to the resident or representative at the time of transfer. The Administrator confirmed the transfer was non-emergent, acknowledged relying on calls or emails rather than written notice, and admitted that written bed-hold information was not given upon this hospital transfer.
A resident with acute respiratory failure and cystic fibrosis had multiple gaps in documentation on the Respiratory Administration Record (RAR), including missing entries for emergency equipment checks, continuous pulse oximetry, oxygen via NC with titration parameters, and rotation of the pulse ox probe on several shifts. Additional omissions involved undocumented q8h Albuterol nebulizer treatments, chest percussion, and HyperSal nebulizer treatments for secretions. The DON confirmed that respiratory care is to be documented on the RAR, that the blanks could not be explained as either care not given or not charted, and that refusals or held treatments should have been recorded per facility policy requiring documentation of all assessments, interventions, treatments, outcomes, and refusals.
The Administrator failed to ensure the Facility Assessment (FA) included all resident types and any ethnic, cultural, or religious factors affecting care. The FA documented care for children but omitted the adult resident population and relevant cultural factors. The Administrator acknowledged the oversight and confirmed the absence of a policy for FA completion, despite following state and federal regulations.
The QAPI committee failed to implement Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. The Administrator acknowledged the issue was not identified until mid-January 2025, and no EBP was in place, potentially exposing all residents, staff, and visitors to harmful infectious agents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, as required by policy and CDC guidance. Observations showed a lack of EBP signage and PPE use during high-contact care activities. Additionally, an increase in respiratory infections in the pediatric unit was not investigated, and quarterly legionella testing was not completed as per the Water Management Program.
The facility did not document, investigate, or resolve resident grievances as required by their policy. During a Resident Council Meeting, residents expressed concerns about unaddressed grievances, with one resident noting a grievance from December 2024 remained unresolved. The Administrator acknowledged the grievance binder was missing after the Licensed Social Worker left, and no efforts were made to recover the information. The policy requires grievances to be investigated and resolved within thirty days, with forms retained for one year.
Expired medications were found in two medication storage rooms and two medication carts, posing a risk of administration to residents. Inspections revealed expired Diphenhydramine, Iron supplements, Geri-Tussin, Ondansetron, and Bisacodyl suppositories. Staff confirmed these should have been removed from active storage according to facility policy.
The facility failed to ensure timely completion of initial and annual elder abuse prevention training for six employees, including the DON, a Registered Dietician, two CNAs, an RN, and an LPN. This deficiency was confirmed by the Office Manager and was contrary to the facility's policy, potentially placing all residents at risk for abuse and neglect.
A facility failed to provide a resident with the required CMS Form 10055 and Form 10123 during a Medicare Part A stay. The resident, admitted with hypertension and muscle weakness, did not receive these forms due to the absence of a social worker or case worker. The Regional Support DON confirmed the oversight and the lack of a policy on beneficiary notifications.
A resident with sleep disorders reported being disturbed by a loud exit door near their room, which disrupted their sleep. Despite submitting a grievance, the facility had not addressed the issue. The Administrator confirmed the door's noise and acknowledged the lack of policy on noise levels in maintaining a homelike environment.
A resident's funds were misappropriated by facility staff when $100 was taken from the resident's property to pay vendors without consent. The Administrator admitted to the action, which violated the facility's policy on resident funds and valuables. The incident was documented in a Facility Reported Incident and a complaint was filed.
A facility failed to ensure the accuracy of an MDS assessment for a resident with hemiplegia, leading to potential impacts on their care plan. The MDS assessment inaccurately documented significant weight loss, which was not supported by the resident's weight records. The MDS RN confirmed that different staff completed various sections of the MDS, and the Dietician was responsible for the incorrect entry in Section K.
The facility failed to ensure that direct care staff maintained current CPR certification for two employees, an LPN and a CNA, whose certifications had expired. The Office Manager confirmed the requirement for all direct care staff to have current CPR certification, as documented in the Facility Assessment.
A facility failed to ensure a PRN psychotherapeutic medication was prescribed with a diagnosed indication, limited to 14 days, and monitored for side effects and behavior for a resident. The resident received Hydroxyzine HCl for anxiety without a documented diagnosis, and the medication was administered beyond the 14-day limit without required monitoring, contrary to facility policy.
A resident with spastic quadriplegic cerebral palsy and muscle weakness did not receive the prescribed physical therapy (PT) sessions for two weeks due to staffing shortages. The physician's order required one hour of PT per week, but the facility failed to provide this, as confirmed by the RSDON and the Director of Rehabilitation.
The facility failed to document pre-restraining assessments for residents prescribed psychotherapeutic medications and did not obtain consent for one resident's medication. Residents with various diagnoses, including anxiety and depression, were affected. The facility's policy required these assessments and consents, but they were not conducted or documented, as confirmed by the Regional Support Director of Nursing.
The facility failed to provide staff education on the Antimicrobial Stewardship Program (ASP) and did not document evaluations to determine if residents met McGeer criteria before starting antibiotics. A RN reported not receiving ASP training, and the RSDON/IP could not confirm staff training. The facility's ASP policy required education and documentation, but the Monthly Line Listing of Resident Infections lacked assessment protocols, and the RSDON/IP confirmed missing documentation of criteria in residents' records.
The facility failed to provide the required twelve hours of in-service training for two CNAs who had been employed for over a year. One CNA did not have an annual performance review by their anniversary date and lacked necessary training. Another CNA had a delayed performance review and also lacked required training. The Office Manager confirmed these deficiencies, noting that all CNAs were required to have annual evaluations by their hire date.
A resident dependent on a ventilator did not receive physician-ordered weaning care, despite documentation by an RT indicating the care was provided. Review of the ventilator's event log revealed no evidence of required setting changes, confirming that the ordered care was not performed and that the RT had engaged in fraudulent charting and neglect.
The facility did not promptly report two separate incidents to the State Agency as required: one involving a resident with chronic respiratory failure who did not receive physician-ordered care from a Respiratory Therapist, and another where a resident's cash was taken from a lock box by the Administrator to pay vendors without consent. In both cases, staff failed to follow mandatory reporting timelines for suspected neglect and misappropriation.
A resident with multiple complex medical conditions experienced a fall with injury while receiving care. The facility submitted an incomplete FRI report that lacked details about the injury and subsequent treatment, and was unable to provide a full investigation report for State Agency review, contrary to facility policy.
A CNA did not receive a timely annual performance evaluation as required by facility policy. The evaluation was not completed by the employee's anniversary date, and the Office Manager confirmed the delay and lack of documentation.
Failure to Provide Written Transfer Notices and Bed Hold Notification
Penalty
Summary
The facility failed to ensure that written notices of transfer were completed and provided to the resident, the resident’s representative, and the Ombudsman when residents were transferred to acute care hospitals for inpatient care. This was identified for Resident #30, Resident #26, Resident #2, and Resident #5 after review of clinical records, MDS assessments, interviews, and document review. The records documented multiple unplanned discharges with return anticipated to acute care hospitals, but the clinical records did not include documentation that written notices of transfer, including the reason for transfer, had been completed and provided for the hospital transfers noted for these residents. Resident #30 was admitted with acute and chronic respiratory failure and had unplanned hospital discharges documented on two occasions. Resident #26 was admitted with diagnoses including NSTEMI, Guillain-Barre Syndrome, and anxiety disorder, and had two unplanned hospital discharges documented. Resident #2 was admitted with acute respiratory failure, quadriplegia C1-C4 complete, ventilator dependence, tracheostomy status, and gastrostomy status, and had four unplanned hospital discharges documented. Resident #5 was admitted with acute and chronic respiratory failure with hypoxia, anoxic brain damage, tracheostomy status, gastrostomy status, and cerebral infarction, and had five unplanned hospital discharges documented. Resident #5’s record also did not include documentation that the resident and/or resident representative were provided notification of the facility’s bed hold policy when the resident was transferred to an acute care hospital. During interview on 05/07/2026, the Administrator stated the Social Worker was not aware that a written notice of transfer was supposed to be sent to the Ombudsman and confirmed that written notices had not been completed and/or sent to the Ombudsman for any resident transferred to an acute care hospital between 03/10/2025 and 05/07/2026, including Residents #26, #30, #2, and #5. The Administrator also confirmed that a bed hold notification had not been completed and sent to Resident #5’s representative for the hospital admission noted in the record.
QAPI Failed to Oversee Staff COVID Vaccine Tracking and On-Site IP Coverage
Penalty
Summary
The facility's QAPI committee failed to ensure the infection prevention program included a process for staff COVID vaccination tracking and documentation. Interview and record review showed the Infection Control Manual did not include staff COVID infection monitoring, staff immunizations, or resident care related to COVID. The Administrator stated the facility did not require staff to obtain COVID vaccinations and did not document the offering, education, or consent for the staff COVID vaccine. The Regional DON stated staff were offered the COVID vaccination through staff vaccine clinics, but the facility did not retain or track staff COVID vaccinations, offerings, education, consented administration, or declination of the vaccine. The DON/IP confirmed the facility used CDC vaccination guidelines, and the IP stated staff COVID vaccination status was required upon hire but was not tracked or monitored by the IP. The facility also failed to ensure an Infection Preventionist worked at the facility from 09/17/2025 through 03/31/2026. The Regional DON confirmed the Regional DON served as the previous facility IP and then worked remotely as the IP from another location, visiting the facility once per month until the current IP became certified on 04/01/2026. The Administrator confirmed there was not an IP on site during that period. The Administrator further stated the QAPI committee discussed immunizations at the last QAPI meeting, but COVID vaccinations were not addressed, and the committee did not identify a concern related to the infection prevention program or establish a process for screening staff for COVID vaccine eligibility, providing education, obtaining consent or declination, and retaining documentation.
Infection Preventionist Oversight and Staff COVID Vaccination Tracking
Penalty
Summary
The facility failed to ensure that an Infection Preventionist (IP) with the required specialized training worked at the facility from 09/17/2025 through 03/31/2026. The Regional DON stated that after taking a position at another location, the Regional DON became the remote IP for the facility and visited once per month until the current IP became certified on 04/01/2026. The facility job description for Infection Preventionist, dated 06/24/2019, stated the IP was responsible for the effective management and operation of the infection prevention program, including staff education and use of evidence-based practices such as CDC guidance. The facility also failed to ensure the IP had a process in place to ensure staff were offered COVID-19 vaccines. The Administrator stated staff were given an informational flyer about signing up for a vaccination clinic provided by a local pharmacy, but the education, offering, and monitoring of staff COVID vaccinations was not documented and was not known to be required. The Regional DON stated COVID vaccinations were offered with other vaccines during staff vaccination clinics but were not documented or tracked, and that staff were required to provide proof of vaccination upon hire only. The IP confirmed there was no documentation showing staff were screened for eligibility, educated about the vaccine, offered the vaccine, or documented as administered or declined, and the IP did not monitor or track each staff member's vaccination status.
Failure to Track and Document Staff COVID-19 Vaccination Status
Penalty
Summary
The facility failed to ensure staff were screened annually for eligibility to receive a COVID-19 vaccine, provided education about the vaccine, and offered the vaccine with documentation of whether it was administered or declined. During interview, the Regional DON, who had also been the previous Infection Preventionist, could not produce documentation showing staff had been screened, educated, or offered the vaccine and stated the facility had a COVID binder with the information but could not locate it. The Regional DON also stated the facility believed it did not have to track the information for staff because it did not have to report it to NHSN. The Administrator stated the facility did not require staff to obtain COVID vaccinations and did not know it was still required to be offered, and said staff were given a flyer about a vaccination clinic to sign up but the facility did not document the offering, education, or administration/declination of staff COVID vaccines. The DON/IP stated staff vaccination status was collected upon hire but was not tracked or monitored, and the facility could not provide a policy related to COVID-19 immunizations.
Missing Full-Time DON Coverage
Penalty
Summary
The facility failed to ensure a Director of Nursing (DON) served on a full-time basis for 2 of 15 months reviewed for sufficient and competent nurse staffing. Interview and document review showed the previous DON resigned with a final working day of 09/17/2025, and the current DON did not start until 12/01/2025. The Administrator stated the facility did not have a DON from September to December 2025, and the Office Manager confirmed the gap in DON coverage. The facility assessment documented that the facility required a full-time DON working 8 hours per day, 5 days per week and on call 24 hours per day, 7 days per week. The DON job description, revised 11/20/2019, listed responsibilities including planning and organizing daily functions, completing pre-admission resident evaluations, participating in interdisciplinary care planning, ensuring regulatory compliance, hiring and training staff, maintaining staffing levels, managing infection control, and overseeing licensed independent practitioners, contractors, vendor services, and continuing education programs.
Verbal Abuse and Neglect by CNA
Penalty
Summary
The facility failed to ensure 3 of 3 residents participating in the resident council were free from verbal abuse and neglect by CNA1. During the resident council interview, residents stated that complaints had been made to the previous DON, current DON, and Administrator about CNA1’s care, including concerns that CNA1 did not provide proper incontinence care after bowel movements, did not wear gloves during peritoneal care, and yelled down the hallway using residents’ first names and personal care needs. Residents also stated that CNA1 exposed private health information by announcing that a resident had a bowel movement, and one resident reported submitting written grievances without being informed of any action taken by the facility. Resident #25, who had diagnoses of anxiety disorder and depression, reported that CNA1 provided peritoneal care without hand hygiene or gloves, then assisted the resident into a wheelchair where feces were observed on the armrest and joystick. The resident also stated CNA1 did not perform hand hygiene before handling dinner service, entered rooms without allowing time for a response after knocking, and left the room without returning when assistance such as water was requested. Resident #25 reported making the same concerns to the DON and Administrator approximately six times and stated CNA1 was repeatedly retrained, but the resident did not observe any change in CNA1’s behavior. Resident #9 reported that CNA1 made upsetting comments, was removed from the resident’s care temporarily, and later returned because the facility was short staffed. Resident #9 also stated CNA1 yelled down the hallway and announced personal care needs, which the resident found embarrassing. Resident #12 reported CNA1 did not pay attention to the resident, yelled the resident’s needs down the hallway, did not ensure water was provided, and emptied a urinal without gloves and without cleaning or disinfecting it. The DON and Administrator stated staff were trained on abuse prevention and that allegations should be reported immediately, but both were aware of concerns involving CNA1, including lack of glove use during peritoneal care and being too loud, while the grievance log lacked documented grievances related to CNA1.
Improper Bed Rail Use and Inconsistent Side Rail Assessment
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards related to the use of side rails for one resident. Resident #11 was admitted and readmitted with diagnoses including spastic quadriplegic cerebral palsy, neuromuscular scoliosis, fusion of the lumbar and thoracic spine, expressive language disorder, and unspecified lack of expected normal physiological development in childhood. On 05/04/2026, the resident was observed in bed with upper and lower half-length bed rails enabled on both sides, and the resident was squirming in the bed and attempting to fit between the upper and lower rails on the left side. The record showed an OT side rail assessment dated 04/13/2026 documenting that the resident's representative requested bilateral upper rails for safety, security, and increased independence with mobility. The assessment noted cognitive impairment, required assistance with repositioning, and stated the resident was at risk for climbing over, around, or between rails or getting caught between the rails and mattress. A developmental bed assessment completed the same day documented spinal precautions, self-stimulatory behaviors, impulsivity, and risk for limb entrapment, while also noting the resident was independent of rolling and functional position changes. The physician ordered bilateral upper side rails up while in bed with checks every two hours for safety, and the care plan included bilateral upper rails as requested by the representative and per physician orders. During interviews, an LPN stated OT was responsible for determining whether side rails were appropriate and identified risks such as falls, suffocation, and entanglement. The OT later stated that residents should be cognitively intact and able to communicate and use the call light, that lower rails could be problematic due to entrapment risk, and that alternate interventions should be attempted before bed rail installation. The OT acknowledged inconsistencies in the assessments and could not confirm whether the resident was impulsive or needed bed mobility assistance at the time of assessment. The DON stated the interdisciplinary team determined side rail safety, that residents should be alert and oriented, and that the resident's representative often enabled the lower side rails despite education that only the upper rails were to be used.
Inaccurate Controlled Drug Records and Medication Documentation
Penalty
Summary
The facility failed to maintain accurate controlled drug records for Resident #5, who was admitted and re-admitted with diagnoses including acute and chronic respiratory failure with hypoxia, anoxic brain damage, tracheostomy status, gastrostomy status, and cerebral infarction. Physician orders included lacosamide 100 mg via g-tube twice daily for seizures and clobazam suspension 8 mL via g-tube every 12 hours for seizures, both controlled substances. On 05/07/2026, the controlled drug record for lacosamide showed the last administration was at 8:50 PM on 05/06/2026 with 10 tablets remaining, but it did not include an entry for the morning dose on 05/07/2026. The controlled drug record for clobazam also did not include an entry for the morning dose on 05/07/2026, and the bottle did not have graduation or measurement marks to show the amount remaining. The DON stated on 05/07/2026 that the lack of graduation marks on the clobazam bottle had first been noticed on 05/06/2026 and confirmed the bottle should have had measurement marks to help nurses identify the remaining amount after each administration. The DON also confirmed no contact had been made with the pharmacy or pharmacist about the issue. Later that day, an LPN stated the morning dose of lacosamide had not been given because the nurse was behind on administering morning medications, and the MAR nevertheless documented the medication as administered. The LPN confirmed the medication had been documented as given even though it had not been administered, and the DON stated not knowing when nurses should document a medication and update the remaining quantity in the controlled drug record when a controlled medication was administered.
Missing Psychotropic Monitoring and Duplicate Pregabalin Orders
Penalty
Summary
Behavior and side effect monitoring was not completed for a resident receiving psychotropic medications. The resident had diagnoses including major depressive disorder, restlessness and agitation, unspecified behavioral and emotional disorders, and generalized anxiety disorder. Physician orders included risperidone for behavior disorder, sertraline for anxiety, and monitoring orders for antianxiety medication, antipsychotic side effects, and antipsychotic behavior monitoring every shift. The care plan also identified behavioral problems such as agitation, poor safety awareness, self-harm, and outbursts, with interventions to administer medications as ordered and monitor for side effects and effectiveness. Review of the TAR showed missing documentation for required behavior and side effect monitoring on multiple shifts. The TAR for February 2026 lacked documentation for the night shift on 02/19/2026, the March 2026 TAR lacked documentation for the day shift on 03/30/2026, the April 2026 TAR lacked documentation for the night shift on 04/08/2026, and the May 2026 TAR lacked documentation for the night shift on 05/04/2026. The Regional DON stated that side effect and behavior monitoring related to administered medication should be documented on the TAR and that a blank TAR meant the monitoring was not done. The DON also stated nursing staff were expected to document behaviors and side effect monitoring daily and per the physician order. A second resident had duplicate active orders for pregabalin. The resident had chronic pain syndrome and an active pregabalin order dated 03/07/2026 for 75 mg by mouth twice daily. A second identical active pregabalin order was entered on 05/05/2026, and both orders remained on the MAR with no stop date. The DON confirmed both orders were active in the order set and on the MAR, and stated that when the second order was entered, the previous order should have been discontinued and removed from the MAR. The DON stated having the medication listed twice as active created a concern because it could result in the resident receiving the medication twice.
Unlabeled and Undated Resident Food in Refrigerator and Freezer
Penalty
Summary
The facility failed to ensure resident food items placed in refrigeration were appropriately labeled and dated. During a pediatric section satellite kitchen inspection on 05/04/2026 at 09:25 AM, surveyors observed resident food on the top shelf of the refrigerator, including a take-out container with accoutrements and a quart of milk, with no visible placement date or use by date. Although a placard in front of the food items identified a resident name and room number, the food containers themselves were not marked. In the freezer, surveyors also observed an uncovered partially consumed ice cream type product in a cup with no visible resident name, placement date, or use by date information.
Failure to Track Staff COVID Vaccination Education and Documentation
Penalty
Summary
Administration failed to verify that the Infection Preventionist (IP) had the required training and competency to educate staff, track, and monitor COVID-19 vaccinations. The Infection Control Manual provided to surveyors did not include COVID staff infection monitoring, staff immunizations, or resident care related to COVID. The DON/IP confirmed the facility followed CDC guidelines, but did not know which guidelines were appropriate for COVID staff vaccinations and did not review or revise the Infection Control Program to include resident or staff COVID education, immunization, or resident care. The facility’s job description for Infection Preventionist, dated 06/24/2019, stated the IP was responsible for the effective management and operation of the infection prevention program, including education of facility staff members and use of evidence-based practices such as CDC guidance. For COVID vaccinations, the Administrator confirmed staff were not required to get vaccinated and were only handed an informational flyer about signing up for a facility vaccination clinic provided by a local pharmacy. The Administrator stated the education, offering, and monitoring of staff COVID vaccinations was not documented and was not known to be required. The DON/IP confirmed there was no documentation that staff were screened for eligibility, educated about the vaccine, or offered the vaccine with documentation of acceptance or declination, and the Regional DON stated COVID vaccinations were offered only when the facility provided a staff vaccination clinic and were not tracked beyond the hire date.
Facility Assessment Did Not Include Nicotine Dependence
Penalty
Summary
The facility failed to ensure its Facility Assessment (FA) was accurate and included nicotine dependence and addiction among the facility’s common diagnoses and conditions. During the entrance conference, the facility provided a list of residents who smoked, which identified three residents as smokers, including one resident who vaped. The designated smoking area was located off the main entrance parking lot and was accessed by residents through the facility’s main entrance. The current FA, dated 01/08/2026, did not include nicotine abuse or addiction and did not document the number of residents with active or current substance abuse disorders. On 05/07/2026, the DON stated she was involved in completing the FA but said that at the time it was developed the facility had only one intermittent smoker. The DON confirmed nicotine addiction was not identified as a diagnosis in the FA and that the FA lacked documentation of the number of residents with active or current substance use disorders. The CDC article reviewed by surveyors stated that substance use disorder is a treatable, chronic disease and can apply to tobacco (nicotine).
QAPI Committee Missing Required Member
Penalty
Summary
The Quality Assurance and Process Improvement (QAPI) committee failed to include the required members during the first quarter 2026 QAPI meeting. On 05/06/2026, the facility provided the sign-in sheet for the Performance Improvement Committee Meeting dated 01/29/2026, which showed attendance by the Administrator, DON, Director of Rehabilitation, Maintenance Director, Medical Director, and direct care staff, but no Infection Preventionist (IP) was present. On 05/07/2026 at 3:54 PM, the Administrator stated the facility did not have the IP at the QAPI meeting on 01/29/2026 and confirmed the facility did not have all required members involved in the QAPI meeting when the IP did not attend the first quarter of 2026 QAPI meeting.
Isolation Precautions and IPCP Deficiencies
Penalty
Summary
Isolation Precautions were not implemented according to facility policy and CDC guidance for a resident with an active rhinovirus infection. Resident #15 was admitted and later readmitted with chronic respiratory failure with hypoxia. A physician ordered Isolation Precautions for seven days for human rhinovirus or enterovirus, or until symptoms resolved, and the care plan documented Droplet Precautions related to the positive rhinovirus and enterovirus test. However, on 05/04/2026, Enhanced Barrier Precautions signage was posted at the entrance to the resident’s room instead of Droplet Precautions signage, and the sign instructed hand hygiene only. During observation and interviews, a Respiratory Therapist stated the resident had recently tested positive for rhinovirus and should have been on Isolation Precautions with mask use by staff and visitors entering the room, but the therapist was unsure who was responsible for ensuring the correct infection control signage was posted. Later that day, the DON replaced the EBP sign with Droplet Precautions signage and stated the physician had ordered Droplet Precautions and new signage was required. An RN later stated the resident should have immediately been placed on isolation precautions for seven days or until symptoms resolved, and that droplet precautions required staff to don a mask, gown, and gloves upon entering the room. The DON also stated nursing staff were expected to post precaution signage immediately upon receiving a physician’s order. The Infection Prevention and Control Plan was also incomplete. The Regional DON, who had been the previous Infection Preventionist, provided the Infection Control Manual, but it did not include COVID staff immunizations, staff work restrictions, or resident care related to COVID. The Regional DON stated the facility was not required to report staff COVID vaccination status to NHSN and therefore thought the facility did not have to track staff immunizations. The DON/Infection Preventionist confirmed the facility followed CDC guidelines but did not know which guidelines were appropriate for COVID staff vaccinations and had not reviewed or revised the Infection Control Program to include resident or staff COVID education, immunization, or care. The DON/IP was unable to locate a facility policy related to COVID for staff or residents.
Late and Missing Abuse Prevention Training
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 2 of 19 sampled employees. Employee #5, a Registered Dietician hired on 01/07/2025, had initial abuse prevention training on the hire date but annual abuse prevention training was completed on 01/14/2026, 7 days late. Employee #11, an RN with an unknown hire date, had no documented evidence of abuse prevention training in the personnel record. During interview on 05/06/2026, the Office Manager stated all staff were required to complete abuse prevention training initially upon hire and annually by the anniversary date, and confirmed Employee #11 worked in the facility with resident contact, but the personnel record lacked documentation of training. The facility policy stated education and training would be provided to healthcare workers during orientation, annually, and as needed on abuse prohibition practices, including the seven components of abuse, how to identify risk factors and victims of abuse, what constituted abuse, neglect, and misappropriation of resident property, abuse prevention, and appropriate intervention and follow-up.
Behavioral Health Training Not Completed Timely
Penalty
Summary
Behavioral health care training was not completed timely for 3 of 19 sampled employees. Employee #5, hired as a Registered Dietician on 01/07/2025, had initial behavioral health care training completed on the hire date, but annual behavioral health care training was completed on 01/14/2026, 7 days late. Employee #16, hired as a CNA on 07/01/2025, had initial behavioral health care training completed on 12/30/2025, 152 days late. Employee #11, hired as an RN with an unknown hire date, had no documented evidence of behavioral health care training in the personnel record. On 05/06/2026 at 9:06 AM, the OM stated all staff were required to complete 8 hours of dementia care training initially upon hire and 4 hours annually by the anniversary date, and confirmed Employee #11 worked in the facility with resident contact. The facility policy titled, Abuse-Dependent Adult or Child, revised 01/06/2016, stated education and training would be conducted for all healthcare workers during orientation, annually, and as needed related to understanding the behavior of residents with dementia and/or cognitive impairments.
Resident Belongings Removed and Poorly Inventoried Without Notification
Penalty
Summary
The deficiency involves the facility’s failure to respect a resident’s right to retain and use personal possessions and to maintain an accurate inventory of those belongings. The resident, who had cerebral palsy, a developmental motor disorder, and dysphagia, was admitted with an inventory list that included clothing, an E‑Reader/iPad, a backpack, a stuffed animal, hair accessories, a wheelchair tool kit, a bathing suit, an iPad stand, a wheelchair, and cushions. The most recent inventory list on file was dated in 2023 and did not reflect all of the resident’s belongings. Staff, including a CNA and the SW, acknowledged that many items present in the resident’s room, such as plants, books, stuffed animals, lotions, blankets, clothing, jackets, nightlights, and pictures, were not documented on the inventory sheet, and that the list was “quite bare” and required updating. The resident’s Guardian reported arriving to find the cupboard in the resident’s room completely empty, although it had previously contained food items, candy, Tupperware, ceramic mugs from vacations, a soup bowl from the resident’s great grandmother, approximately $75 in gift cards, and greeting cards from deceased relatives. The Guardian was not notified that these items had been removed and filed a grievance about the missing property. The SW later learned from the DON that staff had removed the resident’s belongings from the room and placed them in a secure cabinet due to an upcoming survey, and that the gift cards could not be located. The facility’s own policies stated that all personal effects were to be inventoried upon admission and that all items subsequently brought into the facility were to be added to the inventory form, but this was not done for this resident, and belongings were removed from the room without prior notification to the Guardian or documentation on the inventory list.
Failure to Report Alleged School Abuse of a Resident to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency (SA) as required. A resident with spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder returned from school after being picked up due to behaviors. Alert progress notes documented that upon return, the resident was calm and toileting was performed, during which the resident reported to a floor CNA that a teacher at school had abused them, specifically by pulling their hair, pinching their arm, yelling at them, and refusing to change them when requested. The resident became emotional and cried while making this report. The CNA immediately took the resident to the Social Worker (SW) and reported the allegation in the resident’s presence. According to the CNA’s account, the SW disregarded the resident’s report, stated they did not believe the teacher would do what was claimed, and characterized the resident’s account as a fabricated story. The SW also told the resident that if they had another behavior, they would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA then left the SW’s office with the resident and reported the concerns to the DON. A nursing progress note from the same day documented that the resident had an incident at school in which they slid partially out of their wheelchair and scraped their back, resulting in a 9 cm abrasion on the upper back. In subsequent interviews, the CNA reiterated that the resident had reported the teacher pulled their hair, pinched their underarms, yelled at them, and refused to change them, and that the resident stated they were being abused. The CNA stated they notified the DON and later reported the concern to the ombudsman. The SW, when interviewed, described being responsible for case management and acknowledged that abuse allegations should be reported to the Abuse Coordinator or DON and then to the SA, and identified various forms and signs of abuse. The SW recounted a prior incident in which the resident had alleged the teacher hit them first, but the SW believed the resident was not an accurate historian and considered the statement confabulatory. The SW confirmed there was documentation of a 9 cm abrasion on the resident’s back and acknowledged the note indicated the resident returned from school with an injury. The DON stated uncertainty about the process for abuse investigation and reporting, including not being sure who the designee for the Abuse Coordinator would be. The DON reported being told that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON stated they immediately notified the Abuse Coordinator but did not report the concern further. The Abuse Coordinator/Administrator defined abuse and neglect and stated that the facility would be responsible for reporting any allegation of abuse, neglect, exploitation, or misappropriation to law enforcement, the ombudsman, the SA, the physician, and responsible parties, regardless of whether it occurred inside or outside the facility. The Abuse Coordinator acknowledged being notified of the resident’s increased behaviors and being told the resident kicked at the teacher, but was unaware of the resident’s allegation that the teacher hit them first until informed later by the SW. The Abuse Coordinator confirmed that no reports had been made to law enforcement, the ombudsman, the SA, the physician, or responsible parties after being notified of the alleged abuse. The facility’s abuse policy required the Administrator or DON to notify the SA, ombudsman, child protective services, and law enforcement when an alleged or suspected case of neglect, injuries of unknown source, or abuse was reported, but this did not occur in this case.
Failure to Investigate Resident’s Allegation of Abuse by External Caregiver
Penalty
Summary
The facility failed to investigate an allegation of abuse involving Resident #6 after the resident reported being abused by a school teacher. Resident #6, who had spastic hemiplegic cerebral palsy, mixed receptive-expressive language disorder, cognitive communication deficit, major depressive disorder, and generalized anxiety disorder, returned from school on 02/10/2026 and was documented as calm and collected initially. Alert progress notes recorded that after toileting, the resident told a floor CNA that the resident was being abused by the teacher, naming the teacher and describing hair pulling, arm pinching, and yelling. The resident became emotional and cried while reporting this to the CNA. The CNA immediately took Resident #6 to the Social Worker (SW) with the resident present. According to the CNA’s account and documentation, the SW disregarded the resident’s report, stated disbelief that the teacher would do what was alleged, and characterized the resident’s account as a fabricated story. The SW also told the resident that if the resident had another behavior, the resident would be expelled from school and would be denied a virtual visit with a friend as punishment. The CNA and resident then left the SW’s office, and the CNA reported the concerns to the DON. The CNA did not speak with the Abuse Coordinator at that time but documented the experience in the electronic health record and later reported the concern to the ombudsman. A nursing progress note from the same date documented that the resident returned from school with a 9 cm abrasion on the upper back, described as resulting from sliding partially out of the wheelchair and scraping on a pedestal. In subsequent interviews, the SW stated that if notified of an abuse allegation, the SW would report it to the Abuse Coordinator or DON and that abuse included physical and verbal abuse and neglect. The SW recounted that about a month prior, the teacher had reported the resident hit and kicked the teacher, and the resident had responded that the teacher hit the resident first; the SW believed the resident had no physical marks and considered the resident an unreliable historian. A behavior progress note effective 02/10/2026 documented that the SW found the resident’s statement about the teacher hitting first to be confabulatory. The SW acknowledged feeling sorry for the teacher, not believing the teacher would hit the resident, and confirmed that the resident’s right to visit a friend was not contingent on behavior. The SW also acknowledged the note indicating a 9 cm abrasion on the resident’s back and initially believed the resident fell off the toilet, despite documentation that the injury was present upon return from school. The DON reported uncertainty about the abuse investigation and reporting process, including not being sure who the designee for the Abuse Coordinator would be. The DON stated that on the day of the incident, the CNA reported that the resident arrived from school crying and in soiled briefs, and that the resident disliked the teacher because the teacher was mean. The DON did not interview the resident, the teacher, or the SW, and did not review the resident’s electronic health record after being notified of the alleged abuse. The DON was unaware of the alert notes and nursing progress note documenting the new abrasion and acknowledged that a wound assessment should have been completed but was not. The Abuse Coordinator/Administrator described that an abuse investigation should include review of records, shift assignments, and interviews with residents, family, and staff, and confirmed that the facility was responsible for reporting allegations of abuse occurring inside or outside the facility. The Abuse Coordinator stated being notified only of the resident’s increased behaviors and the teacher’s report that the resident kicked at the teacher, and did not speak with anyone else about the allegation at that time. The Abuse Coordinator later learned from the SW that the resident had said the teacher hit first, but because the resident could not specify where, the SW deemed the statement unreliable. The Abuse Coordinator did not obtain written statements from the resident, CNA, SW, or DON, and did not review the resident’s clinical record. The Abuse Coordinator confirmed that no investigation into the allegation of abuse was initiated, despite facility policy requiring, at a minimum, review of the incident report, medical record, and interviews with the reporter, witnesses, resident, staff, roommate, family, and visitors.
Failure to Document Unmet Needs When Declining Hospital Readmission
Penalty
Summary
The deficiency involves the facility’s failure to document specific unmet needs and attempts to meet those needs when declining to readmit a resident following an acute care hospitalization. The resident had diagnoses including acute respiratory failure with hypoxia, C1–C4 complete quadriplegia, and ventilator dependence, and required tracheostomy care, ventilator services, G-tube feeding, pain management, and wound care for a stage 4 pressure injury with a wound vac. The resident was transferred from the facility to an acute care hospital for surgical evaluation and infectious disease consultation related to a right hip/buttock wound. The clinical record at the facility did not contain documentation that the resident returned, nor did it identify any specific needs that the facility could not meet that would prevent readmission. Hospital discharge documentation later showed that the resident’s decubitus ulcers had been evaluated by plastic surgery, no surgical intervention was recommended, the wounds were considered stable with no change to pre-admission management, and IV pain medication had been discontinued in preparation for discharge, with pain status returned to pre-admission levels. Email communications among the Administrator, facility staff, and the Ombudsman showed that the facility initially indicated it would hold the resident’s bed and that the resident would need to be clinically stable prior to return. Subsequent emails documented that the facility expressed concerns that the resident’s condition, including pain medication regimen and wound status, appeared different from when the resident was transferred out, and that there was concern the resident might quickly require a return to acute care. The Administrator and DON later confirmed that decisions about readmission were made by a team and typically documented via email, and that the facility regularly provided wound care and pain management, including a process requiring residents to be off IV pain medication for at least 24 hours prior to admission or readmission. The DON recalled that the facility declined readmission due to perceived worsening wounds and a belief that the resident needed LTACH-level wound care and IV pain management, while acknowledging that hospital records indicated the resident’s wounds were stable and IV pain medication had been stopped. Both the Administrator and DON were unsure whether any documentation existed specifying the resident’s needs that could not be met, attempts to meet those needs, or communication of those needs to the hospital at the time of referral for readmission, and no such documentation was produced during the survey. The facility also lacked a policy regarding permitting a resident to return following hospitalization, despite an admission agreement that addressed transfer, discharge, and bed-hold rights.
Failure to Provide Written Bed-Hold Policy Notice at Hospital Transfer
Penalty
Summary
The facility failed to provide written notice of its bed-hold policy to a resident and the resident's representative upon transfer to an acute care hospital. The resident involved had diagnoses including acute respiratory failure with hypoxia, quadriplegia at C1-C4, and dependence on a ventilator. The clinical record showed the resident was discharged to an acute care hospital for surgical evaluation and an infectious disease consult related to a right hip wound infection. A Social Services Progress Note documented that the social worker notified the resident's guardian of the physician's recommendation for hospital transfer, contacted the hospital, secured a bed, and arranged transportation. However, the clinical record lacked any documented evidence that written notice of the facility's bed-hold policy was provided at the time of transfer. During interview, the Administrator stated they usually called or emailed residents and representatives to provide notification of the bed-hold policy when a resident was transferred, and that in emergent 911 transfers the priority was resident care with notification possibly occurring after the resident left. The Administrator confirmed this resident's transfer was coordinated and not emergent, recalled leaving a message for the resident's representative about paying a bed-hold fee after the transfer, and acknowledged that written notice of the bed-hold policy was not provided to the resident or representative upon transfer. The Administrator also stated the facility did not have separate policies on transfers, discharges, and bed-holds, and that related information was contained in the admission packet. The facility's Resident Admission Agreement included sections on transfers, discharges, and a bed-hold policy, including provisions for bed-hold charges and readmission rights, but there was no documentation that this required written notice was given at the time of the hospital transfer.
Incomplete Respiratory Treatment Documentation in Clinical Record
Penalty
Summary
The facility failed to ensure complete and accurate clinical records for a resident with acute respiratory failure with hypoxia and cystic fibrosis with pulmonary manifestations. Review of the resident’s February 2026 Respiratory Administration Record (RAR) showed multiple scheduled respiratory tasks and treatments with no documentation of completion or reason for omission. These included checking emergency equipment at the bedside every shift, continuous pulse oximetry every shift, oxygen via nasal cannula with titration parameters every shift, and rotation of the pulse oximeter probe every shift, all of which had blank entries on several specified dates. The DON confirmed that respiratory care and treatments were to be documented on the RAR and acknowledged the blank spaces on the record. Further review of the same resident’s RAR revealed missing documentation for ordered respiratory treatments scheduled every eight hours, including Albuterol Sulfate nebulizer treatments for shortness of breath, chest percussion for respiratory insufficiency, and HyperSal (7% Sodium Chloride) nebulizer treatments for secretions, with multiple dates left blank. The DON stated uncertainty as to whether the care or treatments were not provided or were provided but not documented, and confirmed that if care or treatment was held or refused, the RAR should indicate this rather than be left blank. The facility’s documentation policy, revised 11/07/2024, required staff to document assessments, interventions, procedures, treatments, outcomes, services provided, and any refusals of medications and/or treatments in the resident’s record.
Incomplete Facility Assessment Lacks Comprehensive Resident Data
Penalty
Summary
The Administrator failed to ensure the Facility Assessment (FA) included all portions of the facility's resident population and any ethnic, cultural, or religious factors that could affect the care provided. The FA, approved on January 16, 2025, documented that the facility provided post-acute care and rehabilitation to children, from infants to young adults, in a safe, home-like environment. However, the FA lacked documentation related to the facility's adult resident population and did not address any ethnic, cultural, or religious factors that could influence the care provided. On February 19, 2025, the Administrator acknowledged the responsibility to complete the FA annually, which includes reviewing the needs and complexity of the residents, as well as staffing and training needs. The Administrator confirmed that the FA should have included all resident types and addressed any ethnic, cultural, or religious factors. Additionally, the Administrator admitted that the facility did not have a policy related to the completion or required components of the FA, although they followed state and federal regulations.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to implement corrective actions to address the lack of Enhanced Barrier Precautions (EBP) for residents with chronic wounds or indwelling medical devices. This deficiency was identified during a QAPI review with the Administrator, who acknowledged that the facility had not recognized the issue until mid-January 2025. Despite being aware of the problem, the facility did not implement EBP, and no current residents were receiving these precautions. The Administrator's job description, dated 11/29/2011, indicated responsibility for the Performance Improvement Program, yet the deficiency persisted, potentially exposing all residents, staff, and visitors to harmful infectious agents.
Failure to Implement Enhanced Barrier Precautions and Investigate Infections
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for 20 residents with indwelling medical devices, as per the facility's policy and CDC guidance. Observations revealed that there were no EBP signage or personal protective equipment (PPE) carts near residents' rooms, and staff were not wearing gowns during high-contact care activities. Interviews with the Director of Nursing (DON) and the Regional Support DON/Infection Preventionist (RSDON/IP) confirmed that EBP had not been implemented for any residents, despite the presence of indwelling medical devices. The RSDON/IP acknowledged the need for EBP to prevent the transmission of multidrug-resistant organisms (MDROs) but stated that the facility was still working on its implementation. The facility also failed to investigate an increase in respiratory infections in the pediatric unit, affecting four residents in December 2024. The Monthly Line Listing of Resident Infections showed an increase from one respiratory infection in November to four in December, but no investigation was conducted to determine the cause. The RSDON/IP admitted that no enhanced or transmission-based precautions were implemented for the affected residents, and there was no evidence of staff training or in-service provided during the increase in infections. Additionally, the facility did not complete quarterly legionella testing as required by its Water Management Program. The Maintenance Manager revealed that water testing was only performed twice a year instead of quarterly. The facility's Water Management Program outlined the need for quarterly testing to prevent the growth and spread of legionella and other waterborne pathogens, but the results for the remaining quarters of 2024 were not documented or kept with the program.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to ensure that resident grievances were documented, investigated, and resolved, as required by their grievance policy. During a Resident Council Meeting, it was noted that residents had expressed concerns about the facility not responding to written grievances. One resident specifically mentioned that a grievance submitted in December 2024 had not been addressed. The facility's Administrator admitted that the binder containing grievance forms was missing after the Licensed Social Worker left employment, and no attempts had been made to recover or recreate the missing information. The facility's grievance policy mandates that grievances be investigated and a written decision provided to the resident within thirty days, with grievance forms retained for one year.
Expired Medications Found in Active Supply
Penalty
Summary
The facility failed to remove expired medications from the active supply in two medication storage rooms and two medication carts, which had the potential for expired medications to be administered to residents. During an inspection of the medication cart in the 400 unit, a bottle of Diphenhydramine Hydrochloride oral solution was found with an expiration date of January 2025. The Licensed Practical Nurse (LPN) confirmed the medication had expired. Additionally, in the medication storage room on the 400 unit, three bottles of Iron supplement liquid and one bottle of Geri-Tussin were found with expiration dates of December 2024 and October 2024, respectively. The LPN acknowledged these medications were expired and should have been removed from active storage. Further inspections revealed additional expired medications. On the 300 unit, a bubble pack containing Ondansetron tablets with an expiration date of January 2025 was found in the medication cart. The Registered Nurse (RN1) confirmed the tablets were expired and explained the process for handling expired medications, which includes removing them from the cart and placing them in a designated bin for destruction. In the medication storage room on the 200 unit, two boxes of Bisacodyl suppositories with expiration dates of January 2025 were found. RN2 confirmed these were expired and should have been removed. The Director of Nursing (DON) stated that expired medications should be destroyed and removed from active storage to prevent accidental administration to residents. The facility's policy requires expired medications to be stored separately until destroyed or returned to the pharmacy.
Deficiency in Timely Elder Abuse Prevention Training
Penalty
Summary
The facility failed to ensure that initial and annual elder abuse prevention training was completed in a timely manner for six out of eighteen sampled employees. This deficiency was identified through personnel record reviews, interviews, and document reviews. Specifically, the Director of Nursing, hired on December 20, 2024, lacked documented evidence of elder abuse prevention training upon hire. The Registered Dietician, hired on October 18, 2018, had completed training in 2022 but lacked evidence of training in 2024. Two Certified Nursing Assistants, hired in 2023, had completed training in 2023 but not in 2024. Additionally, a Registered Nurse and a Licensed Practical Nurse, both hired in 2022, lacked evidence of annual training, with the LPN also missing initial training documentation. The Office Manager confirmed that abuse training was required to be completed during the first orientation and annually thereafter, and that staff were not permitted to work on the floor prior to completing this training. The facility's policy, revised on October 2, 2024, stipulated that initial abuse training must be completed before starting floor training, and that all healthcare workers receive education and training on abuse during orientation, annually, and as needed. The lack of timely elder abuse training for these employees had the potential to place all residents at risk for abuse and neglect.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required CMS Form 10055 Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF-ABN) and Form 10123, Notice of Medicare Non-Coverage (NOMNC) to a resident discharged from a Medicare-covered Part A stay with benefit days remaining. The resident, who was admitted with diagnoses including essential primary hypertension and generalized muscle weakness, had a Medicare Part A Skilled Services Episode from 12/20/2024 to 02/02/2025. The resident's clinical record lacked documented evidence of receiving these forms. The Regional Support Director of Nursing confirmed the absence of these forms and acknowledged that they may not have been completed due to the lack of a social worker or case worker. Additionally, the facility was unable to locate a policy on beneficiary notifications.
Facility Fails to Address Noise Complaint Affecting Resident's Sleep
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for a resident who reported being disturbed by the loud closing of an exit door used by staff in the 200 Hall. The resident, who was admitted with diagnoses including circadian rhythm sleep disorder and unspecified sleep disorder, submitted a grievance in December 2024 about the noise from the door, which disrupted their sleep multiple times each night. Despite the grievance, the facility had not addressed the issue by the time of the survey. During the survey, the Director of Nursing confirmed that staff used the door next to the resident's room as an exit. The Administrator, upon testing the door, acknowledged that it closed loudly enough to wake residents in the hall. The facility's policy on resident rooms did not include considerations for noise levels, and the Administrator stated that this was the only policy related to maintaining a homelike environment.
Misappropriation of Resident's Funds by Facility Staff
Penalty
Summary
The facility failed to protect a resident from the misappropriation of personal property, specifically involving the wrongful use of the resident's money. The incident involved the facility Administrator and a previous Recreational Therapist, who commingled the resident's property with the facility's petty cash. The resident, who had been admitted with a primary diagnosis of atherosclerotic heart disease, discovered $100 missing from their wallet after signing it out. This was confirmed by the previous Assistant Director of Nursing. A Registered Nurse's statement indicated that the resident's valuables were moved from the medication cart to the Administrator's office at the Administrator's insistence. The Administrator admitted to removing $100 from the resident's property to pay vendors, as there was insufficient time to cash a petty cash check. The Administrator acknowledged this action as misappropriation, as the money was taken without the resident's consent. The facility's policy on resident funds and valuables clearly states that misuse of funds or property, including theft and commingling of funds, is considered misappropriation and must be reported. This incident was documented in a Facility Reported Incident and a complaint was filed, highlighting the failure to adhere to the facility's policy and protect the resident's financial resources.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set 3.0 (MDS) assessment for one resident, which had the potential to impact the resident's person-centered care plan. The resident was admitted with a primary diagnosis of hemiplegia affecting the left nondominant side. An Admission MDS assessment indicated that the resident had experienced significant weight loss, which was not accurate according to the weights and vitals summary. The MDS RN confirmed that different sections of the MDS were completed by different staff members, and the Dietician was responsible for completing Section K, which documented the incorrect weight loss. Upon review, the MDS RN acknowledged that the resident did not actually experience the reported weight loss by the time the MDS assessment was completed.
Expired CPR Certifications Among Direct Care Staff
Penalty
Summary
The facility failed to ensure that direct care staff maintained current Cardio-Pulmonary Resuscitation (CPR) certification for two of twelve sampled direct care employees. Employee #14, a Licensed Practical Nurse (LPN), and Employee #16, a Certified Nursing Assistant (CNA), both had expired CPR certifications. The LPN's certification expired on a specific date, and the CNA's certification also expired on a different date. The Office Manager confirmed that CPR certification was required for all direct care staff and acknowledged that these two employees did not have current certifications. The Facility Assessment indicated that all staff were expected to be Basic Life Support certified.
Failure to Monitor and Limit PRN Psychotherapeutic Medication
Penalty
Summary
The facility failed to ensure that a PRN psychotherapeutic medication was prescribed with a diagnosed indication for use, was limited to 14 days, and was monitored for side effects and behavior for a resident. Resident #19 was admitted with a primary diagnosis of hemiplegia, unspecified affecting the left nondominant side. An active physician's order dated 01/08/2025, prescribed Hydroxyzine Hydrochloride (HCl) 25 mg via gastrostomy tube every 24 hours PRN for episodes of feeling anxious or stressed over recent life changes. However, the resident's electronic health record (EHR) lacked documentation of an anxiety diagnosis, and the physician orders did not include evidence of side effect or behavior monitoring for the medication. The medication administration records indicated that Hydroxyzine HCl was administered from 01/09/2025 through 02/15/2025, exceeding the 14-day limit for PRN psychotherapeutic medications. Interviews with a Registered Nurse and the Regional Support Director of Nursing confirmed the absence of an anxiety diagnosis in the resident's EHR and the lack of required monitoring. The facility's policy on psychotherapeutic medications required that PRN orders be limited to 14 days and include behavior monitoring every shift, which was not adhered to in this case.
Failure to Provide Physical Therapy as Ordered
Penalty
Summary
The facility failed to provide physical therapy (PT) to a resident as per the physician's order, which required one hour of PT per week for 12 weeks. The resident, who was diagnosed with spastic quadriplegic cerebral palsy, muscle weakness, and abnormal posture, was admitted and readmitted to the facility with a care plan that included interventions for limited physical mobility and high fall risk. Despite the physician's order dated 01/08/2025, the resident did not receive PT from 02/02/2025 through 02/15/2025, as confirmed by the Regional Support Director of Nursing (RSDON) and the facility's Director of Rehabilitation. The RSDON acknowledged the lack of PT during this period and attributed it to staffing shortages in the rehabilitation department. Documentation provided by the RSDON and the resident's clinical record confirmed the absence of PT sessions during the specified two-week period. The facility's policy required nursing or designees to provide healthcare as regulated by the physician, which was not adhered to in this case, leading to the deficiency.
Failure to Document Pre-Restraining Assessments and Obtain Consent for Psychotherapeutic Medications
Penalty
Summary
The facility failed to ensure that residents prescribed psychotherapeutic medications had a documented pre-restraining assessment as required by the facility's policy. This deficiency was identified for five residents who were sampled for unnecessary medications. The residents involved had various diagnoses, including anxiety, depression, and cerebral palsy, and were prescribed medications such as Sertraline, Fluoxetine, Lorazepam, Cymbalta, Hydroxyzine, and Escitalopram. The electronic health records of these residents lacked documentation of a pre-restraining assessment related to their psychotherapeutic medications. The Regional Support Director of Nursing confirmed that the facility had not conducted pre-restraining assessments for any residents receiving psychotherapeutic medications, which was a requirement per the facility's policy. Additionally, the facility failed to obtain consent for the administration of a psychotherapeutic medication for one resident. This resident was prescribed Sertraline for anxiety, and the medication was administered without documented evidence of consent being obtained prior to its administration. The facility's policy required that consent be obtained and reviewed by a physician before ordering or administering psychotherapeutic medications. The Regional Support Director of Nursing confirmed that consent had not been obtained for this resident, which was a violation of the facility's policy.
Lack of Antimicrobial Stewardship Education and Documentation
Penalty
Summary
The facility failed to ensure that staff received education regarding the Antimicrobial Stewardship Program (ASP) and did not document evaluations to determine if residents met McGeer criteria before initiating antibiotic therapy. A Registered Nurse (RN) who had been working at the facility for about a year reported not receiving any training related to the facility's ASP. The RN also stated that the facility lacked an antibiotic stewardship program and did not perform antibiotic timeouts, with all antibiotic prescribing decisions being made by the physician. The Regional Support Director of Nursing/Infection Preventionist (RSDON/IP) could not confirm that staff had received formal training on the ASP or its importance. The facility's Antimicrobial Stewardship Program, last reviewed in January 2025, required continuing education for all staff on antimicrobial stewardship, including resistance and appropriate infection assessment. However, the facility did not have a specific form or criteria for documenting suspected infections before starting antibiotic therapy. The Monthly Line Listing of Resident Infections for November and December 2024 showed antibiotics were prescribed for most infections, but did not include an assessment protocol or indicate if residents met criteria for antibiotic therapy. The RSDON/IP confirmed that the facility tracked communicable diseases and antibiotic use but lacked documentation of assessments and criteria in residents' records, as required by the facility's policy.
Deficiency in CNA Training and Performance Evaluations
Penalty
Summary
The facility failed to provide the required twelve hours of in-service training for two Certified Nursing Assistants (CNAs) who had been employed for over a year. Employee #6, hired on September 20, 2023, did not have an annual performance review conducted by their anniversary date of September 20, 2024, and lacked the necessary in-service training. Employee #7, hired on February 17, 2023, had a delayed performance review conducted on July 11, 2024, which was 145 days past their anniversary date of February 17, 2024. Additionally, Employee #7 did not have a performance review completed by their anniversary date of February 17, 2025, and also lacked the required in-service training. The Office Manager confirmed these deficiencies, noting that all CNAs were required to have annual evaluations by their hire date, which were to be completed by the Director of Nursing.
Failure to Provide Physician-Ordered Ventilator Weaning and Fraudulent Charting by RT
Penalty
Summary
A resident with chronic respiratory failure, tracheostomy status, and ventilator dependence was admitted and had a physician's order for daily ventilator weaning using specific sprint settings. The resident's family reported concerns that a Respiratory Therapist (RT) was not providing the ordered care. Upon review, the Respiratory Manager (RM) found that although the RT documented completion of the ventilator weaning, the ventilator's event log did not show any evidence that the required changes to the ventilator settings were made as ordered by the physician. The RM confirmed that the ventilator machine automatically records all setting changes, and no such changes were documented during the relevant period. The RT had charted that the care was provided, but the lack of corresponding evidence in the ventilator log indicated that the care was not actually rendered. This failure to provide physician-ordered care was substantiated as neglect by the facility, as it involved fraudulent charting and professional negligence.
Failure to Timely Report Allegations of Neglect and Misappropriation
Penalty
Summary
The facility failed to ensure timely reporting of two separate allegations to the State Agency (SA) as required by regulation and facility policy. In the first instance, a resident with chronic respiratory failure and tracheostomy status was allegedly neglected when a Respiratory Therapist (RT) did not provide physician-ordered care. The concern was initially reported to a facility employee on 10/30/2024, but the Administrator was not notified until 11/05/2024, at which point the incident was reported to the SA. Facility policy required all staff, including those with contractual agreements, to immediately report suspected abuse or neglect to the Administrator and the SA, but this did not occur in a timely manner. In the second case, an allegation of misappropriation of resident property was not reported to the SA within the required timeframe. A resident discovered $100 missing from their wallet, which had been stored in a lock box in the Administrator's office. The Administrator admitted to removing the cash from the resident's property to pay facility vendors without the resident's consent. Although the incident was known to the Administrator, it was not reported to the SA until several days later, contrary to the policy that required reporting within two hours of discovery. Both incidents involved failures by facility staff, including the Administrator, to follow mandatory reporting requirements for suspected neglect and misappropriation. Documentation and interviews confirmed that the reporting delays were due to staff not immediately notifying the appropriate authorities, as required by both state regulations and facility policy.
Failure to Provide Complete Investigation Documentation for Resident Fall
Penalty
Summary
The facility failed to ensure that a complete investigation report was available for review regarding a fall incident involving a resident with spastic diplegic cerebral palsy, diabetes insipidus, and bilateral knee contractures. The resident experienced a fall with injury while receiving care, as documented in the care plan and the Facility Reported Incident (FRI) submitted to the State Agency. However, the FRI report lacked specific details about the location of the fracture and the additional treatment provided. Upon request, the facility was unable to produce the full investigation report, with only the documents submitted to the State Agency available for review. This was not in accordance with the facility's policy, which requires a written report of the investigation results and actions taken.
Annual CNA Performance Evaluation Not Completed Timely
Penalty
Summary
The facility failed to complete an annual performance evaluation for a Certified Nursing Assistant (CNA) who had been employed for over one year. The CNA was hired on 09/20/2023, but there was no documented evidence of an annual performance review being conducted by the anniversary date of 09/20/2024. The Office Manager confirmed that the evaluation for 2024 was completed late and that the evaluation for 2025 had not yet been completed. Facility policy required annual evaluations for all CNAs by their hire date, to be completed by the Director of Nursing.
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What surveyors actually found near you
We read the 164 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Reno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Advanced Health Care Of Reno | 0.7 mi | ★★★★★ | 12 | 0 |
| Rosewood Rehabilitation Center | 1.8 mi | ★★★★★ | 30 | 0 |
| Alpine Skilled Nursing And Rehabilitation Center | 2.9 mi | ★★★★★ | 16 | 0 |
| Northern Nevada State Veterans Home | 4.3 mi | ★★★★★ | 13 | 0 |
| Alta Skilled Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 19 | 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 August 2026) and official state health department websites.