Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Ormsby Post Acute Rehabilitation during CMS and state inspections, most recent first.
Food handling and sanitation practices were deficient when dietary staff handled food and donned gloves without performing hand hygiene, stored cooked ham in contact with raw pork chops in the walk-in refrigerator, left caramel sauce past its expiration date in the refrigerator, and kept the outdoor barbecue grill covered in char and grease. The Dietary Supervisor confirmed the hand hygiene, storage, expiration, and cleaning expectations during the observations.
Infection surveillance data was not used to identify the cause of multiple facility-acquired infections across several months, including COVID-19, UTIs, PNA, yeast infections, cellulitis, C. diff, skin rashes, and wound infections. The Infection Preventionist stated the facility had not provided staff education specific to the surveillance data and had not analyzed the data to determine why the infections were occurring, despite the facility policy requiring surveillance for prevention, identification, investigation, and control of infections.
Resident-to-resident physical abuse occurred when one resident struck a roommate in the head/face area during an argument over lights and urinal use, and the roommate struck back. The CNA observed the roommate standing over the bed with a clenched fist, and the DON confirmed the investigation found the roommate admitted to hitting the other resident. The affected resident later said the roommate had hit the resident in the face and that the resident no longer trusted the roommate.
A resident reported missing Lyrica doses and family concerns that nurses may have been stealing the medication. A nurse documented the allegation, but it was not reported immediately to the AC, and the DON and Administrator confirmed the allegation of misappropriation was not timely reported or immediately investigated. RN1 continued working for weeks after the allegation was made, and the facility’s records showed the concern involved possible diversion of pain medication.
A resident with paraplegia was kept in a hospital gown without personal clothing, was not provided showers despite wanting them, and reported only hospice bed baths while staff gave conflicting explanations about bathing responsibility. In a separate incident, a CNA entered another resident’s room without knocking and made an embarrassing comment about the room smelling like poop, which the resident said was degrading and embarrassing.
Psychotropic Medication Consent Not Obtained Before Administration: The facility failed to ensure informed consent was obtained before starting psychotropic meds for two residents. One resident with bipolar disorder received quetiapine for manic depression before the consent was documented, and another resident with schizoaffective disorder received olanzapine daily without any documented consent in the record. The DON, ADON, and CNO confirmed the consents were not in place before the meds were administered.
Failure to Repair and Provide Resident’s Electric Wheelchair: A resident with depression, anxiety, and sequelae of CVA was not provided access to the electric wheelchair brought in on admission. The resident reported being unable to leave bed or get to common areas, while staff gave conflicting accounts about the wheelchair’s status; the RN said it was operational, maintenance said it had been sitting in the dining room with a missing footrest, and the DON confirmed it had not been repaired or accommodated.
Failure to Provide Safe Wheelchair and Honor Resident Choice: A resident with paraplegia and hospice needs was found confined to bed with an unused manual wheelchair that the resident said was unsafe due to lack of core strength. The resident wanted to leave the room daily and go outside, but staff had not gotten the resident out of bed or offered to do so since admission. The Activities Director, RN, SW, and DON each confirmed the resident had not left the room, and the DON stated the resident needed a Hoyer lift and a reclining wheelchair because the provided wheelchair was not safe.
A resident with chronic pain had a care plan that did not include non-pharmacological pain interventions, and staff documented pain without recorded interventions. Another resident with ESRD and dialysis refusals had a care plan that lacked refusal-related interventions and education for missed treatments. Additional residents had care plans missing PTSD/trauma-specific interventions, oxygen therapy and respiratory monitoring details, and ordered psychotherapy for adjustment disorder with depressed mood.
Two licensed nurses, including an ADON and an RN, lacked documented current CPR and first aid certification. Personnel and document review confirmed the missing certifications, and the HRC stated that licensed nurses were required to maintain current CPR and first aid credentials upon hire and at expiration.
A resident with a GI infection had a lab result showing C. diff was negative but Entamoeba histolytica was positive, yet the record lacked documentation that the established GI specialist was notified and the care plan did not include the parasite infection. Another resident reported constipation, nausea, and abdominal and rectal pain, with the bowel record showing multiple days without a BM; although PRN Fleet enema and Milk of Magnesia were ordered, no administrations or other constipation interventions were documented.
A resident with right humerus and right femur fracture diagnoses reported ongoing right leg pain, with an acceptable pain level of 4/10. The MAR showed hydromorphone 2 mg was given for pain, but the resident’s pain later remained at 7/10, and the record lacked documented interventions to address it. The RN confirmed no interventions were implemented, and the DON stated the resident should have been evaluated for non-pharmacological measures and offered additional pain relief or provider notification.
Failure to provide trauma-informed care was identified for two residents. One resident had PTSD documented in the record, but no trauma assessment was completed to identify triggers or interventions. Another resident experienced a traumatic family death after admission; although psych assessment noted worsening depression and psychotherapy was ordered, the DSS confirmed no trauma assessment was completed on admission or after the event, and no care plan interventions were in place related to the trauma.
Late CNA Annual Performance Review: The facility failed to ensure that a CNA employed for more than one year had an annual performance review completed by the anniversary date. Personnel record review showed the review was completed 10 days late, and the HRC confirmed the delay. The Administrator stated the facility did not have a policy related to CNA performance reviews but followed federal regulations.
Unattended Medication and Expired Drugs in Storage: An RN left a prepared dose of GlycoLax in a resident’s room during the med pass instead of keeping it under direct observation, and the RN stated this was typical for laxative powders mixed in liquid. Surveyors also found expired medications in a med storage room and on a med cart, including sore throat spray and Vitamin D tablets, both confirmed expired by facility staff.
A resident's lunch tray did not match the diet ticket when dietary staff placed two salt packets on a tray ordered as a regular diet with no added salt. The dietary staff member confirmed the salt packets were present, and the Dietary Manager confirmed the tray should have matched the ticket and provider orders.
Failure to Serve Ordered Minced and Moist Diets: Dietary staff served meals that did not match MM5 diet tickets, including whole chicken breast and other foods not prepared as ordered. A resident with paraplegia and difficulty chewing, who had an active minced and moist diet order, received trays with hard-to-chew items such as a whole ham steak and reported the food was painful to eat and hard to chew.
Improper Dumpster Storage and Debris Around Refuse Area: Surveyors observed two dumpsters at the back of the facility, with one lid left open and exposed trash inside and the other surrounded by trash, including gloves, cans, and paper. The Dietary Supervisor stated the area should be kept clean and the lids closed to prevent animals and pests. The facility policy required outside refuse containers to have tightly fitting lids and surrounding areas kept clean.
Facility assessment was not updated after a change in the contracted medical provider group. The assessment still listed the prior vendor as the primary medical practitioners and did not reflect the new attending MD, on-call coverage, or the qualifications, availability, scope of services, and clinical responsibilities of the newly contracted medical group. The Administrator confirmed the change had occurred and that the assessment language had not been revised.
Failure to designate a hospice coordinator: The ADON stated she was not the hospice coordinator and did not know who was responsible, while the Administrator confirmed the facility had no hospice coordinator despite knowing one was required. The DON also stated she was not the hospice coordinator and said ADONs managed hospice residents on their units. The facility policy on Coordination of Hospice Services did not include language requiring designation of an interdisciplinary team member to coordinate hospice care.
QAPI committee failed to identify and address system-level issues involving the lack of a designated hospice coordinator and concerns about access to employee records for abuse prevention training and CPR/first-aid certifications. The Administrator confirmed both issues were known but had not been addressed through the QAPI process, despite the facility policy requiring QAPI to track, analyze, and correct problem areas.
The facility failed to provide QAPI committee member signature attendance sheets for multiple quarters. During document review and interview, the Administrator said the facility did not have access to the monthly QAPI attendee lists after a change of ownership, and could not confirm which committee members attended the meetings. The QAPI Facility Plan stated that written documentation of meeting attendance records shall be maintained.
Ice Machine Not Kept Clean and in Good Repair. Surveyors observed white mineral deposits on the ice machine’s exterior, door, and the floor around it. The Dietary Supervisor confirmed the machine should have been cleaned and said maintenance and kitchen staff were responsible for the task. The facility policy stated all food service areas must be kept clean and sanitary.
Delayed Elder Abuse Training for Multiple Employees: The facility failed to ensure timely initial elder abuse training for 6 of 20 sampled employees, including the DON, ADON/IP, RNs, Social Services staff, and Housekeeping Supervisor. Personnel records showed the training was completed after hire for each employee, and the HRC confirmed the training was not completed upon hire or before starting work on the floor; no prior elder abuse training records were found.
Failure to provide Medicare non-coverage notice. Based on record review and interview, the facility did not give a NOMNC to one resident before discharge when Medicare Part A skilled services were ending. The resident's chart lacked documentation of the required notice, and the Administrator confirmed the notice was not provided prior to discharge.
A resident with type 1 DM and insulin orders requiring MD notification for BG values outside set parameters experienced multiple episodes of hypoglycemia, including documented BG readings in the 40s. Nursing notes showed insulin was held and hypoglycemia treated, but there was no documentation that the physician was notified of these low BG values as required. Later, the resident was found unresponsive and clammy with a BG of 31 mg/dl; an RN administered oral glucose gel even though the resident could not safely swallow and the standing order required Glucagon SQ/IM for unresponsive residents with hypoglycemia. The BG remained critically low until EMS arrived and administered IV dextrose, after which the resident briefly aroused and then coded, ultimately expiring. Leadership and clinical staff confirmed that physician notification had not occurred for prior low BG readings and that the hypoglycemia treatment orders were not followed during the unresponsive episode.
A resident with type 1 DM and diabetic autonomic neuropathy was found unresponsive and clammy by a CNA during the night. An RN obtained a blood glucose of 31, administered oral glucose gel outside of order guidelines, and did not administer ordered Glucagon. A repeat blood glucose remained 31, EMS administered D10, the resident briefly regained consciousness, then became unresponsive, CPR was initiated, and the resident expired. The Administrator/Abuse Coordinator reported there was no accessible documentation of the required abuse/neglect investigation, stating that records previously maintained by the former DON could not be located and some electronic files were inaccessible after a change of ownership, contrary to the facility’s abuse/neglect policy requiring a complete, documented investigation.
The facility failed to document cooking and holding temperatures for chicken before serving it to residents. Dietary staff removed chicken from the oven and placed it on a steam table without checking temperatures. The Dietary Manager confirmed that temperatures were not documented, and the Registered Dietician acknowledged the lack of temperature recording, which could lead to foodborne illness. The facility lacked a policy on foodborne illness, and no cooking temperature log was found, despite existing policies requiring temperature checks.
A facility failed to coordinate hospice care for three residents, resulting in missing documentation of hospice visits and care provided. The lack of coordination and documentation compromised the quality of hospice care. The DON confirmed that hospice visit notes were not documented in the residents' charts, and the facility did not have evidence of required visits being completed as per the hospice care plans.
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in non-compliance with Medicare requirements. One resident, with conditions including osteoarthritis and respiratory failure, was discharged without receiving the NOMNC. Another resident, with diabetes and kidney disease, did not receive the NOMNC for an extended admission period. The BOM confirmed the absence of documentation for both cases, despite the facility's policy to follow CMS guidelines.
The facility failed to transmit MDS 3.0 assessments to the State within the required 7-day timeframe for 4 out of 10 months, starting in June 2024. A significant percentage of admission assessments were completed late, with the Executive Director confirming that the late filings were due to a change in MDS Coordinators.
The facility failed to ensure accurate MDS assessments for two residents, one receiving hospice care and another discharged home. A resident's hospice care was not documented in the MDS, and another's discharge status was incorrectly recorded as a hospital discharge instead of home. The MDS Consultant confirmed these inaccuracies, and the facility lacked a specific policy for MDS completion, relying on the RAI manual.
A facility failed to develop a person-centered Comprehensive Care Plan for a resident with type 2 diabetes mellitus, omitting documentation of insulin use. Despite physician's orders for HumaLOG and Insulin Glargine being recorded in the MAR, the Care Plan lacked evidence of insulin administration. The DON confirmed this omission, which could impact the resident's care related to insulin management.
A facility failed to ensure behavior monitoring was specific to a resident's condition for psychotropic medication use. The resident, diagnosed with major depressive disorder and generalized anxiety disorder, had multiple psychotropic medications prescribed. However, the behavior monitoring was not tailored to the resident's specific behaviors, potentially leading to unnecessary medication use. The DON noted that CNAs documented behaviors during shifts, but the EMR lacked resident-specific instructions.
The facility failed to properly store and monitor medications, as a refrigerator contained food items alongside vaccines, lacked a temperature log, and was unsecured. A multi-dose vial of Tubersol Solution was expired, and a medication cart was left unattended with an unlocked drawer. These actions violated the facility's policies on medication storage and administration.
A facility failed to protect resident information and maintain complete medical records. A computer screen displaying resident data was left unattended in a public area, and a resident's Treatment Administration Record had missing documentation for scheduled care and medication. The DON confirmed these omissions, which violated facility policies.
A newly assigned agency RN provided direct care without completing required orientation, training, or competency validation. The RN began their shift without reviewing the orientation packet, refused to complete it when prompted by an LPN, and did not administer as-needed medications to several residents, requiring intervention by other staff. Facility policies and the staffing agency contract required completion of orientation and competency checks prior to independent assignment, which were not fulfilled.
A LTC facility failed to protect residents from abuse and neglect, including a CNA refusing to assist a resident out of bed, an LPN verbally abusing a resident, a physician continuing an unwanted breast exam, and a resident-to-resident sexual abuse incident. These incidents involved residents with cognitive impairments and dependencies on staff, highlighting significant deficiencies in care and supervision.
A nurse in an LTC facility was witnessed self-administering insulin prescribed to a resident with type I diabetes. The resident, who is blind, was unaware of the incident until informed by others and expressed feeling upset. The facility's guidelines define this as misappropriation of resident property.
A resident received incorrect medications for three days due to a nurse inputting orders from another resident's discharge summary. The error was discovered after the resident showed symptoms of hypotension and was hospitalized. The physician admitted to signing the orders without thorough review, and the DON expected the provider to question inappropriate orders.
A resident was mistakenly administered medications intended for another resident due to an error in order entry by the admitting nurse. The resident received treatments for conditions they did not have, leading to hospitalization for monitoring adverse side effects. The facility's policy required clarification of medication orders, which was not followed in this instance.
The facility failed to investigate a potential misappropriation of narcotic medication for a resident and did not thoroughly investigate an abuse allegation involving another resident. The alleged perpetrator of the abuse was allowed to continue working, posing a risk to residents. The facility's policies on abuse prevention and investigation were not adequately followed, leading to significant oversights in the investigation process.
The facility failed to ensure the Infection Preventionist (IP) had the skills to review lab results for transmission-based precautions, leading to potential exposure to communicable diseases. Additionally, a nurse lacked competency in medication administration, risking adverse reactions. The IP also lacked knowledge in pneumococcal vaccine administration and failed to complete Antibiotic Stewardship Program (ASP) documentation, risking ineffective antibiotic treatment.
The facility failed to maintain food safety and hygiene standards, with personal items found on food prep counters and staff not performing hand hygiene during meal service. Personal items and charging cords were improperly placed on food prep counters, and staff did not follow hand hygiene protocols when handling meal trays, as confirmed by the Nutritional Services Supervisor.
The facility failed to properly investigate an allegation of sexual abuse, allowing a suspended staff member to continue working unsupervised. Additionally, the Infection Preventionist (IP) lacked the skills to effectively track infections and antibiotic use, and failed to identify residents needing pneumococcal vaccines, increasing the risk of infections with Multi Drug Resistant Organisms (MDROs).
The QAPI committee in a LTC facility failed to identify several critical issues, including concerns with Enhanced Barrier Precautions, incorrect APRN documentation, inadequate abuse investigations, and issues with narcotic medication tracking. Additionally, the absence of a Hospice Coordinator and inadequate pneumococcal vaccine screening were overlooked, indicating a failure in the facility's QAPI processes.
The facility failed to ensure accurate documentation and tracking of infections and antibiotic use, affecting 10 residents prescribed antibiotics. The Infection Preventionist's form lacked necessary elements, leading to incomplete records. Additionally, the facility did not provide required education on antibiotic use and the Antibiotic Stewardship Program to staff and residents.
The facility failed to ensure timely compliance and ethics training for 15 employees, including the Administrator and DON. Document reviews showed that several employees either completed the training late or lacked evidence of completion for 2023. Human Resources staff were unsure about the training requirements, contributing to the deficiency.
Two residents had unsecured medications in their rooms, including powders and inhalers, with CNAs improperly handling them. One resident's CNA applied medicated powders without proper authorization, while another resident's inhalers were left unsecured after being brought in by family. Additionally, a medication cart was left unattended with a CNA watching it, which was outside their scope of practice.
The facility failed to secure and properly store medications, leaving a medication cart unattended with over-the-counter pills, improperly storing Lorazepam that required refrigeration, and not removing discontinued medications. Additionally, medications were found without proper labeling, making them unusable. These actions were against facility policy and professional standards.
Food Handling, Storage, Expiration, and Grill Cleaning Deficiencies
Penalty
Summary
Dietary staff failed to perform proper hand hygiene when handling food and donning gloves during meal preparation. On 05/11/2026, a Dietary staff member was observed holding a baking pan containing potatoes without gloves, placing the pan on the food preparation surface, and then putting on gloves without performing hand hygiene. Similar observations were made on 05/13/2026 with a baking pan containing chicken and on 05/14/2026 with a baking pan containing carrots; in each instance, the staff member was not wearing gloves while holding the food, placed the pan on the preparation surface, and donned gloves without hand hygiene. During the 05/14/2026 observation, the staff member also picked up a ladle and continued stirring soup on the adjacent stove. The Dietary Supervisor confirmed staff were required to perform hand hygiene when donning and changing gloves and stated gloves were required to prevent transmitting illness to residents. Food storage and sanitation practices were also deficient. In the walk-in refrigerator, a shrink-wrapped cooked ham was stored in a bin on the bottom shelf with raw pork chops in a plastic bag placed on top of it, with the ham wrap in contact with the pork chop bag. The Dietary Supervisor confirmed the ham and pork chops should have been stored separately in different bins and stated improper storage could result in resident illness. In the same refrigerator, a metal hotel pan of caramel sauce was sealed with plastic wrap marked with an expiration date of 05/08/2026, but it remained in the refrigerator on 05/11/2026. The Dietary Supervisor confirmed the caramel sauce should have been discarded and stated the refrigerator was checked daily. At the back of the facility, an outside barbecue grill was observed open with the interior grate covered in layers of char and grease, and the Dietary Supervisor confirmed the grill should have been cleaned after use.
Infection surveillance data was not analyzed to identify causes of facility-acquired infections
Penalty
Summary
The facility failed to ensure that data collected through infection surveillance was analyzed to identify the potential cause of facility-acquired infections and to prevent further infections for 5 of 5 months reviewed in 2026. The 2026 Infection Surveillance spreadsheets documented multiple facility-acquired infections, including COVID-19, eye infections, urinary tract infections, pneumonia, fungal/yeast infections, cellulitis, respiratory illness, ear infection, wound infection, shingles, C. diff, skin rashes, oral abscesses, dermatitis, skin infection, and rheumatic fever across January through May 2026. On 05/14/2026 at 1:09 PM, the Infection Preventionist stated the facility had not provided staff education specific to the infection surveillance data and had not analyzed the data to determine the cause of the facility-acquired infections. The facility policy titled Infection Prevention and Control Program, dated 04/11/2025, stated that surveillance would be used for prevention, identification, investigation, and control of infections and communicable diseases for all residents and staff, and that the Infection Preventionist would maintain documentation of incidents, findings, and corrective actions and report surveillance findings to the QAA Committee.
Resident-to-Resident Physical Abuse Not Prevented
Penalty
Summary
The facility failed to ensure Resident #97 was protected from resident-to-resident physical abuse. Resident #97 was admitted and later readmitted with diagnoses including pleural effusion and chronic respiratory failure with hypoxia. On 04/30/2026, while Resident #97 was using a urinal and requesting assistance, the CNA turned on only the light on Resident #97's side of the room because the roommate was sleeping. Resident #97 became upset, yelled, and later reported that the roommate hit Resident #97 in the head/face area. The CNA entered the room and observed the roommate standing over Resident #97's bed with a clenched fist, while both residents were verbally aggressive toward each other. The final FRI report documented that Resident #97 and Resident #81, who were roommates at the time, punched each other after Resident #81 struck Resident #97 in the head. Resident #97 later recalled that the roommate would not allow the light to remain on long enough for urinal use and stated the roommate hit Resident #97 in the face with a closed fist. Resident #97 then grabbed the roommate by the shirt and hit the roommate back. Resident #97 denied injuries but stated the resident no longer trusted the roommate and was afraid to sleep because of concern the roommate would stick a knife in the resident's chest. The DON stated abuse could include physical abuse such as striking a resident, and confirmed the investigation found Resident #81 admitted to hitting Resident #97, with Resident #81 claiming the resident reacted after being hit first.
Delayed Reporting of Alleged Medication Misappropriation
Penalty
Summary
The facility failed to ensure Resident #62 was protected from potential misappropriation of property when an allegation that a nurse stole the resident’s medication was not reported to the Abuse Coordinator in a timely manner. Resident #62 was admitted with diagnoses including chronic respiratory failure and chronic pain. During an interview, the resident stated the resident had pain in both arms, relied on Lyrica for pain control, and recalled two or three times when an ordered dose was not received and the facility said it had run out of the medication. The resident also stated the missed doses occurred when two specific staff members were working, although those staff members no longer worked at the facility. A nurse’s note documented that the resident’s family member reported the resident had concerns that medications were not being administered and that nurses may have been stealing Pregabalin (Lyrica). Another nurse’s note documented follow-up by the DON, who spoke with the ADON and the resident about the medication being broken in half when removed from the packet; the resident remained suspicious. The DON later confirmed that the note from the family member documented an allegation of misappropriation of resident property and should have been reported immediately, but it was not reported to facility leadership. The DON and Administrator confirmed that allegations of abuse, neglect, or misappropriation were expected to be reported immediately to the Administrator/AC. The Administrator/AC acknowledged awareness of the later incident involving pain medications but stated the matter was mostly clinical and that the DON conducted most of the investigation. The Administrator/AC also confirmed the allegation from the nurse’s note was not reported timely, that an immediate investigation was not initiated, and that no protections were put in place on or around the date of the allegation. The DON further confirmed RN1 continued working in the facility from the date the allegation was made until several weeks later.
Failure to Protect Resident Dignity and Personal Rights
Penalty
Summary
The facility failed to ensure a resident had the right to wear personal clothing. Resident #3, who was admitted with paraplegia, adult failure to thrive, and atherosclerotic heart disease, was observed lying in bed in a hospital gown on multiple days with no personal items visible in the room. The resident stated being admitted without personal belongings and reported repeated attempts to have staff help obtain clothing left in the resident’s apartment, but the resident felt nothing would be done. The resident’s belongings inventory listed only four items, and the DON confirmed the resident had not been accommodated, offered, or provided personal clothing in place of the hospital gown. The facility also failed to provide a shower to Resident #3, who stated a desire to take a shower and reported receiving only one shower since admission, with hospice providing bed baths once weekly or every one to two weeks. The resident was observed with peeling skin on the hands and stated the skin on the chest was dying from not receiving a shower and that the head was itching. Staff gave conflicting explanations about bathing responsibility, with an RN stating hospice was in charge of showers and a CNA stating residents were to receive two showers per week. The shower schedule and follow-up question report documented bed baths provided by hospice, while the hospice plan of care lacked documentation that hospice would provide bathing as part of the terminal prognosis. The facility further failed to treat a resident with respect and dignity when a CNA entered Resident #81’s room without knocking and stated, “I was told it smelled like poop and to come change you.” Resident #81 said the comment was embarrassing and reported the CNA rarely knocked before entering. The CNA acknowledged the statement may have embarrassed the resident and should have knocked before entering. The facility’s residents’ rights policy stated residents must be treated with dignity and respect.
Psychotropic Medication Consent Not Obtained Before Administration
Penalty
Summary
The facility failed to ensure that residents were fully informed about the purpose and common side effects of psychotropic medications before the medications were started for 2 of 19 sampled residents. Resident #5, who had diagnoses including bipolar disorder with manic severe psychotic features and anxiety disorder, had an order for quetiapine fumarate 300 mg daily for manic depression. The MAR showed the medication was administered beginning on 03/12/2026, but the Psychotropic Medication Consent was not documented until 04/21/2026, after the medication had already been given. On 05/13/2026, the CNO stated the consent was not completed before the psychotropic medication was started and that the resident's representative should have had the opportunity to consent or refuse before administration. Resident #64, who had diagnoses including schizoaffective disorder, bipolar type, personality disorder, dissociative and conversion disorder, and major depressive disorder, had a physician's order for olanzapine 5 mg daily beginning on 01/21/2026. The January, February, and March 2026 MARs showed the medication was administered daily through 03/30/2026, except for one missed dose on 02/01/2026, but the clinical record lacked documented evidence of a Psychotropic Medication Consent. The DON stated staff were required to obtain consent prior to administration of psychotropic medications and that the consent was used to inform the resident about the risks and benefits of the medication. The ADON and CNO later confirmed the facility did not have informed consent for Resident #64 prior to olanzapine administration.
Failure to Repair and Provide Resident’s Electric Wheelchair
Penalty
Summary
The facility failed to reasonably accommodate Resident #8 by not ensuring the resident’s electric wheelchair was repaired and available for use. Resident #8 was admitted with diagnoses including major depressive disorder, anxiety disorder, and sequelae of cerebral infarction. During interview, the resident stated the electric wheelchair had not been available since admission, the resident did not know where it had gone, and the resident had remained in bed and had not gone out into the facility’s common areas. The resident also reported the right leg was non-operational and that both heels had begun to hurt from staying in bed. The resident’s personal belonging inventory documented admission with one electric chair and charger. Staff interviews showed the Activities Director was unaware the resident had an electric wheelchair, an RN stated the wheelchair had been operational but maintenance would not touch it because it was considered a safety liability, and the Maintenance Supervisor said the wheelchair had been sitting in the dining room for about two weeks with a missing footrest and had not been repaired because the manufacturer had not been contacted. The DON later confirmed the wheelchair belonged to Resident #8, was still in the dining room, and had not been accommodated or repaired, and the facility could not produce the claimed email correspondence with the family about ordering parts.
Failure to Provide Safe Wheelchair and Honor Resident Choice
Penalty
Summary
The facility failed to ensure Resident #3’s right to make choices about significant aspects of life in the facility by not providing an appropriate wheelchair that would allow the resident to get out of bed. Resident #3 was admitted with diagnoses including paraplegia, adult failure to thrive, and atherosclerotic heart disease. During observation, the resident was found lying in bed with a manual wheelchair beside the bed that had plastic wrap around each wheel and no markings showing it had been used. The resident stated the wheelchair had been provided by the facility but had never been used, and explained that due to paraplegia and lack of core strength, the resident could not sit safely in it. The resident also stated a desire to leave the room daily and go outside to enjoy the sunshine, but reported staff had not gotten the resident out of bed or offered to do so since admission. The Activities Director stated residents could go outside and staff would assist if needed, and confirmed the resident had not left the room since admission. An RN was not aware the resident could not use the wheelchair provided. The Social Worker stated no conversations, assessments, or support had been provided to the resident and did not know the resident’s preferences. The DON stated the resident needed a Hoyer lift to get out of bed and that the manual wheelchair was not safe for the resident, confirming the resident had not left the room since admission.
Care plans lacked required individualized interventions for pain, dialysis refusal, trauma, oxygen therapy, and behavioral health needs
Penalty
Summary
Resident #2, admitted with diagnoses including sequela of an upper right humerus fracture and a lower right femur fracture, reported right leg pain during the survey. The resident stated a new pill had been started but was unsure whether it was working because the pain continued and caused the resident to spend more time in bed. The MAR documented hydromorphone 2 mg was given for pain, and the pain level summary documented a pain score of 7 later that morning, but the record lacked documented interventions to address the pain at that time. Resident #2’s chronic pain care plan did not include non-pharmacological interventions for pain management. The RN confirmed the pain score had been 7 and stated no interventions had been implemented, explaining the RN was waiting to see whether the hydromorphone given earlier would help. The DON confirmed the resident should have been evaluated for a non-pharmacological intervention when the pain score was 7 and that the care plan should have included such interventions so they could be provided. Resident #97, admitted with end stage renal disease and dependence on renal dialysis, had multiple documented refusals to go to dialysis, including refusals on several dates in April and May. The resident stated the resident usually went to dialysis on Mondays, Wednesdays, and Fridays but had missed the last two scheduled treatments due to constipation and abdominal pain. The care plan identified the need for dialysis and risk for complications related to refusals, but it did not include interventions to address reasons for refusal, education to provide at the time of refusal, or interventions staff could use to get the resident to agree to go. Resident #12 had a documented diagnosis of PTSD, but the care plan did not include the diagnosis, trauma history, triggers, stressors, or interventions to reduce the potential for re-traumatization. Resident #71 had chronic respiratory failure with hypoxia and COPD and was receiving oxygen therapy, but the care plan did not document the respiratory diagnoses, oxygen administration, flow rates, or monitoring for changes in condition and complications related to oxygen use. Resident #88 had an order for behavioral interventions, including psychotherapy, for adjustment disorder with depressed mood related to the violent death of the resident’s grandson and adjustment to LTC placement, but the care plan did not include psychotherapy or the updated behavioral interventions.
Missing Current CPR Certification for Two Licensed Nurses
Penalty
Summary
The facility failed to ensure 2 of 20 sampled employees, Employee #4 and Employee #17, had current CPR training. Employee #4 was hired as an Assistant Director of Nursing, and Employee #17 was hired as a Registered Nurse. Personnel and document review showed both employees lacked documented evidence of current CPR and first aid certification. During an interview, the Human Resources Coordinator stated that all licensed nurses were required to have current CPR and first aid certification upon hire and when the current certification expired, and confirmed that Employee #4 and Employee #17 were licensed nurses without CPR and first aid certification. The facility policy titled Cardiopulmonary Resuscitation (CPR) stated that staff would maintain current CPR certification for healthcare providers through a CPR provider with hands-on training in accordance with acceptable national standards.
Failure to Coordinate GI Infection Care and Address Constipation
Penalty
Summary
The facility failed to coordinate care for a resident with a gastrointestinal infection and failed to ensure interventions were implemented for another resident’s constipation. For Resident #44, the record showed a GI specialist consultation note stating the resident would continue to follow up with the specialist, and a GI panel on 04/27/2026 was negative for C. diff but positive for Entamoeba histolytica. The care plan was revised on 04/23/2026 and documented a history of C. diff, but it did not include the parasite infection. The clinical record also lacked documentation that the resident’s established GI specialist was notified of the parasite result. For Resident #97, the resident reported constipation, nausea, and lower abdominal and rectal pain during an interview on 05/11/2026, and stated the resident had not had a bowel movement in a couple of days and had previously reported the symptoms to nursing staff. The bowel and bladder elimination record showed no bowel movement on multiple dates in May 2026, including a five-day period from 05/03/2026 through 05/07/2026. The care plan identified a potential for constipation related to debility and ESRD and included interventions such as following bowel management protocol, monitoring for constipation-related complications, and keeping the physician informed. The MAR showed physician orders for Fleet enema and Milk of Magnesia tied to the resident’s lack of bowel movement, but there were no administrations documented for either medication. The record also lacked documented evidence that staff implemented any interventions to address the resident’s lack of bowel movement during the five-day period. The DON reviewed the record and confirmed there were no interventions documented to address the constipation, and the Administrator stated the facility did not have a bowel management or constipation policy and would follow protocol/physician orders.
Pain Not Addressed to Resident’s Acceptable Level
Penalty
Summary
The facility failed to ensure Resident #2’s report of pain was addressed with an intervention to reduce the pain to the resident’s acceptable level. Resident #2 was admitted and later readmitted with diagnoses including an unspecified fracture of the upper end of the right humerus and an unspecified fracture of the lower end of the right femur. A Pain Evaluation Assessment dated 04/30/2026 documented the resident’s acceptable pain level as 4 out of 10. On 05/11/2026 at 10:05 AM, the resident stated having pain in the right leg, reported having a new pill, and said the pain continued and caused the resident to spend more time in bed. The Medication Administration Record documented that on 05/12/2026 at 4:53 AM the resident’s pain was 6 out of 10 and hydromorphone 2 mg was administered. The Pain Level Summary documented the resident’s pain as 7 out of 10 at 8:02 AM the same day, but the record lacked documented interventions to address the pain, and the chronic pain care plan lacked non-pharmacological interventions. The RN confirmed no interventions had been implemented for the pain level of 7 and stated the hydromorphone given earlier was being allowed time to work. The DON stated the resident should have been evaluated for non-pharmacological intervention, the care plan should have included such interventions, and pain medication should have been offered or the provider paged.
Failure to Complete Trauma Assessments for Residents with Trauma Histories
Penalty
Summary
Provide care or services that was trauma informed and/or culturally competent was not ensured for 2 of 19 sampled residents. Resident #12 was admitted with a diagnosis of PTSD, and the clinical record included the Health and Physical, Physician Diagnoses Verification Summary, and MDS documentation confirming PTSD, but the record lacked documentation that a trauma assessment had been completed based on that diagnosis. On 05/14/2026, the DON confirmed a trauma assessment should have been completed for Resident #12 related to the PTSD diagnosis, including assessment of triggers to establish appropriate interventions and decrease the potential of re-traumatizing the resident. Resident #88 was admitted with diagnoses including CHF, cardiomegaly, CKD stage four, generalized anxiety, and psychoactive substance dependence. A psychiatric assessment documented that the resident’s chronic illness/depression was exacerbated by the recent violent death of the resident’s grandson, and psychotherapy was ordered. The Administrator stated a trauma assessment would be completed upon admission by the DON, while the ADON stated trauma assessments were completed by the Social Worker; however, the Director of Social Services confirmed a trauma assessment had not been done upon admission or after the traumatic event, and the resident did not have interventions in the Care Plan related to the traumatic life event. The facility policy titled Trauma Informed Care stated the facility is to provide care using approaches that address the needs of trauma survivors by minimizing triggers for re-traumatization.
Late CNA Annual Performance Review
Penalty
Summary
The facility failed to ensure that a CNA employed for more than one year had an annual performance review completed on time for 1 of 4 CNAs reviewed, Employee #9. Employee #9 was hired on 11/04/2025 as a CNA, and the personnel record showed a performance review completed on 11/14/2024. During an interview on 05/13/2026, the Human Resource Coordinator stated that all CNAs were required to have a performance review completed by their anniversary date and confirmed that Employee #9's review was completed 10 days late. On 05/14/2026, the Administrator stated the facility did not have a policy related to CNA performance reviews, but followed all federal regulations.
Unattended Medication and Expired Drugs in Storage
Penalty
Summary
A medication was left unattended in a resident’s room during the morning medication pass. Resident #4 was admitted with spinal stenosis of the lumbar region with neurogenic claudication and had an order for GlycoLax powder, 17 grams by mouth daily for constipation. An RN prepared the medication by dissolving 17 grams of GlycoLax in water, entered the resident’s room, administered the other prepared medications, then handed the cup containing the GlycoLax mixture to the resident and left the room. The RN later confirmed the medication was left in the room and stated the RN typically left medications such as laxative powders dissolved in liquids in residents’ rooms because it was a lot of liquid for residents to take in within a few minutes and the RN had to continue with the medication pass. Expired medications were also found in medication storage areas. In the Brookside unit medication storage room, a bottle of cherry flavored sore throat spray was found in an upper cabinet with an expiration date of 03/2026 printed on the label, and the CNO confirmed it had expired. In the Classics unit 200 hall medication cart, a bottle of Vitamin D 25 microgram tablets was found with an expiration date of 02/2026, and an LPN confirmed the medication had expired and should have been removed from the cart. The DON stated expired medications were to be removed from medication carts and cabinets in medication storage rooms no later than the expiration date printed on the container.
Therapeutic Diet Order Not Followed
Penalty
Summary
The facility failed to ensure a dietary recommendation was followed when a resident's lunch tray did not match the diet ticket. During observation of the lunch tray line on 05/13/2026 at 11:40 AM, the resident's diet ticket indicated a regular diet with no added salt, but dietary staff placed two extra salt packets on the tray. At 11:45 AM, the dietary staff member confirmed the tray contained two salt packets. At 12:00 PM, the Dietary Manager confirmed the meal did not match the diet ticket and stated the ticket should have been followed to support resident health and comply with provider orders. A facility policy titled Therapeutic Diet Orders, implemented 04/11/2025, stated the facility provided residents with foods in the appropriate form and/or nutritive content as prescribed by a physician.
Failure to Serve Ordered Minced and Moist Diets
Penalty
Summary
The facility failed to prepare food in the form ordered for residents on a minced and moist diet and failed to ensure Resident #3 received meals consistent with the resident’s prescribed diet. During a lunch tray line observation on 05/13/2026, dietary staff served a whole chicken breast, green peas, and cornbread to three residents whose meal tickets indicated a minced and moist diet. The approved menu for that meal called for baked chicken, garlic mashed potatoes, sliced carrots, soaked cornbread, margarine, vanilla pudding, coffee, and milk. The Dietary [NAME] stated being unaware of what the MM5 diet was, and the Dietary Manager confirmed the meals did not match the diet tickets and should have been followed to prevent a choking hazard. Resident #3 was admitted with diagnoses including paraplegia, adult failure to thrive, and atherosclerotic heart disease. The resident had a diet order for a regular diet with Level 5 minced and moist texture and thin liquids for difficulty chewing. On 05/11/2026, Resident #3 was observed in bed with an untouched meal tray and stated the food was horrible and hard to chew. On 05/12/2026, the resident received a tray with a whole ham steak, Brussels sprouts, sweet potato mash, a dinner roll, and baked apples, and the resident stated the dentures fit well but food collected underneath them and it was painful to eat. The resident also said the ham was too hard to chew and the Brussels sprouts were burnt. The Nutritionally-At-Risk Resident Interdisciplinary Team Review documented that the resident was to be provided and served the diet as ordered with intake monitoring at each meal, and the RN confirmed the resident had a current and active minced and moist diet order. Later that day, the Kitchen Manager confirmed Resident #3 was on a minced and moist diet and that the food being served did not follow the prescribed diet order.
Improper Dumpster Storage and Debris Around Refuse Area
Penalty
Summary
The facility failed to ensure that outside garbage receptacles were sealed with lids closed and that the surrounding pavement was free of debris. On 05/11/2026 at 9:22 AM, surveyors observed two dumpsters at the back of the facility, with one dumpster left open and trash exposed, and the second dumpster surrounded by trash on the ground, including gloves, cans, and paper. On 05/11/2026 at 9:30 AM, the Dietary Supervisor stated that the dumpster area should be kept clean and the lids closed to prevent animals and pests. A facility policy titled, Disposal of Garbage and Refuse, implemented 04/08/2026, stated that refuse containers and dumpsters kept outside the facility shall have tightly fitting lids, doors, or covers, shall be covered when not being loaded, and surrounding areas shall be kept clean to minimize debris and insect/rodent attractions.
Facility Assessment Not Updated After Medical Provider Change
Penalty
Summary
The facility failed to update its facility assessment after a change in the contracted medical provider group. The assessment, updated 03/19/2026, still identified a third-party vendor as the primary medical practitioners providing care to residents and stated the facility would review and update the assessment whenever changes required modifications to any part of it. During interview on 05/13/2026 at 12:33 PM, the Administrator confirmed the facility had changed its contracted medical group and provider as of 03/11/2026, and that the third-party vendor was no longer the contracted medical provider group. The Administrator stated he had been responsible for updating the facility assessment but missed changing the language to reflect the new provider group. The assessment did not document that it had been updated to reflect the change in the facility's medical provider structure, including the transition of the primary attending physician and associated on-call coverage. It continued to reference the previous medical group and did not reflect the qualifications, availability, scope of services, or clinical responsibilities of the newly contracted medical provider group. The facility policy titled Facility Assessment, revised 03/10/2026, stated the assessment would be reviewed and updated as necessary, at least annually, or whenever the facility planned for or had a change requiring modification or update.
Failure to Designate a Hospice Coordinator
Penalty
Summary
The facility failed to designate a member of the interdisciplinary team responsible for coordinating the care of residents receiving hospice services. During interviews, the ADON stated she was not the hospice coordinator and did not know who was responsible for that role. The Administrator confirmed awareness of the requirement for a hospice coordinator but stated the facility did not currently have one. The Administrator also said hospice services were coordinated as a team effort by several staff members, with oversight of hospice care expected to be handled by the DON. The DON stated she was not the hospice coordinator and said it was the responsibility of the respective ADONs to manage residents on hospice care within their units. Later, the DON confirmed the facility still did not have a hospice coordinator and that this created the potential for a resident on hospice not receiving properly coordinated care. The facility policy titled, Coordination of Hospice Services, dated 04/11/2025, did not include language requiring the facility to designate a member of the interdisciplinary team to coordinate the care of residents receiving hospice services.
QAPI Committee Failed to Address Hospice Coordinator and Personnel Documentation Issues
Penalty
Summary
The facility's QAPI committee failed to identify and address system-level issues related to the lack of a designated hospice coordinator and concerns about personnel training requirements for abuse prevention, CPR, and first-aid certifications. During interview, the Administrator confirmed the facility did not have a designated hospice coordinator and stated that this concern had not been addressed through the QAPI process. The Administrator also confirmed understanding that the hospice coordinator role was intended to ensure continuity and coordination of resident care between the facility and the hospice provider. The Administrator further stated the facility was unable to access employee documents, including abuse prevention training records and CPR and first-aid certifications, because of the change of ownership of the facility in [DATE]. As of [DATE], the facility still did not have access to employee documentation prior to [DATE], and this concern also had not been addressed in the QAPI process. The facility policy titled, Quality Assurance and Performance Improvement (QAPI), dated [DATE], stated the QAPI committee would identify, address, and correct problem areas by tracking and measuring performance, setting improvement goals, identifying and prioritizing quality issues, analyzing the causes of deficiencies, implementing corrective or improvement actions, monitoring effectiveness, and revising actions as needed.
Missing QAPI Committee Attendance Documentation
Penalty
Summary
The facility failed to provide QAPI committee member signature attendance sheets for the second, third, and fourth quarters of 2025. During document review and interview, the Administrator stated on 05/14/2026 at 2:30 PM that the facility did not have access to the monthly QAPI meeting attendee lists from April 2025 to [DATE] because the facility changed ownership in January 2026. The Administrator could not confirm which committee members participated in or attended the meetings during those months. The facility’s QAPI Facility Plan, dated April 2026, stated that the committee shall maintain written documentation of meeting attendance records.
Ice Machine Not Kept Clean and in Good Repair
Penalty
Summary
The facility failed to maintain the kitchen ice machine in good repair. On 05/11/2026 at 8:30 AM, surveyors observed white mineral deposits on the exterior surfaces and door of the ice machine, with similar deposits present on the ground surrounding the machine. At 8:36 AM, the Dietary Supervisor confirmed the ice machine should have been cleaned and stated that maintenance and kitchen staff were responsible for the task. The Dietary Supervisor also stated that keeping the ice machine clean was necessary to prevent residents from becoming ill. A facility policy titled Sanitation Inspection, implemented 12/22/2025, stated that all food service areas shall be kept clean and sanitary.
Delayed Elder Abuse Training for Multiple Employees
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 6 of 20 sampled employees: Employee #2, #3, #16, #17, #18, and #19. Personnel record review showed that Employee #2, hired as the DON on 12/30/2025, completed initial elder abuse training on 02/16/2026; Employee #3, hired as the ADON/Infection Preventionist on 09/15/2025, completed training on 02/06/2026; Employee #16, hired as an RN on 01/30/2026, completed training on 02/13/2026; Employee #17, hired as an RN on 01/30/2026, completed training on 02/12/2026; Employee #18, hired as Social Services Staff on 04/07/2026, completed training on 04/12/2026; and Employee #19, hired as Housekeeping Supervisor on 01/27/2026, completed training on 02/02/2026. On 05/13/2026, the HRC stated that all staff were required to complete elder abuse training upon hire, prior to starting work on the floor, and annually thereafter. The HRC confirmed that Employees #2, #3, #16, #17, #18, and #19 did not complete initial elder abuse training timely, prior to starting work on the floor, and that no previous elder abuse trainings could be located. On 05/14/2026, the Administrator stated the facility did not have a policy related to elder abuse training, but followed all federal regulations.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Based on document review and interview, the facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) upon discharge for 1 of 3 sampled residents, Resident #13. Resident #13 was admitted to the facility on 04/07/2026 and later discharged. The resident's clinical record lacked documented evidence that a NOMNC notification was given for termination of Medicare Part A services provided. On 05/12/2026 at 11:07 AM, the Administrator confirmed that Resident #13 did not have notification of NOMNC prior to discharge from the facility.
Failure to Notify Physician of Recurrent Hypoglycemia and to Follow Hypoglycemia Treatment Orders
Penalty
Summary
The deficiency involves the facility’s failure to protect a diabetic resident from neglect when nursing staff did not follow physician orders for monitoring and responding to hypoglycemia and did not notify the physician of critical low blood glucose (BG) values. The resident had type 1 diabetes mellitus with circulatory complications and diabetic autonomic neuropathy and was ordered multiple insulin regimens, including Lantus and sliding-scale Insulin Aspart, with explicit instructions to notify the physician for BG less than 80 mg/dl or greater than 350 mg/dl. The resident also had PRN orders for oral glucose gel for BG less than 70 mg/dl with symptoms of hypoglycemia if able to swallow, and for Glucagon to be given SQ or IM for BG less than 70 mg/dl with signs of hypoglycemia when the resident was unable to swallow or was unresponsive. The resident’s care plan included monitoring, documenting, and reporting signs and symptoms of hypoglycemia. On two separate dates prior to the fatal event, the resident experienced documented episodes of hypoglycemia with BG readings below the ordered parameters. A progress note documented that on one date the resident’s Lantus was held due to a blood sugar of 46 mg/dl and that Glucagon was administered, with a plan to recheck. Another progress note documented a low blood sugar of 47 mg/dl prior to breakfast, after which the resident was given juices and other fluids and the BG increased to 103 mg/dl. During this second episode, staff discussed with the resident the concern about hypoglycemia and suggested contacting the provider to lower the Lantus dose, but the resident declined changes and staff planned to remind the next shift to offer midnight snacks. The clinical record, however, lacked documentation that the physician was notified of these BG readings below 80 mg/dl, despite the physician order requiring notification for BG values outside the specified parameters. On the night of the fatal incident, a CNA found the resident unresponsive and clammy. An RN assessed the resident and obtained a fingerstick blood glucose of 31 mg/dl. Despite the resident being unresponsive and unable to drink or eat, the RN administered one tube of oral glucose gel, which was not in accordance with the physician’s order that specified Glucagon for hypoglycemia in residents who were unable to swallow or unresponsive. A repeat BG 20 minutes later remained 31 mg/dl. Emergency Medical Services were called, and when they arrived, the resident’s BG was 19 mg/dl. EMS administered D10, after which the resident briefly became arousable and then became unresponsive again, leading to CPR and subsequent death. Facility leadership, including the DON and CNO, confirmed that the physician had not been notified of the earlier low BG readings and that Glucose gel was inappropriately used instead of Glucagon when the resident was unresponsive, constituting a failure to follow physician orders and a failure to report changes in condition as required by facility policy and job descriptions.
Failure to Document Investigation of Neglect-Related Hypoglycemic Event and Death
Penalty
Summary
The deficiency involves the facility’s failure to provide documented evidence of a thorough investigation into an incident suspicious for neglect involving Resident #8. Resident #8 had diagnoses including type 1 diabetes mellitus with circulatory complications and diabetic autonomic (poly) neuropathy. According to the Facility Reported Incident (FRI), a CNA found the resident unresponsive and clammy at approximately 1:00 AM. An RN assessed the resident, obtained a blood glucose result of 31, and administered oral glucose gel outside of order guidelines instead of administering the prescribed Glucagon per physician order. A repeat finger-stick blood glucose remained 31, EMS was called, and EMS administered 10% Dextrose. The resident briefly regained consciousness, then became unresponsive again, CPR was initiated by EMS, and the resident expired. The Administrator/Abuse Coordinator stated there was no documentation of the facility’s investigation of this incident. The Administrator/Abuse Coordinator reported that the former DON had the investigation documentation, but it could not be located in the former DON’s office, and many electronic files were inaccessible following a change of ownership in February 2026. This lack of available documentation was inconsistent with the facility’s Abuse, Neglect, and Exploitation policy, which required an immediate investigation upon suspicion or reports of abuse, neglect, or exploitation, including identifying responsible staff, interviewing all involved persons and witnesses, and providing complete and thorough documentation of the investigation.
Failure to Document Food Temperatures
Penalty
Summary
The facility failed to obtain and document cooking and holding temperatures for chicken before serving it to residents during lunch service. On the specified date, dietary staff removed three large trays of chicken breasts from the oven and transferred them to a holding tray on the steam table. The chicken was then plated and prepared for delivery to residents without the necessary temperature checks. The Dietary Manager confirmed that temperatures were neither taken nor documented before serving, although they claimed temperatures were checked during cooking. However, no documentation or observation of these checks was available. The Registered Dietician acknowledged that the facility did not record cooking temperatures and was following the facility's policy, which could potentially lead to foodborne illness if the chicken was undercooked. The Executive Director admitted that the facility lacked a policy related to foodborne illness. The facility's existing policies required a minimum cooking temperature of 165 degrees Fahrenheit for chicken and a holding temperature of at least 140 degrees Fahrenheit, with food temperatures to be documented daily before meal service. However, a cooking temperature log could not be located, indicating a lapse in adherence to these policies.
Deficient Coordination of Hospice Care
Penalty
Summary
The facility failed to ensure proper coordination of hospice care between the facility and hospice agencies for three residents receiving hospice services. This deficiency was identified through clinical record reviews, document reviews, and interviews. The lack of coordination resulted in missing documentation of hospice visits and care provided, which was not available in the residents' clinical records or hospice binders. This failure to document and coordinate care had the potential to compromise the quality of hospice care provided to the residents. Resident #230 was admitted to hospice care with a care plan that included skilled nursing, CNA visits, social worker, and chaplain services. However, the facility's records lacked documentation of these visits, and the hospice binder did not have a sign-in sheet for hospice staff. The DON confirmed that hospice visit notes were not documented in the resident's chart prior to a specific date, and the facility did not have evidence of the required CNA visits being completed as per the hospice care plan. Similarly, Resident #50 and Resident #4 also experienced deficiencies in the documentation and coordination of hospice care. Resident #50's records lacked hospice visit notes, and the sign-in sheets were incomplete. For Resident #4, the hospice communication binder and EMR lacked visit notes, and the facility did not have a current hospice care plan or documentation of completed visits. The DON confirmed that the facility did not have documented evidence of completed hospice visits for these residents and that the hospice agency did not consistently use a sign-in log to track hospice staff visits.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the proper Notice of Medicare Non-Coverage (NOMNC) to two residents, resulting in non-compliance with Medicare requirements. For the first resident, who was admitted with conditions including primary generalized osteoarthritis and chronic respiratory failure, there was no documented evidence that the NOMNC was provided before their discharge home. The Business Office Manager (BOM) confirmed the absence of the NOMNC in the resident's clinical record, despite the facility's policy to follow CMS instructions for the NOMNC. Similarly, the second resident, admitted with diagnoses such as type 2 diabetes mellitus and chronic kidney disease, did not receive the NOMNC for an extended admission period. Although the resident's discharge was initially planned for an earlier date, it was extended due to a medical condition. The BOM confirmed the lack of documentation for the NOMNC related to this extension. The facility's Executive Director acknowledged the expectation to provide the NOMNC two days before the end of benefits, as per CMS guidelines, but this was not adhered to in these cases.
Late Submission of MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were transmitted to the State within the required 7-day timeframe for 4 out of 10 months, starting in June 2024. This deficiency was identified through interviews and document reviews, revealing that a significant percentage of admission assessments were completed late during these months. Specifically, in June 2024, 10.3% of admission assessments were late, followed by 12.5%, 14.5%, 13.5%, and 11.9% in subsequent months. The Executive Director confirmed that the MDS Coordinator was responsible for submitting these assessments and acknowledged that the late filings were due to a change in MDS Coordinators at the facility.
Inaccurate MDS Assessments for Hospice and Discharge Status
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for two residents, which could potentially deprive them of necessary care and services. Resident #4, who was admitted with diagnoses including spondylopathies and unspecified dementia, was receiving hospice services as documented in a Hospice Plan of Care. However, the quarterly MDS assessment did not indicate that Resident #4 was receiving hospice care, as required by the Resident Assessment Instrument (RAI) manual. This oversight was confirmed by the MDS Consultant upon review of the clinical record. Similarly, Resident #79, admitted with a diagnosis of a femur fracture, was documented in a Nursing Progress Note as being discharged home. However, the discharge MDS assessment inaccurately recorded the resident as being discharged to a short-term general hospital. The MDS Consultant confirmed this discrepancy upon reviewing the clinical record. The Director of Nursing acknowledged that the facility did not have a specific policy for completing MDS assessments and relied on the RAI manual for guidance.
Failure to Document Insulin Use in Care Plan
Penalty
Summary
The facility failed to develop a person-centered Comprehensive Care Plan for a resident with type 2 diabetes mellitus, specifically regarding the use of insulin. The resident was admitted with a diagnosis of type 2 diabetes mellitus and had physician's orders for HumaLOG and Insulin Glargine to be administered subcutaneously. Despite these orders being documented in the Medication Administration Record, the resident's Care Plan lacked documented evidence of the use of insulin. The Director of Nursing confirmed the absence of insulin-specific documentation in the Care Plan and expressed an expectation that the care plan would not be insulin-specific. According to the Resident Assessment Instrument (RAI) 3.0 manual, the care plan should be used to provide services to maintain the resident's highest practicable wellbeing and should be revised based on changing needs and interventions. The failure to include insulin use in the care plan had the potential to result in residents not receiving necessary care and services related to insulin management.
Failure to Monitor Resident-Specific Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that behaviors monitored were associated with the specific condition indicated by the physician for the use of psychotropic medications for one resident. This deficiency was identified during an interview, clinical record review, and document review. The resident in question was admitted with diagnoses including major depressive disorder and generalized anxiety disorder. The resident's psychotropic medication orders included Buspirone, Clonazepam, Duloxetine, Trazodone, and Wellbutrin, prescribed for anxiety and depression. However, the behavior monitoring instructions in the electronic medical record were not specific to the behaviors that needed to be monitored for this resident. The Director of Nursing explained that CNAs documented behavior monitoring during each shift, inputting progress notes for new and escalating behaviors. However, the behavior monitoring was not tailored to the resident's specific behaviors. The facility's policy on psychotropic drugs required that residents with such medication orders be evaluated and appropriate interventions implemented, with the interdisciplinary team ensuring appropriate diagnoses of behavioral symptoms. Despite this policy, the lack of resident-specific behavior monitoring led to the potential for the resident to use unnecessary medication with possible adverse effects.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and monitoring of medications and biologicals, as evidenced by several deficiencies. One of the medication storage refrigerators, located in the Staff Development Coordinator (SDC) office, contained food items such as mozzarella cheese sticks, soda cans, yogurt, queso cheese, sour cream, and jalapeno stuffed olives, stored alongside vaccines and a vial of Tubersol Solution. The refrigerator lacked a temperature log, and the SDC confirmed that the refrigerator was left unsecured and that food should not have been stored with vaccines or biologicals. Additionally, a multi-dose vial of Tubersol Solution was found to be expired, having been open for 49 days, exceeding the facility's policy of discarding such vials 28 days after opening. The Director of Nursing (DON) and a Registered Nurse (RN) confirmed the expiration policy, and the DON acknowledged the vial should have been discarded as its efficacy would have been reduced. The facility's policy mandates that outdated or expired medications be immediately removed from stock and disposed of. Furthermore, a medication cart in the 200 hallway was left unattended with the top drawer unlocked, allowing access to resident medications. The facility's policy requires medication carts to be kept closed and locked when out of sight of the medication nurse. These deficiencies indicate lapses in the facility's adherence to its medication storage and administration policies, potentially compromising medication integrity and safety.
Deficient Practices in Resident Information Security and Record Keeping
Penalty
Summary
The facility failed to safeguard resident-identifiable information and maintain complete medical records, as observed during a survey. A computer screen on a medication cart was left unattended and displayed resident medication information in a public area, which was confirmed by a Registered Nurse (RN) upon returning to the cart. This practice was against the facility's policy that required resident health information to remain private and not visible when not in direct use. Additionally, the facility did not maintain complete clinical records for a resident who had been admitted with conditions including orthopedic aftercare following surgical amputation and basal cell carcinoma. The Treatment Administration Record (TAR) for this resident had multiple blank spaces for scheduled administrations of wound care and medication, indicating missing documentation. The Director of Nursing (DON) confirmed these omissions, which were contrary to the facility's policies requiring documentation of care and medication administration in accordance with prescriber's orders.
Failure to Document and Complete Required Orientation and Competency for Agency RN
Penalty
Summary
The facility failed to document and ensure completion of required orientation, training, and competency validation for a newly assigned agency Registered Nurse (RN) prior to the RN providing direct resident care. The RN began working an overnight shift without having completed the facility's orientation packet, which included training competencies, as required by facility policy. The Staff Development Coordinator (SDC) and Executive Director (ED) confirmed that the RN did not arrive at the scheduled time to complete orientation and started the shift without documented orientation, skills check, or training. The RN also refused to review or fill out the orientation packet when prompted by an LPN assigned to train them. During the shift, several residents reported that the RN did not administer as-needed medications, prompting the LPN to notify management and administer the medications themselves. The Director of Nursing (DON) confirmed that the RN had not completed any documented orientation or training before providing care. The facility's contract with the staffing agency and internal policies required that all agency staff receive appropriate orientation and competency validation, including medication administration and infection control, prior to independent assignment. These requirements were not met in this instance.
Multiple Incidents of Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to protect residents from various forms of abuse and neglect, as evidenced by several incidents involving different residents. One resident was neglected when a CNA refused to assist them out of bed and closed the door to prevent them from calling for help, despite the resident's increased anxiety at night and dependence on staff for mobility. This incident was verified by the facility, and the CNA admitted to the actions. Additionally, the same resident experienced neglect when their brief was not changed for eight hours, resulting in them sitting in soiled conditions, which was also confirmed by the facility's investigation. Another resident was verbally abused by an LPN who yelled at them during care, causing the resident to feel unsafe and cry the following day. Witnesses corroborated the resident's account, noting the LPN's inappropriate behavior and use of a cell phone during the incident. The facility verified the verbal abuse allegation and took action against the LPN involved. A separate incident involved a physician who continued a breast examination on a resident despite the resident's repeated requests to stop, making the resident uncomfortable. Witnesses confirmed the resident's account, and the facility acknowledged the situation as a potential concern of abuse. Additionally, a resident-to-resident sexual abuse incident occurred when one resident kissed another on the lips without consent, despite the latter's cognitive impairments and inability to consent. The facility was aware of the offending resident's history of inappropriate behavior, yet the incident still occurred.
Misappropriation of Resident's Insulin by Staff
Penalty
Summary
The facility failed to protect a resident's medication from being wrongfully used by a staff member. A Licensed Practical Nurse (LPN) was witnessed by another nurse self-administering insulin that was prescribed to a resident diagnosed with type I diabetes mellitus. The incident was documented in a Facility Reported Incident (FRI) on 08/05/2024, and the nurse involved admitted to the act in a signed statement dated 08/09/2024. The Director of Nursing (DON) expressed that the nurse should have sought management support or emergency medical care instead of using the resident's medication. The resident involved, who is blind, was unaware of the incident until informed by another resident and staff. The resident expressed feeling upset as the nurse did not seek permission to use the insulin. The facility's PRIDE Education Module, updated in 10/2022, defines misappropriation of resident property as the deliberate use of a resident's belongings without consent, and diversion of medication for staff use is cited as an example of such misappropriation.
Medication Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to ensure professional standards for prescribing medications were followed, resulting in a resident receiving incorrect medications. A nurse mistakenly input medication orders for a resident from another resident's hospital discharge summary. This error went unnoticed for three days, during which the resident received medications for conditions they did not have, such as hypertension and Parkinson's disease. The error was discovered and reported after the resident exhibited symptoms of hypotension and was unable to stay awake or alert. The resident, who had been admitted with diagnoses including metabolic encephalopathy and protein-calorie malnutrition, was readmitted to the facility from the hospital. The incorrect medications were administered multiple times over the course of three days, leading to the resident being sent to the Emergency Department and subsequently hospitalized for four days. The medications included acetaminophen, asenapine, benztropine, and others, which were not appropriate for the resident's actual medical conditions. The physician involved admitted to having skimmed through the orders and signing them without thorough review, relying on the nurse to contact them with any questions. The Director of Nursing expressed an expectation that the provider should have questioned the orders for medications treating diagnoses the resident did not have. The facility's Medical Director Independent Contractor Agreement outlined the provider's responsibility for coordinating medical care and ensuring the facility provided the required care, which was not adhered to in this instance.
Medication Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, resulting in a significant medication error. A resident was readmitted to the facility with specific diagnoses, including metabolic encephalopathy and sequelae of protein-calorie malnutrition. However, upon readmission, the admitting nurse mistakenly input medication orders from another resident's hospital discharge summary. This error led to the resident receiving incorrect medications for three days before the mistake was discovered. The medications administered included treatments for conditions such as hypertension, Parkinson's disease, and hyperlipidemia, which the resident did not have. The error was identified when the resident exhibited symptoms such as hypotension and an inability to stay awake or alert, prompting a transfer to the Emergency Department for further evaluation. The facility's policy on medication administration required that medications be administered according to the prescriber's written orders and that any discrepancies be clarified with the provider pharmacy or prescriber before administration. Despite this policy, the resident received medications unrelated to their diagnoses, leading to hospitalization to monitor for adverse side effects.
Failure to Investigate Misappropriation and Abuse Allegations
Penalty
Summary
The facility failed to investigate a potential incident of misappropriation of a resident's prescribed narcotic pain medication. This involved Resident #44, whose Morphine Sulfate solution appeared tampered with, as noted by a hospice RN. The medication was discolored, and a paper-like substance was visible in the bottle. Despite these observations, the facility did not initiate an investigation into the potential misappropriation of property until prompted by the surveyors. Additionally, the facility did not thoroughly investigate an allegation of abuse involving Resident #19. The resident alleged inappropriate touching by a male staff member during care. Despite the serious nature of the allegation, the facility allowed the alleged perpetrator to continue working in the facility, thereby failing to protect Resident #19 and other residents from potential further abuse. The DNS did not review the clinical records to verify the involvement of the staff member, which was a critical oversight in the investigation process. The facility's policies on abuse prevention and investigation were not adequately followed, as evidenced by the lack of immediate suspension of the alleged perpetrator and the failure to conduct a thorough investigation. The DNS admitted to not reviewing the clinical records as part of the investigation, which could have confirmed the staff member's involvement in providing care to Resident #19. This oversight allowed the alleged perpetrator to continue working, posing a risk to the safety and well-being of all residents.
Removal Plan
- The alleged perpetrator was suspended to ensure completion of the investigation regarding care provided to the resident of concern.
- All residents were interviewed related to sexual abuse, and non-interviewable residents were assessed for sexual trauma.
- All facility staff would be educated on Abuse Prevention and Investigation.
Deficiencies in Infection Control and Medication Administration
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) possessed the necessary skills to review lab results for determining the appropriateness of implementing transmission-based precautions (TBP). The IP incorrectly believed that a resident had to be symptomatic with visible signs of infection to be placed in TBP and did not consider lab results as a basis for isolation. Additionally, the IP did not review wound cultures obtained by a hospital prior to a resident's admission, despite the facility's policy allowing such reviews. This lack of competency in infection prevention could lead to residents not being placed on necessary precautions, potentially exposing others to communicable diseases. The facility also failed to ensure that a nurse administering medications had completed a competency for medication administration. A Registered Nurse (RN) incorrectly stated that medicated powders could be left in a resident's room and applied by Certified Nursing Assistants (CNAs). The Director of Nursing Services (DNS) admitted that the facility did not complete a competency checklist with nurses but relied on a pharmacy audit tool, which was not provided upon request. This deficiency could result in residents not receiving medications as prescribed, increasing the potential for adverse medication reactions. Furthermore, the IP lacked the knowledge necessary for the appropriate selection and administration of pneumococcal vaccines. The IP incorrectly believed that pneumococcal vaccines expired after five years and needed to be repeated, and the facility did not offer certain vaccines recommended by the CDC. The IP also failed to use CDC guidance, including decision flow sheets, to determine vaccine needs. Additionally, the IP did not correctly complete the Antibiotic Stewardship Program (ASP) tools and documentation, including antibiotic time outs, which could lead to residents being treated with ineffective antibiotics, resulting in prolonged infections or the development of multi-drug resistant organisms (MDRO).
Deficiencies in Food Safety and Hand Hygiene Practices
Penalty
Summary
The facility failed to maintain proper food safety and hygiene standards in its dietary services. Personal items, including a beverage from a fast-food restaurant and a personal bag, were found on a food preparation counter, which was confirmed by the Nutritional Services Supervisor to be inappropriate. Additionally, charging cords were present on another food prep counter where sandwiches were being prepared, which the supervisor also acknowledged should not have been there. The facility lacked a policy regarding personal items in the kitchen, as confirmed by the Nutritional Services Supervisor. The facility also failed to ensure proper hand hygiene practices during meal service. A CNA did not perform hand hygiene after handling a soiled tray before delivering a new meal tray to another resident. Similarly, a Nursing Aid in Training and another CNA did not perform hand hygiene before delivering meal trays to residents. Both staff members acknowledged the requirement for hand hygiene but denied failing to perform it. The Nutritional Services Supervisor was unaware of these lapses in hand hygiene, which contradicted the facility's hand hygiene policy that mandates the use of alcohol-based hand rub or soap and water before and after handling food or assisting residents with meals.
Deficiencies in Abuse Investigation and Infection Control
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident. The Director of Nursing Services (DNS) was aware of the allegation but did not review the resident's clinical record to verify if the alleged perpetrators, a Certified Nursing Assistant (CNA) and a Nurse-Aid in Training (NAT), had provided care to the resident. Despite the ongoing investigation, the NAT continued to work unsupervised, as the DNS was unable to contact the NAT to inform them of the suspension. This oversight potentially exposed residents to further abuse. The Infection Preventionist (IP) at the facility lacked the necessary skills and knowledge to effectively monitor and track infections and antibiotic use. The IP failed to consistently document critical information such as the type of infection, the prescribed antibiotic, and lab results on the Line Listing Report. This omission hindered the facility's ability to track infections and antibiotic use accurately, increasing the risk of residents developing infections with Multi Drug Resistant Organisms (MDROs). Additionally, the IP demonstrated a lack of understanding regarding the administration of pneumococcal vaccines. The IP did not utilize CDC guidance or provide floor nurses with tools to determine which vaccines residents were eligible for. This resulted in the facility's failure to identify residents in need of additional pneumococcal vaccines, potentially compromising their health.
QAPI Committee Oversights in LTC Facility
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify several critical issues, leading to deficiencies in care and management. The committee did not recognize concerns related to Enhanced Barrier Precautions (EBP) and Transmission Based Precautions (TBP), which could have been identified through audits and led to necessary staff education. Additionally, the committee overlooked an Advanced Practice Registered Nurse (APRN) signing documentation with the credentials of a Medical Doctor, a discrepancy that could have been caught by Medical Records during daily audits. Furthermore, there was a lack of thorough investigation into resident abuse allegations, which could have been addressed by verifying employee contact information upon hire. The QAPI committee also failed to identify issues with tracking and reconciling narcotic medications, including those for hospice care, and the absence of a designated Hospice Coordinator, which affected communication regarding medications. Moreover, the committee did not address concerns related to the screening and offering of pneumococcal vaccines to residents, which could have been identified through immunization audits. These oversights indicate a failure in the facility's QAPI processes to effectively identify and address quality deficiencies and opportunities for improvement.
Deficiency in Antibiotic Use Monitoring and Education
Penalty
Summary
The facility failed to ensure that the Infection Preventionist (IP) accurately documented and tracked infections and antibiotic use among residents. The Line Listing for Infections by Resident form, used by the IP, lacked necessary elements such as the prescribed antibiotic, start and stop dates, ordered lab work, and lab results. This omission affected the documentation for 10 out of 31 residents who were prescribed antibiotics for infections between January and May 2024. The IP confirmed that the form did not include a space to document the type of infection, and the column for Transmission Based Precautions was pre-populated with 'none', requiring manual changes. The IP's process for tracking infections involved daily reviews of the Orders Listing Report, which included physician orders for antibiotics. However, discrepancies were found between the Orders Listing Report and the Line Listing for Infections by Resident form. Several residents with physician orders for antibiotics were not included in the Line Listing Report for various months, indicating incomplete or outdated documentation. The IP acknowledged these discrepancies and confirmed that the documentation was not current. Additionally, the facility failed to provide education related to antibiotic use and the Antibiotic Stewardship Program (ASP) to both staff and residents. The Director of Nursing (DON) confirmed the lack of educational provision. The facility's policy on the ASP, dated September 2017, required education for nursing staff, providers, and residents, but there was no documented evidence of such education being provided. This lack of education and incomplete documentation could potentially affect the entire resident census of 89.
Failure to Ensure Timely Compliance and Ethics Training
Penalty
Summary
The facility failed to ensure timely completion of compliance and ethics training for 15 out of 20 sampled employees. The deficiency was identified through interviews and document reviews, revealing that several employees did not complete the required training upon hire or annually as stipulated by the facility's policy. Employees, including the Administrator, Director of Nursing, Activities Director, Dietary Manager, and others, either completed the training late or lacked documented evidence of having completed it for the year 2023. The Human Resources staff admitted to being unsure about the timing and frequency of the required compliance and ethics training. This uncertainty contributed to the failure in ensuring that employees received the necessary training to prevent and detect violations and promote quality care. The facility's policy, published in November 2019, clearly stated the requirement for all staff to complete this training upon hire and annually thereafter, but this was not adhered to, leading to the identified deficiency.
Unsecured Medications and Improper Delegation of Duties
Penalty
Summary
The facility failed to ensure that medications were not left unsecured at a resident's bedside, as observed with two residents. For one resident, medications including Nystop powder, Phytoplex antifungal powder, and Fluticasone Propionate nasal spray were found unsecured in the resident's room. The CNA responsible for the resident's care admitted to applying the powders, which was outside their scope of practice, as they were not trained to administer medications. The RN confirmed the nasal spray should have been secured in the medication cart, and the Director of Nursing Services stated that CNAs should not apply medicated powders and that medications should not be left at the bedside. Another resident had multiple inhalers, including Albuterol, Spiriva, and Symbicort, left unsecured in their room. These inhalers were brought in by the resident's family due to the facility's initial lack of availability. A CNA found the Albuterol inhaler on the resident's lunch tray and returned it to the resident, intending to inform the nurse, which did not happen. The LPN was unaware the inhalers remained in the room and later removed them, placing them in the medication cart. The facility's policy prohibits medications from being left in resident rooms unsupervised due to safety concerns. Additionally, a medication cart was left unattended with over-the-counter medications on top while a CNA watched it as the nurse used the restroom. The CNA acknowledged that watching medications was not within their scope of practice. The facility's policy states that medications should only be accessible to licensed nursing personnel or authorized staff. The Nevada Nurse Practice Act supports this by prohibiting the delegation of tasks to unqualified personnel.
Medication Security and Storage Deficiencies
Penalty
Summary
The facility failed to ensure the security and proper storage of medications, as observed during a survey. A medication cart was left unattended with over 20 over-the-counter plastic bottles containing pills on top, while a CNA was asked to watch the cart as the nurse used the restroom. The CNA confirmed that watching medications was not within their scope of practice. The RN acknowledged that vitamins are considered medications and should not have been left unsecured. Facility policy states that medication supplies should only be accessible to licensed nursing personnel or those authorized to administer medications. Additionally, the facility did not store medications according to manufacturer guidelines and failed to remove discontinued medications from the medication cart. A bottle of Lactulose solution belonging to a deceased resident was found in the cart, despite the medication being discontinued. Furthermore, a bottle of Lorazepam was improperly stored in the medication cart instead of being refrigerated as required by the manufacturer. The LPN confirmed the improper storage and the need for refrigeration. The ADON and DNS acknowledged the expectation for medications to be stored according to guidelines and removed when discontinued. The facility also failed to ensure proper labeling of medications. An unopened bottle of Morphine Sulfate oral solution and a bottle of Lorazepam were found without proper labels, making them unusable. The RN2 and RCM confirmed the lack of labeling and explained that medications without complete labels should not be used. The facility's policy and the Pharmacy Services Agreement require medications to be labeled according to professional standards, but this was not adhered to in these instances.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 209 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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Carson City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sierra Basin Post Acute | 1.3 mi | ★★★★★ | 13 | 0 |
| Northstar Post Acute | 2.3 mi | ★★★★★ | 42 | 0 |
| Mountain View Health And Rehabilitation | 3.7 mi | ★★★★★ | 22 | 0 |
| Gardnerville Health & Rehabilitation Center | 16.7 mi | ★★★★★ | 3 | 0 |
| Life Care Center Of Reno | 17.7 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 August 2026) and official state health department websites.